Catheter-Associated Urinary Tract Infections (CAUTIs)

Frederick Foley was a doctor who invented the Foley urinary balloon catheter in 1935 (Feneley et al., 2015). With today's bioengineering, the materials have changed, but the basic design has not. The humble urinary catheter has endured to this day and is an important medical technology despite its associated problems. The urinary catheter is a simple concept of a device. A long, firm, but flexible tube is slid into the patient's urethra and into the bladder, where the body continuously creates urine. A balloon or cuff is inflated with five to 30 milliliters of normal saline to keep it from falling out. The inflation also has the benefit of plugging the bladder exit, preventing leakage around the catheter tube. Then, the tubing is connected to a gravity drainage collection device.

Urinary Catheter

As you know, there are many variations of the urinary catheter now. We have intermittent, antibacterial, noble metal, and indwelling catheters of many material descriptions. Some are coated with hydrophilic polymers that cause water-based lubricants to adhere to the sides. Others are made of ultra-smooth materials that glide easily past the uroepithelial cells of the urethra. Some have two urine drain holes in the tip, and some have more. There are different shaped tips and sizes of balloons and tubing. The permutations are nearly endless. However, one downside of this great invention is the development of a catheter-associated urinary tract infection or CAUTI.

Many companies make urinary catheters now. Hospitals and facilities have favorites for their patients and budgets. Safety, cost, and efficiency drive the more than 30 million catheters sold annually in the United States. If only 20 % of those catheters are involved in urinary tract infections (UTIs), that comes to six million CAUTIs annually! In the United States, up to 80% of complicated urinary tract infections are due to indwelling urinary catheters (Ellahi et al., 2021).

The prevailing thoughts are, "Perhaps if medical personnel knew more about the catheters and the mechanisms for infection, that number could be reduced." Another thought about this might be, "If only we could hold all healthcare providers accountable for sterility during insertion of the urinary catheter, the number of CAUTIs would be reduced." Most hospitals and other medically-themed facilities have put policies and procedures in place that should, in theory, at least, make a CAUTI very unlikely. CAUTI bundles are comprehensive programs based on evidence-based interventions designed to teach healthcare providers to insert and manage urinary catheters without incurring any patient urinary infections (Gupta et al., 2023; Whittiker et al., 2023).

Sterile procedures such as inserting and changing a urinary catheter are taught, practiced, and evaluated annually in nursing schools. What are we missing? What are the mechanisms of this misfortune? Is it the product, the environment, the practitioner, or the patient's body causing this seemingly impossible outcome? What will be the future of CAUTIs? Let's look at this like scientists trying to solve the puzzle. How can we "Do no harm"? Can we change what, when, where, and how? Which patients need catheters, and for how long? Which patients can we avoid adding this extra risk factor to their care? What else can we learn about this subject we have already trained on so well?

The Foley balloon catheter is used during and after surgeries to keep the patient from urinating on the sterile surgical field and ensure that all the fluids pumped into the patient return afterward. The catheter relieves bladder over-extension until anesthesia wears off and the patient's bladder begins operating normally. In the case of severe burns where intra-abdominal hypertension is a major complication, urinary catheters are required to monitor intra-abdominal pressure and prevent urinary retention (Brockway et al., 2022).

There are surgeries such as the TURP, where the two-way or three-way urinary catheter is integral in keeping the bladder clear following the surgery. Immediately after a TURP, continuous normal saline is flushed through the bladder and returned to clear the blood clots and allow healing (Agrawal & Mishra, 2022). Other urological procedures also require the support of the urinary catheter. To keep the sterile fields sterile and the medical providers dry, urinary catheters are used for many surgeries that require general anesthesia for more than three or four hours (Meddings et al., 2019). Depending on the patient's condition, catheters are often placed when surgeries take longer than an hour.

In many situations, intermittent and indwelling urinary catheters are used outside the surgical suite. The intermittent catheter is usually a smooth, firmer catheter inserted into the bladder through the urethra and removed after emptying. These catheters can be found in disposable closed or open systems. The less expensive version is sometimes washed with soap and water, stored, and reused. An in-and-out catheter is preferred in the home environment when an external alternative is impossible. The patient who has lost neurologic control of the bladder, perhaps congenitally, from a stroke or coma, spinal injury, or surgical means may need to either be catheterized regularly or have an indwelling catheter.

We see indwelling catheters in hospitals, nursing homes, and private residences. Terminally ill patients at home and in facilities may be catheterized for their comfort and skin integrity. Suppose the patient is unable to self-catheterize, and the caregiver is unable to do this. In that case, an indwelling catheter is required to prevent complications such as urinary retention and skin breakdown. Indwelling catheters are currently changed monthly in these situations. However, 30 days is a long time for a closed system to operate without any secondary biological activity.

Another important use for the urinary catheter is to insert medications directly into the bladder; this is called intravesical drug delivery and is used in several different urological diseases, such as urinary cancer and interstitial cystitis (Jhang et al., 2022; Shawky et al., 2022).

Suprapubic catheters are basic urinary balloon catheters inserted into a direct opening to the bladder through the lower abdomen. These are used as indwelling catheters and must be changed periodically. With this application, there is a similar rate of CAUTI and relatively more complications possible (Quallich et al., 2023). Also, there are nephrostomy tubes; according to Kar et al. (2022), the infection rate for these is about 53%, with 41% of those hospital-acquired infections.

During studies where specific bundles of policies and procedures were implemented with strict adherence to evidence-based practices, CAUTIs were prevented 100% of the time, assuming there were accurate reporting measures from the medical units in the studies (Brockway et al., 2022; Gupta et al., 2023; Whitaker et al., 2023). Guidelines for meticulous patient selection criteria for urinary catheter placement, stringent sterile insertion technique, system maintenance, and carefully limited dwell times constitute CAUTI bundles. CAUTI bundles include administrative management sections such as documentation, orders, quality control, and laboratory testing rules.

According to Gupta et al. (2023), while HAIs occur at the rate of 40%, CAUTIs were 23% of those. It is estimated that CAUTI costs between $1,200.00 and $4,700.00 per event. An estimated cost of CAUTIs could be at least 1.2 billion dollars or more per year; the cost is enormous (Gupta et al., 2023). The hospital and all the costs of running a hospital, right down to healthcare providers changing these urinary catheters, are part of the overall cost of CAUTIs. The cost to the patients is exorbitant when you realize that some patients have serious complications related to CAUTIs, from sepsis to death.

During the three years starting at the beginning of the coronavirus disease 2019 (COVID-19) pandemic, a nurse-led, multidisciplinary, quality improvement initiative for CAUTI prevention was implemented at a hospital in Parma, Ohio. Aside from teaching staff, patients, and families the benefits of not using an indwelling urinary catheter, the plan was simple. First, a checklist was made to insert the indwelling urinary catheter. Secondly, going by the checklist, employ the skills and knowledge of two registered nurses to maintain sterility and aseptic accountability during the insertion of the indwelling urinary catheter. Then, take the indwelling urinary catheter out as soon as medically indicated, as evidenced by failure to meet certain criteria. Daily nursing huddles were performed for every patient with an indwelling urinary catheter. In these meetings, strict criteria for continuing the indwelling urinary catheters were reviewed. If none of the criteria are met, the indwelling urinary catheter is removed. The criteria for continuation included the following (Whitaker et al., 2023):

• Provide patient relief from outlet obstruction of the urinary tract
• Provide daily fluid intake and output for patients who are critically ill or
• if in urological surgeries or near urologic organ areas with higher volumes of fluid infused where the indwelling urinary catheter would be expected to be needed for a prolonged time
• After surgery for up to only 24 hours (preferably)
• If incontinent patients had open wounds in the peri-areas
• If patients were completely immobile by requirement and expected to need the indwelling urinary catheter for prolonged periods
• If in comfort care (terminal patients)  

Whitaker et al. (2023) showed that the number of CAUTIs decreased from an SIR of 0.37 to an SIR of 0.00 in three years, as monitored by the National Healthcare Safety Network (NHSN).

Studies have proven certain things do work when it comes to preventing CAUTIs. The first thing in the hospital bundle is to train everyone on sterile placement and management of the urinary catheters. When a patient needs a catheter and when to remove it are critically important criteria covered in the bundles.

What more can we learn? The number of places to break sterile fields is surprising. We cannot let any portion of our clothing or equipment touch the sterile field. Then, you cannot let any part of the female labia touch the catheter before the tip of the catheter enters the urethra and, finally, moments later, the bladder. Plus, we do not want to hurt the patient because we are in a hurry and focusing on not injecting germs straight into the bladder. It is recommended that we have two people place a urinary catheter. Assuming the staff is available for that, and both are permitted to perform sterile procedures, that's a great idea. One staff member could clean the patient's urethra and hold or open the area. The other maintains sterility during the actual placement without wishing they had two more (sterile) fingers per hand. Then, finally, someone should feel empowered to say "STOP!" if that sterile procedure is suddenly no longer sterile. With the right approach, the sterile technique can be an art.

For more on placing a urinary catheter, click HERE for a complete CDC booklet.

One study by Hendren et al. (2023) showed that out of 200 surgical patients, 129 received a urinary catheter at the time of surgery. Of those, 6% suffered urinary trauma. Urinary trauma was listed as hypospadias (the creation of a new urinary exit), internal tears, and external tears. Another 12% had urinary retention following removal. While this is a small study limited to surgical patients, if 30 million indwelling urinary catheters are sold in the United States yearly, you can extrapolate that at least 1.8 million cases of urinary trauma may occur in the United States alone. There are more noninfectious indwelling catheter-related, iatrogenic damages than infectious ones (Saint et al., 2018).

Whatever type of catheter is used, healthcare providers are trained to avoid producing physical stresses and injuries to the urethra and bladder. Unfortunately, the insertion is invisible, so a nurse cannot see what is happening inside. The patients normally complain about discomfort during insertion, and any mechanical stress to the inner tissues will likely begin the inflammation cascade in the urothelial cells. The inflammation cascade is where the bacterial activity occurs first due to the increased compression of the tissues to the sides of the catheter. After all, the catheter remains in place, traumatizing the urethra and bladder; this is why there is a strict two-day limit on how long the catheter can stay inside that injured urethra. Even if the urethra is not damaged and a target of bacterial colonization, any lapse of sterility and direct insertion of viable bacteria will come into play in two days. People are breathing out germs, and air movement is carrying who knows what to your working areas, and honestly, inconsistent sterile techniques are used. Healthcare providers are only human, and we know germs are everywhere.

Patients are only human. The simple presence of a foreign body is traumatizing to the urothelial tissues, along with the extra damage caused by the patient's movements and accidental pulling in attempts to adjust the catheter tubing to make it more comfortable. Patients cannot help touching, moving, or pulling at the tubing. Plus, after it is in the bladder and protruding from the urethra, no one can keep the meatus of the urethra sterile and completely undamaged. It seems counterintuitive that we need to put a sterile catheter in and pull it back out in two days to see if the patient can do without it. If they cannot do without it, we start over again. Maybe one of the external catheters will work in this situation. Whether or not a urine sample is tested depends on which "bundle" your team is using. We do know that if symptoms begin to appear after the removal, we will term the infection a CAUTI, especially if certain red flags start after two days of insertion.

CAUTI red flags, according to the Infectious Disease Society of America (IDSA), are:

• If the urinary catheter is in place for more than 48 hours and any of the following occur:
  • Fever
  • Suprapubic tenderness
  • Costovertebral angle tenderness
  • Urgency
  • Dysuria
  • A concurrent urine culture positive for one uropathogen with >105 colony-forming units or CFUs per milliliter or mL (Musco et al., 2022)

Most CAUTIs are from Escherichia coli (E. coli). Due to antimicrobial resistance in and out of the hospital, we have patients who have extremely complex infections. These patients may require multiple courses of intravenous (IV) antibiotics to cure. Carbapenems and fluoroquinolones are not useful for gram-negative organisms. The rare gram-positive organisms, Staphylococcus saprophyticus (S. saprophyticus), Enterococcus faecalis (E. faecalis), Streptococcus agalactiae (S. agalactiae), Streptococcus pyogenes (S. pyogenes), Staphylococcus aureus (S. aureus), and Bacillus subtilis (B. subtilis), which are also resistant to many antibiotics, and are treated differently per the uropathogenic's cultured susceptibility (Hassan et al. 2023). We have studies proving that antimicrobial stewardship plans (ASPs) are successful. Most hospitals have ASPs in place.

The first two case studies are based on a study by Cui et al. (2022). The study was intended to show that an increased length of stay was precipitated by risk factors noted in these case histories.

The 2022 study by Zilberberg et al. showed that about 20% of all the complicated UTI patients entering the emergency department were CAUTI patients. The picture of those patients was like our Mr. Stone- a Caucasian (71%) male (63%) aged 62-83 (48%). The guilty uropathogens were extended-spectrum beta-lactamase (ESBL) at a rate of over two and a half percent, the multidrug-resistant cases were right at two and a half percent, and one percent of the uropathogens were resistant to carbapenem and fluoroquinolones. Of these CAUTI patients, 17.8% went on to develop sepsis, and 3.4% of those patients died. Overall, 22% were routinely discharged home, 48% were transferred to some follow-up skilled nursing facility, and about 27% went home with home health to continue IV antibiotics and other medical care. These 7,735 CAUTIs to Medicare cost approximately $8,660.00 each or approximately 67 million dollars. If this number were generalized to 3.4% of all UTIs that are hospitalized, the cost would be exorbitant (Zilberberg et al., 2022).

In a Swiss study by D'Incau et al. (2023), the five most common uropathogens in the CAUTIs were E. coli, Klebsiella pneumoniae (K. pneumoniae), Pseudomonas aeruginosa (P. aeruginosa), Proteus mirabilis (P. mirabilis), and E. faecalis were the highest in number, with E. coli higher than K. pneumoniae and P. aeruginosa combined. There were no differences between hospital-acquired and community-acquired infections. All oral medications were proven not useful except for nitrofurantoin and fosfomycin. Fortunately, these antibiotics are less associated with iatrogenic harm. CAUTIs are considered "complicated" all the time, whether in the kidneys or the bladder, so fosfomycin can be used to lower CAUTIs. It is not useful for upper CAUTIs because it cannot get into the parenchymal cells of the kidneys (CDC, 2015).

Are the reasons we are putting the patient at risk of permanent damage to the urinary tract, infection, and even death from sepsis worth it? Has the medical profession gotten less careful, or is the paradigm of doing more with less staff the real culprit? Healthcare providers must make placing the urinary catheter of importance with extreme caution.

One answer is the invention of a faster, safer way to control urine. There are newly developed products like the EUDWA. These have decreased urinary infections in women (Beeson et al., 2023). External drainage devices for men's anatomy were already developed. In the condom catheter or "bagging" methods, do the infections decrease substantially? No, infections are still half as likely with these methods due to the static-enclosed urine collection in the skin of the area. Skin is easily damaged by the pH change following urease-producing organisms such as the S. aureus metabolism. Skin is acidic, and the alkaline changes cause skin breakdown (Kohta et al., 2023). No sterile urine specimen is possible with these. A sterile specimen is rarely possible, regardless of the method. However, a sample obtained by aspirating urine with a needle directly through the aseptically sterilized skin from the bladder is the most sterile method (Peters & Medina-Blasini, 2023).

In an interesting research piece by Dai et al. (2023), they say that polymer coatings are designed to kill or repel uropathogens almost completely. These thin coatings, which form a biofilm, can stop the bacteriostatic activity and prevent CAUTIs (Dai et al., 2023). Unfortunately, these are not the perfect answer…yet. Someday, soon, they will be more effective and inexpensive enough to use all the time. As of now, scientists are still working on it.

Could intravesical drug delivery prevent UTIs (Shawky et al., 2022; Werneburg et al., 2022)? According to a study by Werneburg et al. (2022), gentamicin can be given with intravesical drug delivery to prevent CAUTIs and reduce other prevention measures. The tough urothelial interior of the bladder reduces side effects by limiting systemic absorption (Ong et al., 2022). There have been trials of non-pharmacologic installations that have been at least partly successful. Intravesical installation of various nanoparticles has also been studied for this use (Ong et al., 2022; Shawky et al., 2022).

"Although data is limited, both antibiotic and non-antibiotic intravesical instillations show promise in mitigating the impact of recurrent UTIs both on patients and on antibiotic resistance" (Marantidis & Sussman, 2023).

Nurses are known for being the best patient advocates. They are in the trenches and can see firsthand the problems and what can be done to change them. Remember that distinguished healthcare providers learn as much as they can (nursing school and college), provide the best methods (research and evidence-based interventions), and teach them to others (stewardship and advocacy). This can begin on the unit or in your practice setting by:

1. Learning more about your practice's needs.
2. Sharing your knowledge, insights, and skills.
3. Becoming the one who is the subject matter expert on the job.
4. Helping others to see the patients' vulnerabilities in urinary catheterization.
5. Making sterile technique an art.

In advocating for the use of newer, safer, more efficient products for the benefit of our patients, a nurse's voice working alone has very little power. At the unit level, membership in a committee is the way to nudge the "Powers that be" towards better patient outcomes. Quality control and outcome improvement committees are the quickest way to get involved with day-to-day decisions in search of the best products and activities to decrease specific problems in patient care. However, a nurse who advocates through a larger group of nurses with similar views and far-reaching reputations may be able to swing entire states in their direction. The nursing associations in the United States and other countries also work to change minds, practices, and laws in their areas of expertise. Every nurse can belong to one of these associations and contribute as much (or as little) time, money, or know-how as they wish. Changes can become the law of the land. Regrettably, it is not magically fast or "Once, and you're done." These changes take determination and patience to bring about.

CAUTIs are often a puzzle. On the one hand, we have a genius-level medical tool in the urinary balloon catheter; on the other hand, we have infections and antimicrobial resistance. The benefits often outweigh the risks. We cannot give up the dry, sterile surgical field or the mechanical cure for neurogenic urinary retention. We also must be able to directly instill drugs and other molecules into the urinary tract where they are more effective with fewer side effects. Research is ongoing. If we healthcare providers learn, adapt, teach, and perform at our best, the risk of infection drops to near zero. Many CAUTI bundles are based on the IDSA and CDC guidelines, but all are as good as the professionals and the processes. Nursing education cannot stop at schools. Those who know, whether new or experienced, need to learn, teach, and push for what is needed for the best patient outcomes. Teams need to participate in attaining increasingly better results with our use of urinary catheters. Evidence-based practice is available in the form of CAUTI bundles. Nursing leaders can use these to improve costs, complications, and lives. CAUTI bundles are well thought out and intentionally easy to follow. Who can make these things urgent, critical, and imperative? The "go-to healthcare providers" are the ones who must lead the rest of the healthcare providers into the future of zero CAUTIs, zero iatrogenic harm, and zero antimicrobial resistance. We must advocate for better outcomes and lead the action to prevent the harm. It has become more than "Do no harm." It is now, "Allow no harm."

The CDC's National Healthcare Safety Network is a healthcare-associated infection tracking system and provides data to identify problem areas and measure the progress of prevention efforts.

• Tools for understanding and reporting CAUTIs 

Tools for advocacy:

• American Nurses' Association + State Nurses' Associations
• Hispanic Nurses' Association
• Canadian Nurses' Association
• Society of Urology Nursing and Associates
• Association of periOperative Registered Nurses
• Association for Home Care and Hospice

Tools for educating staff and patients about antimicrobial stewardship:

• Patient education fact sheet Antibiotic Stewardship JC
• Association Between Antimicrobial Stewardship Programs and Antibiotic Use Globally
• Using e-learning to increase Nurses' Knowledge of Antimicrobial Stewardship

Tools for re-educating nurses in CAUTI prevention:

• A Hands-on Approach to Catheter-Associated Urinary Tract Infections
• Bundle Up to Control CAUTI

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Additional Resources:

• Anderson, J., & Dearmon, V. (2023). Bundle Up to Improve CAUTI. University of South Alabama. Visit Source.
• Bell, N., & Yates, J. (2022). A hands on approach to catheter associated urinary tract infections. Advocate Aurora Health Institutional Repository. Visit Source.
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• Centers for Disease Control and Prevention (CDC). (n.d.). Catheter-associated Urinary Tract Infection (CAUTI). Visit Source.
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