Catheter-Acquired Urinary Tract Infection: The Once and Future Guidelines

Abstract

From the Department of Internal Medicine and Medical Microbiology, University of Manitoba Health Sciences Centre, Winnipeg, Manitoba, Canada Received December 21, 2009; accepted December 27, 2009; electronically published February 15, 2010. Infect Control Hosp Epidemiol 2010; 31:327-329 2010 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2010/3104-0002$15.00. DOI: 10.1086/651092 Catheter-acquired urinary tract infection (CAUTI) is one of the most common hospital-acquired infections. The rate of acquisition of new infection is 3%–7% per day while the indwelling urinary catheter remains in place. More than 80% of hospital-acquired urinary tract infections are catheter associated, and 12%–16% of patients who are admitted to acute care hospitals have an indwelling catheter placed at some time during hospitalization. In addition, approximately 5% of longterm care facility residents have voiding managed with a chronic indwelling catheter. However, morbidity or mortality with catheter use is modest, compared with other deviceassociated infections. Infection with an indwelling urethral catheter is overwhelmingly asymptomatic. Symptomatic infection is uncommon, and the severe manifestation of bacteremia attributable to CAUTI is reported in prospective studies for less than 1% of patients with catheters and less than 5% of patients with CAUTI. Costs directly attributable to CAUTI are also modest and are estimated to average only $589 per infection. Despite these considerations, the intensity of urinary catheter use in healthcare settings means that the cumulative contribution of CAUTI to the burden of hospitalacquired infections is substantial. In addition, there are adverse effects of indwelling urethral catheters beyond infection. Trauma and inflammation from the catheter or complications from patient immobility are other patient-specific adverse effects, and urine drainage bags are a reservoir for drugresistant bacteria in the healthcare environment. In 1981, the Centers for Disease Control and Prevention developed guidelines for the prevention of CAUTI. Now, in 2010, almost 30 years later, the Healthcare Infection Control Practices Advisory Committee (HICPAC) has updated these guidelines. For many of us, the interval from publication of the initial guideline to this first revision spans the greater part of a professional career. Even more extraordinary, the 1981 guideline did not simply fade away as it was eclipsed by time but continued to be a reference for appropriate practice. It is only recently that alternate guidelines addressing CAUTI have been developed, such as the Department of Health of Great Britain guidelines published in 2001 and updated in 2007 and the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America/Association for Professionals in Infection Control Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals published in 2008. Why has there been such an extraordinary lapse of time before this revision? Limited substantive change in practices to prevent CAUTI during the past 3 decades meant there was never any urgent need to update the document, because the initial guidelines were never incorrect. This is, itself, a distressing observation. In an interval of 30 years during which there has been intense interest and continuing progress in addressing hospital-acquired infections, one would have hoped for some meaningful advances in the prevention of CAUTI. A second likely explanation for the delayed revision is that CAUTI has been considered a relatively unimportant hospital-acquired infection. Morbidity with symptomatic urinary infection is uncommon relative to the intensity of urinary catheter use, and attributable mortality is rare, compared with the attributable mortality of other device-related infections, such as central-line bacteremia and ventilator-associated pneumonia. The landmark Study on the Efficacy of Nosocomial Infection Control by Haley et al, published in the 1980s, was important in encouraging this perspective. This study reported that nosocomial urinary infection could be decreased by 31%–41% with an intense infection control program and would achieve the greatest absolute number of infections potentially prevented, compared with programs to prevent surgical wound, lower respiratory, or bloodstream infections. However, the mean extra length of stay was only 2 days for symptomatic urinary infection and 0.4 days for asymptomatic infection, compared with 5.2 days for lower respiratory infection, 7.4 days for bloodstream infection, and 7.7 days for surgical wound infection. With the introduction of surveillance by objective, CAUTI became the most dispensable component. Why are the guidelines updated now? The revision itself