Disclaimer: This post is for academic purposes only. Please read the original document if you intend to use them for clinical purposes.
This document summarizes key information from the Association for Professionals in Infection Control and Epidemiology (APIC) guide to prevent Catheter-Associated Urinary Tract Infections (CAUTI) published in March 2025. It aims to provide information and tools for reducing CAUTI risk across various healthcare settings by condensing evidence-based guidelines and recommending achievable strategies for performance improvement. It highlights the significant impact of CAUTIs on patient safety, healthcare costs, and mortality, and emphasizes the importance of a multidisciplinary approach to prevention. The guide outlines core components of a CAUTI prevention program, essential and additional best practices, methods for measuring program effectiveness, and setting-based case studies with associated tools.
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1. Introduction and Background:
The guide’s purpose is to provide information and tools to reduce the risk of infection due to indwelling urinary catheters in various practice settings. It aims to translate evidence-based guidelines into actionable elements for mitigating risks and improving performance.
- Significance of CAUTI: The guide underscores the persistent threat of CAUTIs despite recent declines. In 2023, a total of 21,525 CAUTIs were reported through the National Healthcare Safety Network (NHSN), USA. While acute care hospitals saw an 11% decrease from 2022, CAUTI remains a significant patient safety concern.
- Consequences of CAUTI: CAUTIs are associated with increased length of stay, patient discomfort, excess healthcare costs (estimated at $13,793 per CAUTI in 2017), and increased risk of death (estimated at 36 excess deaths per 1,000 CAUTIs in 2017).
- Risk Factors and Reduction Strategies: Key risk factors include catheter duration, female anatomy, age-related changes, and certain medical conditions. Effective reduction strategies include:
- Not inserting an IUC unless strict criteria are met (e.g., neurogenic bladder, obstructive uropathy)
- Using external urinary catheters when appropriate for the patient
- Limiting the duration of the IUC by using facility-specific removal criteria
- Following aseptic techniques for insertion and maintenance of IUC
2. Core Components of a CAUTI Prevention Program:
The guide emphasizes that a CAUTI prevention program should be tailored to the facility’s unique needs and patient population, built upon a multidisciplinary team and a thorough risk assessment:
- Infrastructure: The program needs to identify key stakeholders and conduct a risk assessment to determine specific risks and appropriate interventions.
- Key Stakeholders: An effective program necessitates a multidisciplinary team with identified leads and clear roles. Essential roles include:
- Infection Prevention (primary)
- Nursing (primary)
- Physician (primary)
- Clinical Education (participant)
- Patient Care Technicians/Certified Nursing Assistants (participant)
- Laboratory (participant)
- Information Technology (participant)
- Environmental Services (participant)
- Supply Chain (participant)
- Clinical and/or Operational Leadership (executive sponsorship)
- Risk Assessment: A systematic process to identify and evaluate potential risks. Considerations include:
- Current and historical CAUTI rates and Standardized Infection Ratios (SIRs)
- Current and historical Indwelling Urinary Catheter (IUC) Standardized Utilization Ratios (SURs)
- Root/apparent cause analyses of previous CAUTIs
- Compliance with existing prevention program process measures
- Risks specific to the patient population
- Availability of key resources and supplies
- Organizational culture and leadership support
- Equipment and Supplies: Facilities must ensure availability, organization, and staff training on appropriate supplies, including:
- IUCs of various sizes, materials (considering antimicrobial coatings), and specialty types.
- Insertion kits that align with facility protocols.
- Appropriate securement devices.
- Patient hygiene products for bathing and perineal care.
- Alternatives to IUCs, such as external catheters, straight catheters, and incontinence management supplies.
- Training and Education: Vital for all relevant staff, including initial and annual training with updates. A multidisciplinary team should oversee the process, covering role-specific topics such as:
- Appropriate indications for catheter insertion and alternatives.
- Aseptic insertion techniques and securement.
- Daily assessment of catheter necessity and nurse-driven removal protocols (if used).
- Diagnostic stewardship for urine culture ordering.
- Proper urine culture collection and storage.
- Catheter maintenance and patient hygiene practices.
- Policies and Procedures: Essential for communicating expectations. Policies should be based on Evidence Based Guidelines (EBG)s and avoid referencing elements that change frequently (e.g., brand names). Procedures provide detailed instructions. Key topics for CAUTI policies and procedures include:
- Patient assessment for alternatives to IUC.
- Appropriate indications for IUC use.
- Frequency of review of catheter necessity.
- Ordering and documentation of IUC insertion.
- Aseptic insertion and maintenance practices.
- Patient hygiene and catheter care.
- Monitoring and surveillance practices.
- Specimen collection and storage.
- Education and training.
- Catheter removal practices.
- Responsibilities for CAUTI prevention.
- Information Technology: Can enhance accuracy, efficiency, and reliability through:
- Electronic Medical Record (EMR): Decision support for clinicians, prompts for high-risk scenarios (e.g., overdue pericare), and monitoring compliance with documentation. Example: Modifying urinalysis and culture order workflows within the EMR to encourage use of the most appropriate laboratory test for patients with an IUC
- Infection Prevention Surveillance Software: Improves data management and efficiency.
- Dashboards and Reporting Software: Communicates key outcome and process metrics to stakeholders.
3. Best Practices for Prevention:
The guide categorizes best practices into essential and additional practices.
- Essential practices: Widely considered fundamental for CAUTI prevention, focusing on Insertion and Maintenance.
- Insertion elements:
- Use IUCs only when necessary and appropriately indicated
- Consider lower-risk alternatives like external catheters or intermittent catheterization.
- Use appropriate insertion practices (hand hygiene, aseptic/sterile technique, sterile supplies)
- Secure IUC after insertion
- Maintenance elements:
- Maintain a sterile, continuously closed drainage system
- Consider replacing the catheter and collection system if breaks in aseptic technique, disconnection, or leakage occur
- Use proper technique for urine culture collection, transport, and storage
- Ensure urine flow remains unobstructed
- Perform routine patient hygiene using proper technique
- Remove the IUC as soon as indications for continued use are no longer met
- Insertion elements:
- Additional practices: Considered in settings with persistently high CAUTI rates despite implementing essential practices. These often target specific patient populations or practices with limited evidence. Implementation requires careful review and discussion with stakeholders. Examples include:
- Bladder scanning algorithms for postoperative urinary retention
- Monitoring catheter use and adverse events beyond CAUTI (e.g., obstruction, unintended removal)
- Non-catheter-associated urinary tract infection surveillance related to IUC alternatives
- Nurse-driven IUC removal protocols
- Replacing IUC prior to collecting urine culture specimens to reduce false positives
- “Foley Free” emergency department initiatives to limit IUC insertion
- Chlorhexidine gluconate (CHG) use on urinary catheter tubing
4. Measuring a CAUTI Prevention Program:
The guide emphasizes the importance of measuring both outcome and process metrics to assess the effectiveness of a CAUTI prevention program
- Outcome Metrics: Reflect the impact on patient health status. Common metrics include:
- CAUTI Rate
- CAUTI Standardized Infection Ratio (SIR)
- Indwelling Urinary Catheter (IUC) Standardized Utilization Ratio (SUR)
- Cumulative Attributable Difference (CAD)
- Targeted Assessments for Prevention (TAP) Reports
- Process Metrics: Measure compliance with essential prevention practices. Five methods of process measurement are described:
- 1) Direct observation of practice
- 2) Point prevalence rounding
- 3) Automated data extraction from the EMR
- 4) Manual chart review
- 5) Surveys
- Examples of Process Metrics Linked to Essential Practices: The guide provides detailed examples of process metrics for each essential practice, including the definition, when to consider using the metric, and data collection methods (primarily automated EMR data, direct observation, and point prevalence rounding). Examples include:
- Compliance with documentation of indication at insertion
- External device compliance
- Insertion bundle element frequency
- Compliance with appropriate securement
- Frequency of drainage bag below the bladder
- Compliance with documenting patient bathing
- Compliance with documenting indication daily
- Average IUC dwell time by catheter type
- Epidemiologic Questions to Investigate: A comprehensive chart review of CAUTI cases is recommended to identify trends and effective interventions. The guide provides a list of epidemiologic questions related to patient characteristics, insertion practices, maintenance practices, hygiene, and urine culture ordering.
5. Associated Tools:
The guide includes sample tools that can be adapted:
- Acute Urinary Retention (AUR) Pathway (Adult): An algorithm for managing adult patients with urinary retention, focusing on assessing voiding, post-void residual (PVR), and the use of intermittent catheterization.
- Alternatives to Indwelling Urinary Catheter Algorithm – Insertion and Ongoing Assessment (Adult): An algorithm to guide the decision-making process for IUC insertion by validating clinical indications and considering alternatives. It also outlines ongoing assessment for continued necessity and removal protocols.
Conclusion:
The APIC guide to prevent CAUTI offers a comprehensive and practical framework for healthcare facilities to reduce the incidence of these significant healthcare-associated infections. By emphasizing a multidisciplinary approach, evidence-based practices, robust measurement, and the use of practical tools, the guide aims to empower IPs and other healthcare professionals to enhance patient safety and improve outcomes related to indwelling urinary catheter use.
Citation: “Guide to preventing Catheter-Associated Urinary Tract Infections” APIC – Association for Professionals in Infection Control and Epidemiology. 2025
