In our practice at Penn Urology, in women with recurrent UTIs, we prescribe Hiprex (methenamine) 1000mg twice a day with Vitamin C 1000mg twice a day as a “prophylaxis.”   Methenamine salts act via the production of formaldehyde from hexamine, which in turn acts as a bacteriostatic agent.  The may prevent UTIs by urine acidification as the direct bacteriostatic effect of hippuric acid contribute significantly to its action.   A Cochrane review (2007) noted that “methenamine salts are well tolerated and adverse effects, including minor gastrointestinal upsets, dysuria, abdominal cramps, anorexia, rash and stomatitis, are generally mild.”  

Lee BB, Simpson JM, Craig JC, Bhuta T.  Methenamine hippurate for preventing urinary tract infections. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD003265.

I was recently asked if there is a better time of day to remove an indwelling urinary catheter.  I searched the literature and found a Cochrane reviewed that looked at the best strategies for removal of catheters. They found that when comparing late night versus early morning removal, removal at midnight resulted in a longer time to first void and patients passing significantly larger volumes. Also, patients with catheters removed at midnight were discharged from the hospital significantly earlier than those with morning removal.  So, when removing a catheter, do it at bedtime.


Griffiths R, Fernandez R. Strategies for the removal of short-term indwelling urethral catheters in adults. Cochrane Database Syst Rev. 2007 Apr 18;(2):CD004011.

The Center for Disease Control and Prevention (CDC) estimates that 1 of every 10 to 20 patients hospitalized in the United States develops a healthcare-associated infection (HAI). Urinary tract infection (UTI), a type of HAI, accounts for approximately 32% of infections reported by acute care hospitals and approximately 18% to 25% of all nosocomial bacteremia. The majority of hospital-associated UTIs are caused by instrumentation of the urinary tract, mainly from an indwelling urinary catheter (IUC). Catheter-associated urinary tract infections (CAUTIs) can result in increased morbidity, mortality, hospital cost, and length of stay.
Hospital staffs, particularly nursing staffs, are developing clinical pathways for removal of IUCs and for bladder monitoring, to ensure patient safety and evidence-based practice (EBP) at a lower cost. This website was created in part to create a single place for accessibility of the evidence, perspectives on implementing CAUTI prevention strategies and tools that can be shared to assist all of us in achieving sustainable prevention goals.
We have heard from many readers who are actively engaged in implementing CAUTI prevention programs for their hospitals.  They have raised opportunities to update the algorithm which is truly a living pathway.  The latest algorithm is located: http://www.cautichallenge.com/images/stories/site_images/foley3132012.jpg

This living algorithm is a tool for all of us and will continue to evolve as you provide your feedback.  Thank you for your participation in this Challenge! 

I have noticed that recently there has been a significant increase in publications on the prevention of CAUTI.  This is encouraging as we many of us are working to implement programs in our hospitals towards reducing and preventing catheter-associated UTI's.  I am now providing our readers of this site with brief commentaries on a selection of the publications.  In this updated CAUTI CHALLENGE resource you can easily locate the abstracts of the articles from throughout multiple journals in the Publications area of this site. 

I wanted to share the most recent posting with you as it highlights an electronic tool that was developed for validation at a 413-bed university-affiliated urban teaching hospital in Seattle Washington.  Choudhuri and colleagues developed an electronic surveillance tool for CAUTI and urinary catheter utilization based on the objective components of the National Healthcare Safety Network (NHSN) definitions including fever, urinalysis, and urine culture. Results were compared to manual chart review by an infection preventionist (IP).  The tool provided objective criteria to determine UTI surveillance. The tool captured urinary catheter days by unit and service. They were also able to document discrete start and stop times for the device, resulting in improved detection.
The results reported indicate that the tool was successful as it helped increase surveillance and reporting demands, so they could focus more on implementing best practice preventing efforts at the bedside.  This seems to also provide a necessary component to the electronic health record.  Are others of you using this or another similar tool to automate surveillance?  I look forward to hearing from you on this novel approach or on other methods you are using. 

Welcome to the Newly Updated CAUTI Challenge website.   We have listened to our users comments and many have been integrated to the elements of this new site to improve navigation, search functionality, as well as an improved blog and area for sharing best practices.  

We have also recently updated the paper Indwelling Urinary Catheters in Acute Care: A step-by-Step Clinical Pathway for Nurses to provide the most current evidence-based clinical information on managing Foley catheters. The article notes that the Joint Commission has made CAUTIs a 2012 National Patient Safety Goal. The CDC has noted that the total expense of these infections is $450,000,000 per year.   The article emphasizes quality improvement initiatives and provides suggestions for implementation. Minimizing catheterization and insuring early Foley catheter removal are key components of such a program. The literature supporting the use of bladder scanning technology to avoid unnecessary catheterizations has also grown.

We look forward to your comments and engagement in the onging challenge of preventing CAUTI. 

I have been in discussions with CAUTI Challenge users
Another area of gray for me surrounds removal of a urinary catheter / re-insertion of a new catheter before a urine culture is obtained. As you know, APIC guidelines state cultures from "recently inserted" catheters yield reliable results...suggest changing out urinary catheters, but does not give guidance as to a time frame. You mention in your pp that catheters should be changed if in longer than 10 days. Univ of CO Denver requires a urinary catheter be changed before culture if it has been in > 72 hrs.

I appreciate your guidance and expertise in helping me develop an accurate Computer Based Training (CBT) module for Memorial Health System's staff.
I am glad you have found the information on the CAUTI center on UroToday helpful.  It gets lots of traffic and many inquiries, similar to yours.

There is no information or evidence-based recommendations on when a catheter should be removed/changed in a hospital patient.  If a urinary tract infection is suspected and a urine C&S is to be obtained, it is strongly suggested that a new catheter and collection system be placed and the urine C&S obtained from the new system.  But the evidence on this is very little.  Look at this one reference:

Raz, R. (2000). Chronic indwelling catheter replacement before antimicrobial therapy for symptomatic urinary tract infection, Urol. 164:1254-58.

If it’s not possible or may cause the patient harm or burden to change the system then it is recommended that staff obtain the urine sample from the established system by clamping tubing distal to the collection port for short time to allow urine to accumulate, disinfect port with alcohol or chloroprep and allow to dry and use sampling port to draw samples.

As most experts believe that the course of treatment will be improved if the catheter and collection system is changed prior to or along with starting antibiotics, we will always change the system before starting antibiotics on a pt who has a CAUTI.

I hope this is helpful.

Diane

Since 2008, the Centers for Medicare & Medicaid Services (CMS) has held acute-care hospitals accountable for failing to avert preventable harms resulting from medical care. CMS is denying additional payments to hospitals for preventable hospital-acquired conditions, such as a CAUTI. Monitoring these infections has become both a federal and state function. In 2007, Pennsylvania became the first state to require hospitals and nursing homes to report facility-acquired infections to the CDC.

Methods to decrease IUC use and prevent hospital-acquired CAUTIs have been identified and they include: instituting hospital-wide administrative interventions, implementing quality improvement programs, educating physician and nursing staff on indications and evidence-based nursing care of an indwelling urinary catheter to prevent infection.

Some acute care hospitals have been successful in implementing facility-wide programs to decrease CAUTI. One successful program has been reported by Wenger and colleagues (2010) who describe an initiative implemented in 2006, at Lancaster General Hospital, a 550-bed Magnet hospital in Lancaster, Pennsylvania. They decided to start an initiative to decrease CAUTIs when they determined that the CAUTI rate in their critical care units was at the upper range (7.9 per 1,000 device or catheter days) of the national mean (3.1 to 7.5 per 1,000 device days). They knew that what was needed was a multifaceted approach and thus, instituted a three-pronged initiative—beginning with education, progressing to tests of new and better products, and ending with a nurse-driven protocol for catheter removal. This hospital used the Plan-Do-Study-Act model in which change is first proposed, and then it is tested and assessed before implanted. After implementation, the model requires ongoing monitoring.

A key element of the initiative was education, particularly education of bedside nurses on practices that contribute to CAUTIs (e.g. urine collection, insertion technique). Product enhancement was also studied and the use of a tamper-evident seal system (manufactured by Bard Medical Division) and securing the catheter were two product changes that were instituted. These products have been standard catheter supplies in my hospital, Hospital of the University of Pennsylvania in Philadelphia, for many years. The final element was a nurse-driven protocol, eliminating the need for a physician order to “pull the catheter.” By developing a protocol driven algorithm, they were able to remove unnecessary catheters in a timely fashion.

This initiative was successful as over a 3 year period, UTI rates significantly decreased (from 2.75 per 1000 device days to 1.02). It shows that with a concerted effort, these devices can be used safely, while minimizing CAUTIs.

Wenger, J.E. (2010). Cultivating quality: reducing rates of catheter-associated urinary tract infection. American Journal of Nursing. 110(8):40-5

William B. Munier, MD, Director of the Center for Quality Improvement and Patient Safety, Agency for Healthcare Research and Quality (AHRQ), presented AHRQ’s projects to eliminate health care-acquired conditions (HACs) at the Academy Health Annual Research Meeting on June 12, 2011. Dr. Muniers presentation included information on Secretary Sibelius program aiming to reduce costs while improving patient safety. The Partnership for Patients program is a nationwide public-private partnership to reduce preventable harm to patients. The focus on catheter-associated urinary tract infections was included in this presentation. Since catheters are used in nearly all major surgeries and in many other hospitalized patients, it has been estimated that more than 560,000 health-care associated UTI’s have occurred annually. The Partnership for Patients estimates that 40% of CAUTIs are preventable, the goal set for hospitals is to cut the number of these preventable events in half by 2013. The updated 2009 CDC guidelines for caUTI prevention encourage the assessment if a catheter is necessary. This is a critical question and as they include in the guideline, a Bladder Scan may be indicated. The Bladder scan quickly, accurately, and noninvasively measures bladder volume. The bladder scan helps assess urinary retention and post-operative urinary retention (POUR). As such it helps prevent unnecessary catheterization. As such the bladder scan helps reduce rates of catheter-associated urinary tract infection (caUTI) and helps improve efficiency, reduce costs and save staff time. It is easy for the staff to use and does not require a sonographer. Considering alternatives to catheterization is a major first step in preventing caUTI.