Risk of urinary tract infection

The use of these devices places each patient at risk of developing a urinary tract infection (UTI), a condition caused by the presence and multiplication of microorganisms in the urinary tract.

UTIs are unpleasant and painful experiences for patients and, as the infection can develop into sepsis, they are also potentially life-threatening.

UTIs are the most common healthcare-acquired infection (HCAI), accounting for 19% of all cases, according to epic3, guidance commissioned by the Department of Health and Social Care to reduce rates of HCAIs in England.

Data from the US suggests that 75% of UTIs in hospital are associated with a catheter.

Catheter-associated UTI (CAUTI) is defined by the National Institute for Health and Care Excellence (NICE) as a symptomatic bladder or kidney infection in a person with a catheter.

Signs include a raised or low temperature, shivering or shaking, new or worsening delirium or confusion, lethargy, back pain, pelvic discomfort and blood in the urine.

NICE guidance is clear that bacteria in the urine alone is not sufficient to diagnose a CAUTI in most cases, as this is so common with a urethral catheter. After one month with a catheter most people have bacteriuria (bacteria in the urine).

Time is a major factor

The main risk factor for developing a CAUTI is the length of time that a catheter is in place.

A major US study of nearly 48,000 patients published by BMJ Open found that the risk increased for each day, with 97% of patients clear of a CAUTI at ten days of catheterisation, 88% at 30 days, and only 72% at 60 days.

Risks of a CAUTI were highest in women, and people with paraplegia and cerebrovascular disease, the 2019 study found.

Lack of awareness

Jacqui Prieto is a registered nurse and associate clinical professor in infection prevention at the University of Southampton and University Hospital Southampton NHS Foundation Trust.

‘Every extra day with a urinary catheter in place increases the risk of a UTI. Sometimes UTI goes under the radar, and healthcare professionals don’t always consider this to be a serious infection,’ she says.

‘When it comes to an intravascular device, everyone seems aware of the risks it causes with potential blood stream infections. A catheter is also an invasive device but doctors and nurses do not always seem as aware of the risk of infection and other complications.’

Catheters predispose to infection because microorganisms are able to bypass natural mechanisms to keep them out, such as the urethra and urination, and gain entry to the bladder.

In 2018, NICE published guidance on treatment and self-management when a CAUTI is suspected (see box, above).

In addition, RCN catheter care guidance published in 2021 says that people with a CAUTI should be closely monitored to ensure the infection is treated appropriately due to the risk of sepsis.

Guidance from NICE, epic3 and the RCN emphasise the need for careful insertion and management of catheters to reduce infection risk.

CAUTIs can affect the bladder and kidneys

Picture credit: iStock

Catheter insertion, taking a urine sample, changing a catheter bag or valve, and administering any form of catheter management fluid instillation, should all be undertaken using aseptic techniques, the RCN Catheter Care guidance says.

Reducing catheter use

Another essential part of tackling CAUTIs is reducing the use of catheters, and the length of time they are in.

Dr Prieto, who helped write epic3, says that far too many catheters are still used without good clinical reason.

If wearing gloves, a fresh pair should be used and removed after fitting or changing a catheter

Picture credit: iStock

Urinary catheters may be inserted without robust clinical indication in 30% to 50% of cases, according to a paper drawing on international studies.

‘The most common reasons for an indwelling catheter in hospital are to monitor urine output and manage acute urine retention,’ Dr Prieto says. ‘But often alternatives are available and should be considered. They should never be used for staff convenience.’

One of the fundamental problems is that catheters, once in place, are often left there longer than needed.

The epic3 guidance says that when a catheter is inserted, the reason for this and the expected date of removal should be recorded. The catheter should be assessed every day and removed when no longer clinically required.

‘Once the catheter is in, it often seems that no one takes the decision to remove it or it just gets a bit forgotten,’ Dr Prieto says.

‘There is not that sense of urgency to carry out daily checks of catheters, unlike with intravenous devices.

‘This leaves some patients facing longer periods of catheter use than is actually necessary, with higher risks of CAUTI and other complications.’

And the longer that a patient has a catheter, the longer it can take for bladder function to return to normal once the catheter is removed, as bladder tone can be rapidly affected, Dr Prieto says.

Decision-making

There can sometimes be confusion around who is responsible for making the decision to remove a catheter, Dr Prieto says.

‘Catheters should be a last resort, rather than a first resort’

Jacqui Prieto, pictured, associate clinical professor in infection prevention, University of Southampton

A US study in 2000 found that doctors often did not know if their patients had a catheter. In 28% of patient-doctor interactions, the doctor was not aware if the patient was catheterised.

‘It always used to be a nurse-led intervention, and doctors say that catheter management is fundamentally nursing care,’ Dr Prieto says.

‘When we have a ward with lots of experienced staff, generally they can make that decision in most cases without a doctor. But often it seems to fall through a gap. Everyone thinks someone else is checking it and no one is. Nurses have an important role to play in catheter stewardship and should be asking, ‘Does the patient need this catheter?’’

A number of trusts use the HOUDINI protocol, a nurse-led approach that sets out clinical reasons when a catheter is needed and suggests a trial without catheter (TWOC) when this is no longer the case.

NHS England has published a patient plan for nurses to complete when using the HOUDINI approach.

The risk of a CAUTI can also be increased by poor communication between community staff and hospitals, when information on why the patient has a catheter, and when it needs to be changed or removed, can be lost.

NHS England published a template catheter passport and catheter card, which can be carried by the patient to explain why they have the catheter, when it was inserted and when it should be changed.

CAUTIs can cause back pain and pelvic discomfort

Picture credit: iStock

Improving communication

Fiona Le Ber, community continence and stoma sister for Family Nursing and Home Care Jersey, says communication can be problematic.

‘We aim to change the catheter of someone within 48 hours of going onto antibiotics for a CAUTI, but we are not always told by GPs that it is happening,’ she says.

Reducing the risk of CAUTIs

Picture credit: iStock

• » Gloves should only be worn if indicated– such as to avoid contact with blood/body fluids

• » Hands should be washed/decontaminated before and after attending to a catheter or performing catheter care. If wearing gloves, a fresh pair should be used and removed after the procedure

• » Care and observation of the meatal stricture (narrowing at the end of the urethra) is best undertaken during daily hygiene practices. Only soap and water are needed to maintain meatal hygiene

• » Drainage bags with taps must be emptied often enough to maintain urinary flow and prevent reflux

• » A separate container must be used for each patient and contact between the tap and the container avoided

• » Drainage bags should be changed when they become discoloured, contain sediment, smell offensive or are damaged. The healthcare professional must consider the risk of too frequent changes as breaking the sterile system

• » All drainable day and night bags must be changed at least every seven days, in line with manufacturer’s guidelines. It should be noted some drainage bags are designed for longer use (up to 28 days for some belly bags)

• » Never reuse urine bags by washing and reconnecting them in any care setting, unless the manufacturer has put in writing that this is an acceptable practice and you have the resources and facilities to comply with this

• » Consider use of non-drainable bags

• » Antiseptic or antimicrobial solutions must not be added to drainage bags

• » Always challenge the need for catheterisation and catheter usage

• » Review your own competence and challenge others where you have concerns

• » All staff involved in catheter care must be educated, trained and competent to manage urinary catheters

Adapted from RCN Catheter Care guidance

In her team, there has been a focus on carrying out TWOCs and training nurses, carers and patients.

‘We train about cleaning the catheters and equipment properly. We care for some poorly patients, who are at high risk of sepsis,’ she says.

‘We emphasise washing with mild soap and water every day, wash where their catheter goes in with a clean cloth, and wipe down four inches of the catheter tube four times, with a clean cloth each time.

“Sometimes patients are afraid to clean the area as they are worried they will pull the catheter out, so this education is important.’

Overall, the message is that reducing the use of catheters and using them only for the shortest time is critical to reducing CAUTIs.

‘Catheters should be a last resort, rather than a first resort,’ Dr Prieto says. ‘We need a zero-tolerance approach.’

Find out more

Variation in the prevalence of urinary catheters: a profile of National Health Service patients in England tinyurl.com/bmj-catheter-study

epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England tinyurl.com/epic3-HCAIs

Catheter-associated Urinary Tract Infections (CAUTI) tinyurl.com/cdc-CAUTI

UTI (catheter): antimicrobial prescribing tinyurl.com/nice-catheter-antimicrobial

Urinary tract infection (catheter-associated): antimicrobial prescribing nice.org.uk/guidance/ng113

Variation in the prevalence of urinary catheters tinyurl.com/BMJ-catheter-prevalence

Are physicians aware which of their patients have indwelling urinary catheters? tinyurl.com/catheter-awareness

HOUDINI – make that catheter disappear tinyurl.com/HOUDINI-catheter