Sanjay Saint, MD: Why Are CAUTI Still Common?

The incidence of catheter-associated urinary tract infections (CAUTI ) in hospital patients can be significantly reduced by some simple steps—but they are ones that may involve a change in hospital culture.

In a talk at the American College of Physicians Internal Medicine meeting in San Diego today, Sanjay Saint, MD, (photo) went over the best prevention practices and treatment for these infections.

The most important step in prevention, Saint said, is to drastically reduce the use of Foley catheters, an in-dwelling device that may make life easier for nursing staff but puts the patient at risk. Not only does the device carry a risk of infection of about 25%—partly due to a biofilm of microbes that can collect on the tubing surfaces—it keeps patients from resuming activities needed to get them ambulatory, healthy and out of the hospital.

The infection risk begins with the likelihood that the device will not be placed properly, increasing the chances it will become contaminated with microbes.

Many patients get these catheters automatically, particularly in emergency department settings, when actually they could do better with intermittent straight catheterization—something many patients can easily learn to do themselves—or by having a bedside urinal.

When indwelling, catheters are medically indicated, there are risks of contamination if staff touch the patient’s abdomen or thigh in inserting the device.

In female patients, particularly if they are obese, nurses may accidentally insert the device into the vagina instead of the urethra and then make a second attempt at insertion with a catheter that has just been contaminated.

Another problem is that urine collection bags must be lower than the bladder, but when patients are transported for imaging or other procedures, that sometimes does not happen, and microbes can seep back into the bladder. In general, the longer a patient is catheterized, the greater the risk of infection, Saint said.

As part of his quest to lower CAUTI rates in his own hospital, a Veterans Administration facility in Michigan, Saint has instituted a protocol where catheter use orders automatically expire after a day or two and physicians must evaluate whether a patient still needs the device.

He said a study in The New England Journal of Medicine showed that practice could reduce the incidence of CAUTI by 53%. The situation is more complicated in the intensive care unit, he said, when patients may need an hourly assessment of urine output.

But the devices are too frequently used even on patients who are no longer required to stay in bed. “I’ve seen patients on treadmills with collection bags,” he said, “it’s hospital culture and convenience.” The team approach to reducing CAUTI involves getting a nurse leader on board, he advised.

Catheter care is largely a nursing function, and removing a catheter can make more work for nurses, both in helping patients get out of bed to urinate more frequently and changing bedding if they become urinary incontinent. “You’ll get pushback from nurses,” he said.

The inconvenience is worth it, he said, because these infections can be dangerous. The message must be that patients’ bladders need time to overcome the de-conditioning that occurs when they get a catheter, a loss of muscle tone in the bladder that is temporary.

To overcome nursing resistance, he advised that physicians “pick a unit you know can be successful—you know which ones they will be in your hospital.” He advised not choosing the emergency department, “because it’s the wild west.” By choosing a unit likely to be compliant with new protocols and a nurse leader to whom other nurses will listen, Saint said he has achieved a 60% drop in CAUTI.

In cases where patients will permanently need catheters, such as those with spinal cord injuries or multiple sclerosis, Saint said that a super-pubic catheter or straight catheterization every few hours is better than a standard indwelling catheter.

When infections do occur, diagnosis of organisms responsible can be challenging, he said.

The mere presence of bacteria in the urine does not necessarily mean there is an infection that needs treating because about 10% of the population has such bacteria in the urine and it does not cause problems.

He predicted that within five to 10 years there will be biomarker tests to determine which organisms are involved and whether they need treating, but for now, diagnosis is a matter of clinical judgment.

Weaning patients from catheters is not likely to happen in long-term care facilities, he said, where physicians do not visit patients daily and nursing staff likes the convenience of patients' having them. “When these patients come to the hospital, we’re their best shot at weaning,” he said, an opportunity physicians should seize. He referred physicians interested in starting a CAUTI reduction program to a www.catheterout.org.