Healthcare-Associated Infections _ ______________________________________________________________
Treatment The presence of bacteriuria (as defined by a positive urine cul- ture) in a patient with a chronic indwelling catheter should be interpreted with caution. Often, this represents poor culture technique or may reflect an asymptomatic infection that need not be treated until the catheter can be removed or unless there is fever, flank pain, or worsening renal function. The IDSA recommends that in the absence of such signs these infections not be treated, as treatment has not been found to be beneficial [32; 156; 157]. However, for symptomatic infection, the results of urine culture and antibiotic sensitivities are an essential guide to effective treatment [32]. For patients with a catheter in place, the catheter should be discontinued, if possible, and the urine specimen should be one that is voided midstream (level III, A) [32]. If the catheter has been in place for more than 2 weeks and continued catheterization is necessary, the catheter should be replaced (level I, A) and the urine specimen should be collected from the newly placed catheter (level II, A) [32]. The IDSA guidelines do not specify which antimicrobial to use for treatment but do recommend duration of treatment. Treatment for 7 days is recommended for patients in whom symptoms resolve promptly, and treatment for 10 to 14 days is recommended for patients in whom symptom response is delayed (level III, A) [32]. The guidelines note that a five-day regimen of levofloxacin may be considered for patients who are not severely ill (level III, B) [32]. Guideline Adherence and Quality Improvement It has been suggested that catheter-associated urinary tract infection is the most preventable HAI [51]. Some studies have noted an increase in adherence to strategies to prevent catheter-associated urinary tract infection [55]. The greatest adherence has been to guidelines for wearing gloves (97%), using appropriate hand hygiene (89%), and maintaining a sterile barrier (81%) [158]. However, adherence to appropri- ate catheterization (in terms of both initial indication and duration) has been suboptimal, with studies demonstrating the following [32; 149; 150; 159; 160]: • No justifiable indication or an inappropriate indication (such as incontinence) for more than 50% of catheterizations • Lack of awareness of catheterization in 25% of physicians • Catheterization for more than two days among 50% of postoperative patients • No system for monitoring which patients had insertion of catheters in 56% of hospitals • No system for monitoring duration of catheterization in 74% • Policy for nurse-initiated discontinuation of catheterization in 10% of hospitals Use of alternatives to catheterization is also low, ranging from 14% to 20% [159; 160].
The use of provider reminder systems—alone or in combination with base strategies—has a moderate strength of evidence [1]. In one study, the combination of prompts in a computerized order-entry system and handheld bladder scanners led to an 81% decrease in the use of catheters and a 73% reduction in HAIs [161]. For hospitals without order-entry systems, a handwritten reminder that the patient has a catheter has been effective in reducing the rate of infection [162]. However, the use of reminder systems has been reported to be 9% to 12% [159; 160]. The use of bundled interventions (e.g., staff education, electronic daily checklist, a nurse-driven removal protocol for indwelling urinary catheters) for reducing the rate of catheter-associated urinary tract infections was examined in a population of critically ill patients 18 years of age and older who were admitted to the ICU of one hospital [163]. The hospital had previously reported 13 catheter-associated urinary tract infections during one year (6 in the ICU), which exceeded the institution’s goal of four or fewer such events annually. Researchers set objectives of a 30% reduction in reported catheter-associated urinary tract infections, a 20% reduction in urinary catheter days, and a 75% compliance rating in catheter-related documentation in the ICU. During the intervention phase, no catheter-associated urinary tract infections were reported, which reduced the rate by 1.33 per 1,000 catheter days. Documentation compliance increased significantly from 50.0% before intervention to 83.3% during intervention. The increase in catheter days (10.5%) was not statistically significant [163]. Despite the lack of adherence to prevention guidelines, some progress has been made in reducing this HAI; the rate of symp- tomatic catheter-associated urinary tract infections decreased from 9.4 cases per 100 catheterizations in 2001 to 5.3 cases in 2010 [164]. Compliance with a nurse-driven evidence-based checklist led to a decrease in infections from 2.88/1,000 catheter days to 1.46/1,000 catheter days [165]. The CDC guidelines note that the following are effective ele- ments of a quality improvement program [23]: • A system of alerts or reminders to identify all patients with urinary catheters and assess the need for continued catheterization • Guidelines and protocols for nurse-directed removal of unnecessary urinary catheters • Education and performance feedback regarding appropriate use, hand hygiene, and catheter care • Guidelines and algorithms for appropriate perioperative catheter management (such as procedure-specific guidelines for catheter placement and postoperative catheter removal and protocols for management of postoperative urinary retention, such as nurse-directed use of intermittent catheterization and use of bladder ultrasound scanners)
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