Catheter Associated Urinary Tract Infection
Catheter associated urinary tract infection (“CAUTI”) is one of the most common nosocomial infections in hospitalized patients. Prior studies have revealed that CAUTI is the lead point for approximately 20% of bacteremia occurring in acute care facilities, and almost 50% in long-term care facilities—staggering figures for an infection that may be preventable (1). Although prior prevalence studies demonstrate that up to 23% of admitted patients at US hospitals have indwelling catheters, it is likely that foley catheters are being used outside the CDC approved indications (2,3):
Acute urinary retention or bladder outlet obstruction
Accurate measurement of urinary output in critically ill patients
Perioperative use for patients undergoing urologic/genitourinary tract surgery
Prolonged duration of surgery
Large volume infusions or diuretics during surgery
Assistance with healing of sacral/perineal wounds in incontinent patients
Prolonged immobilization secondary to injury or condition
Improvement of end of life care
Despite knowledge that indwelling urinary catheters lead to higher rates of infection when compared to intermittent catheterization, no large scale studies have been conducted comparing infection risk of indwelling urinary catheters compared to external urinary catheters (4). The use of external urinary catheters, the male external catheter, colloquially known as the “condom catheter,” and the wicking catheter, most often used in females, may help prevent the occurrence of CAUTI. In the Emergency Department, we are poised in a position where what we do (or don't do, such as insert a foley) has the potential to reduce iatrogenic harm throughout the hospital.
Male External Catheters:
It’s not rocket science to infer that avoiding placement of indwelling urinary catheters could prevent Catheter Associated Urinary Tract Infections (CAUTIs). In some cases, foley catheters are placed for inappropriate indications when alternatives may suffice. In many cases, a strategy of intermittent straight catheterization may be applied, or external urinary devices can be used to manage urinary incontinence, avoiding invasive catheterization altogether and the accompanying risks of CAUTI.
Historically, the most common such alternative has been the Male External Catheter (MEC) – more often referred to as the condom or Texas catheter (5). The Institute for Healthcare Improvement highlights that the use of MECs can improve patient comfort, avoid limitations on patient mobility, and decrease risk of symptomatic UTI (6). The basis for this claim is most robustly found in a randomized controlled trial published in 2006. While an N of 75 patients wasn’t huge, the authors reported risk-adjusted adverse outcomes were less common in MEC use compared to indwelling urinary catheter use (7). In a subset analysis of male patients without dementia, the group assigned to indwelling catheter had a higher risk of a combined outcome measure of bacteriuria, symptomatic UTI, or death (hazard ratio=4.84 [95%CI 1.46-16.02]) (7).
Obviously MECs are not for all patients: they are poor choices in men with suspected urinary retention or bladder outlet obstruction, which can be evaluated with bedside ultrasound. MECs do have risks of skin irritation, although there is a dearth of literature evaluating the frequency and significance of skin injury. At the extremes, MECs that are poorly sized, poorly applied, or poorly maintained can induce necrosis of distal penile tissue or tissue at points of constriction (see, e.g., Steinhardt and McRoberts 1980 ).
More recently, though, an external option for female patients has been developed.
female external Wicking CATHETERS:
Wicking catheters are external urine collection devices that can be used as an alternative to indwelling catheters in female patients. A wicking catheter consists of an elongated tube wrapped in wicking, sponge-like, material attached to a continuous vacuum source. The device is placed between the labia and the gluteal cleft approaching the anus with the exposed wicking surface facing the urethra. This device has been shown to be effective in wicking urine away from the patient and into a designated collection canister if replaced every 8 to 12 hours. It allows for non-invasive monitoring of urine output in female patients. There are multiple variations of wicking catheters that vary in length, shape, and rigidity. While wicking catheters provide a potential opportunity to reduce catheter associated urinary tract infections, they are not widely used or understood. A consensus panel identified knowledge gaps pertaining to efficacy, safety, costs, patient satisfaction, and health-related quality of life (9).
Newton et. al. conducted a case study with 16 immobilized female patients over 1843 days of wicking catheter use. Throughout this time there were no instances of urinary tract infection, skin breakdown or irritation caused by the wicking catheter system. Caregivers of the patients reported that the device was 95% effective in capturing urine and noted that the device was easy to use (10). Although wicking catheters are new devices, the current limited data suggests that these catheters are safe and may decrease urinary tract infections associated with more invasive urinary collection systems, such as a traditional Foley catheter.
Indwelling urinary catheters are potentially avoidable source of iatrogenic harm for emergency department patients.
Avoid placing indwelling urinary catheters in patients outside of approved indications.
As alternatives, consider intermittent catheterization, a condom catheter, or the female external wicking catheter.
Authors: Adam Gottula, MD - Bennett Lane, MD - Shan Modi, MD
Editors: David Thompson, MD - Jeremy Liebman, MD
Nicolle, L. E. Catheter associated urinary tract infections. Antimicrobial Resistance and Infection Control 3, 23 (2014).
Guideline for Prevention of Catheter Associated Urinary Tract Infections 2009.Available at: https://www.cdc.gov/infectioncontrol/pdf/guidelines/cauti-guidelines.pdf. (Accessed: 19th November 2018)
Multistate point-prevalence survey of health care-associated infections. - PubMed - NCBI. Available at: https://www.ncbi.nlm.nih.gov/pubmed/24670166?dopt=Abstract. (Accessed: 19th November 2018)
Hooton, T. M. et al. Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis 50, 625–663 (2010).
Geng V, Bonns E, Eelen P, et al. The Male External Catheter. Arnhem, NL: European Association of Urology Nurses; 2008. Accessed at: http://files.sld.cu/urologia-enfermeria/files/2012/03/eaun_mec_guidelines_en_2008_lr.pdf. Access date 6 Nov 2018.
IHI, How-to Guide: Prevent Catheter-Associated Urinary Tract Infections. Cambridge, MA: Institute for Healthcare Improvement; 2011. (Available at www.ihi.org).]
Saint S, Kaufman SR, Rogers MA, et al. Condom versus indwelling urinary catheters: a randomized trial. J Am Geriatr Soc 2006 54(7):1055-61.
Steinhardt G and McRoberts JW. Total Distal Penile Necrosis Caused by Condom Catheter. JAMA 1980;244(11):1238.
Gray, Mikel. “External Collection Devices as an Alternative to the Indwelling Urinary Catheter.” Journal of Wound, Ostomy and Continence Nursing, vol. 43, no. 4, 2016, p. 413., doi:10.1097/won.0000000000000251.
Newton, Camille, et al. “Measuring Safety, Effectiveness and Ease of Use of PureWick in the Management of Urinary Incontinence in Bedbound Women: Case Studies.”