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Catheter-Associated Urinary Tract Infections (CAUTIs)

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This peer reviewed course is applicable for the following professions:
Advanced Practice Registered Nurse (APRN), Certified Nurse Midwife, Certified Nurse Practitioner, Certified Registered Nurse Practitioner, Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Midwife (MW), Nursing Student, Registered Nurse (RN), Registered Nurse Practitioner
This course will be updated or discontinued on or before Friday, January 9, 2026

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.


≥ 92% of participants will know the main uropathogens in catheter-associated urinary tract infections (CAUTIs) and medical care guidelines for this infection.


Following the completion of this continuing education course, the participant will be able to:

  1. Recall new material about urinary catheters and catheter-associated urinary tract infections (CAUTIs).
  2. Define CAUTI and identify its risk factors in different medical settings.
  3. Identify current evidence-based practices to prevent CAUTIs.
  4. Assess the effectiveness of CAUTI prevention strategy bundles.
  5. Outline the latest research on new technologies and approaches to urinary catheterization and their potential impact on CAUTI rates.
  6. Acquire tools to advocate for policies and practices that support CAUTI prevention and antimicrobial stewardship principles.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

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Catheter-Associated Urinary Tract Infections (CAUTIs)
To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    Celeste Barefield (MSN, APRN, FNP-BC)


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.

graphic showing urinary catheter

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?


photo of urinary tract infection medication

Urinary Tract Infection

Aseptic and sterile technique - Sterile signifies a state devoid of all living microorganisms, whereas aseptic denotes an environment free from contamination by unwanted microorganisms. For example, sterile urinary catheter supply kits (the environment) can become contaminated if not handled aseptically or without contamination (Venes, 2021a; Venes, 2021d).

HAI- healthcare-acquired infections.

Hydrophilic- water-loving.

IAH- intra-abdominal hypertension.

Iatrogenic harm- any non-negligent specific physical or mental harm caused by any provider, device, medication, or procedure in the care of a patient (Venes, 2021b).

Needle aspiration of urine for sterile collection- drawing urine from the bladder directly through the anesthetized skin of the lower abdomen using a 22-gauge needle. The procedure is usually for children and infants but can also be done for adults with a stricture or other urethral obstruction (Peters & Medina-Blasini, 2023).

Negligence- failure to perform duties or activities with due diligence and attention to standards of care (Venes, 2021c).

Polymer coating- a hydrogel application that clings tightly to the polyvinyl surface of the catheter and tubing. The coating absorbs water, increasing lubrication and smoothness. It can also be made with antimicrobial contents such as silver (Cui et al., 2022; Negut et al., 2022).

Standardized infection ratio (SIR) - Number of observed CAUTI incidents divided by the number of predicted CAUTI incidents (Centers for Disease Control and Prevention [CDC], 2015).

Suprapubic-above the pubic bone.

Suprapubic urinary catheter- a urinary catheter inserted just above the pubic bone, through the abdominal wall, and into the bladder (with ultrasound guidance) to drain urine continually out of the bladder (Corder & LaGrange, 2022).

TURP (transurethral resection of the prostate)- may be required when lower urinary tract symptoms do not respond well to treatments for chronic urinary retention, hydronephrosis caused by urinary reflux pressure, benign prostatic hyperplasia, bladder stones, and diverticula (Agrawal & Mishra, 2022).

Uroepithelial- cells that line the urethra and the bladder.

The earliest record in an ancient Egyptian papyrus (the Ebers papyrus) of treatment of urinary retention using transurethral bronze tubes, reeds, straws, and curled-up palm leaves was in 1500 BC (Feneley et al., 2015)

Background Information

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.

Catheter-associated Urinary Tract Infection Care Bundle

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.

Iatrogenic Harm

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)

Pathogens and Antibiotics

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.

“In this systematic review and meta-analysis …with more than 1.7 million patients conducted in different health care and income settings, ASPs were associated with reduced consumption of antibiotics overall as well as of antibiotics in the World Health Organization Watch group" (Ya et al., 2023, p.1).

Case Studies

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.

Case Study #1

Mr. Adams is a 71-year-old male. Mr. Adams is undergoing a voluntary two-level spinal fusion surgery at 8:00 AM. He had not used alcohol or smoked in the last two weeks. His preoperative blood work was all within normal limits, so he's not anemic. He's had a preoperative non-opioid analgesic. He's also had a Foley urinary catheter placed. His surgery went well, without any complications. The length of time under anesthesia was normal, and he did not require an allogeneic blood transfusion. He was able to have his Foley catheter removed and ambulated on the first day after surgery. He did not incur an infection of his wound or his bladder. He went home after two and a half days.

Case Study #2

Miss Jones, a 76-year-old female, went for the same surgery. She followed all the same recommendations that Mr. Adams did and had normal preoperative labs. However, due to mild complications, her operation time was about 43 minutes longer, and her anesthesia time was prolonged by about 45 minutes. She also had an allogenic blood transfusion to balance her blood loss during surgery. She could not ambulate or have her catheter removed on the first day after surgery. These differences increased her total length of hospital stay to about four and a half days. Unfortunately, she was one of the 1.6% of 186 patients operated on during the study who incurred a UTI. Her postoperative symptoms were also greater, with higher reported pain in her back and leg.

Case Study #3

Mr. Stone, a 64-year-old male who is Caucasian, had a closed traumatic brain injury 20 years ago from an event that caused prolonged hypoxia. He has expressive aphasia and full-body flaccid paralysis. He is a 100% total care patient. He gets enteral feedings, medications, and free water through a G-tube. His stools are loose, and his urine output is good. He takes a variety of medications, including a multivitamin, pantoprazole, metoprolol, gabapentin, sertraline, and acetaminophen. He also has a host of as-needed medications for pain, sleep, anxiety, diarrhea, and more. He's been in this condition for many years. He has an indwelling Foley catheter for gravity drainage, which is changed monthly by a home health nurse. His home health nurses are often different from month to month. They work at different skill and professional levels from each other. He has a nurse practitioner that sees him every three months. Over the space of a year, he has had approximately three UTIs. His wife is a nurse's aide and knowledgeable about his home care.

This is a good example of a situation where a caregiver cannot perform an in-and-out catheterization every two to four hours. Mrs. Stone works nearby part-time. She checks on him during her break time and has various family members present in their homes while she is out. When his urine becomes stronger smelling, darker-colored, and cloudy, and he develops a fever, it is assumed he may have another UTI. Studies have shown that the characteristics of color and smell are not a good indicator of infection without a fever in a CAUTI (Gupta et al., 2023). If there are changes like these and a fever, there is a good indication for testing. Often, at this point, his wife will call the home health nurse, and there will be an empirical prescription of antibiotics ordered by the primary provider for the patient. The only way to tell if he has developed another UTI is for the home health nurse to get a specimen from the port of the catheter and take it (on ice) to the lab within two hours. After 24 hours, the lab reports if there is growth. If there is growth, reflexively, a new culture is made with sensitivity to antibiotics tested. After 24-48 hours of growth, the correct antibiotic can be prescribed; this patient is a good representative of the many home health patients using indwelling catheters in similar situations.

What can be done? The family might agree to use a condom catheter for Mr. Stone. Aside from holding all the healthcare providers responsible for better sterile technique, we can speed up the specimen to accurate antibiotic prescription time. A study by Webber et al. (2022) reports that the antibiotic sensitivity reading could be done as soon as six to ten hours after the first urine culture regrowth. This would mean at least 18 hours less for the right antibiotic prescription. If the specimen was turned into the lab early in the morning, the patient could have his medication the next afternoon without the risk of an incorrect empirical prescription. Studies have repeatedly proven incorrect empiric antibiotic prescribing leads to antibiotic resistance (Zilberberg et al., 2022).

If Mr. Stone has another CAUTI, his allergies, and all standard UTI antibiotics will be checked against the uropathogen's sensitivities, and an antibiotic will be ordered for the fewest days possible to reinforce antibiotic stewardship. If this patient develops antimicrobial-resistant CAUTI, he will be hospitalized for IV antibiotics. Home health may be called in to complete the IV antibiotic infusion therapy in his home and reduce his hospital stay.

Statistical Data

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).

These patients all had complicated UTIs; 20 percent are CAUTIs.
UropathogenNon-CAUTI patientsCAUTI  patients
ESBL, extended-spectrum beta-lactamase; MDR, multidrug-resistant; FQR, fluoroquinolone-resistant; CR, carbapenem-resistant. (Adapted from Zilberberg et al. (2022).
“CAUTI pathogens were more often resistant to recommended (commonly prescribed) empirical antibiotics than non-CAUTI pathogens. This finding emphasizes the need for urine sampling for culturing before initiating therapy for CAUTI and the importance of considering therapeutic alternatives” (D’Incau et al., 2023, p.1).

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).

Case Study #4

Mrs. Stanley is 86 years old and has recently been unable to walk. The hospital reports that she may have had a stroke. She also has been having urinary infections. Antibiotics seemed to clear it up, but then, within two weeks after she had finished the antibiotic, she had another UTI. Her bladder was checked after voiding using a handheld portable ultrasound device, and she does have some urinary retention. The nursing home staff does not have the time to catheterize the patient with an in-and-out catheter every two to four hours. Urinary retention is universally known to cause UTIs (Eckert et al., 2020). The patient was given a Foley catheter to prevent urinary retention. Unfortunately, this required her to have a new urinary catheter every 30 days, causing her to have more UTIs. What can be done?

There is now a product that can be used for a non-ambulatory patient like Mrs. Stanley. It is called the external urine drainage device for women's anatomy (EUDWA). It is a slender, curved, banana-shaped device placed outside the urethra within the labia minora and majora. The EUDWA fits from the upper vulva to the anus. It can be worn while sitting or lying down (Beeson et al., 2023; Won et al., 2023). It is attached to gentle suction and wicks away urine as it occurs; this leaves the staff free to ultrasound her bladder twice a day and to use a physical maneuver to drain any remaining urine. If an in-and-out catheter is then required, her relative risk of infection has still been decreased substantially.

The Future of Urine Control Products

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."

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Implicit Bias Statement

CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.


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Additional Resources:

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  • 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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