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Catheter-associated urinary tract infection

  • Leyland Chuang
    Affiliations
    Raffles Internal Medicine Centre, Raffles Hospital, Singapore
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  • Paul Anantharajah Tambyah
    Correspondence
    Corresponding author. Department of Medicine, University Medicine Cluster, National University Hospital, 5 Lower Kent Ridge Road, 119074, Singapore.
    Affiliations
    University Medicine Cluster, National University Health System, Singapore

    Infectious Diseases Translational Research Programme, Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
    Search for articles by this author
Open AccessPublished:August 04, 2021DOI:https://doi.org/10.1016/j.jiac.2021.07.022

      Abstract

      This guideline contains updated recommendations on the management and prevention of CAUTIs by the Urological Association of Asia and the Asian Association of Urinary Tract Infection and Sexually Transmitted Infection.

      Keywords

      Abbreviations

      CAASB
      catheter-associated asymptomatic bacteriuria
      CAUTI
      catheter-associated urinary tract infection
      CDC
      Centers for Disease Control and Prevention
      CFU
      colony-forming unit
      HAI/HCAI
      healthcare-associated infections
      ICU
      intensive care unit
      NHSN
      National Healthcare Safety Network
      US
      United States
      UTI
      urinary tract infection
      WBC
      white blood cell

      1. Summary of recommendations

      • 1.
        CAUTIs are a leading cause of nosocomial infections. Definitions remain controversial, but the US NHSN definitions [
        • Us Centers for Disease Control and Prevention
        Urinary tract infections (UTI) events catheter-associated urinary tract infection (CAUTI) and non-catheter-associated urinary tract infection (UTI) (and other urinary system infection (USI)).
        ] have been widely accepted.
      • 2.
        Higher rates of CAUTIs and antibiotic resistant organisms have been reported in parts of Asia. Hence, antimicrobial treatment choice should be guided by local antibiograms and culture results (LE: 4).
      • 3.
        CAASB should not be routinely treated with antibiotics (LE: 1b). Routine surveillance cultures in catheterized patients are not warranted and should not be done.
      • 4.
        Reducing the duration of urethral catheterization remains key to the prevention of CAUTIs (LE: 2b), for which various reminder systems have been shown to be effective (LE: 1a).
      • 5.
        Urinary catheter care bundles have also been shown to reduce CAUTI rates (LE: 2a).

      2. Introduction

      This guideline is an update of published guidelines from Asia [
      • Tenke P.
      • Kovacs B.
      • Bjerklund Johansen T.E.
      • Matsumoto T.
      • Tambyah P.A.
      • Naber K.G.
      European and Asian guidelines on management and prevention of catheter-associated urinary tract infections.
      ] and beyond [
      • Lo E.
      • Nicolle L.E.
      • Coffin S.E.
      • Gould C.
      • Maragakis L.L.
      • Meddings J.
      • et al.
      Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update.
      ,
      • Gould C.V.
      • Umscheid C.A.
      • Agarwal R.K.
      • Kuntz G.
      • Pegues D.A.
      Guideline for prevention of catheter-associated urinary tract infections 2009.
      ,
      • Bonkat G.
      • Bartoletti R.
      • Bruyère F.
      • Cai T.
      • Geerlings S.E.
      • Köves B.
      • et al.
      EAU guidelines on urological infections.
      ] on the management and prevention of CAUTIs .
      Fig. 1
      Fig. 1Algorithm for diagnosis, classification and management of CAUTI and CAASB.

      3. Methods

      A systematic literature search was performed in PubMed using the following search terms: urinary tract infection OR bacteriuria OR CAUTI OR UTI, AND catheter. Search was limited to studies published over the past ten years in English with abstract available. Sixty-two papers were shortlisted for further review, together with other major clinical trials cited in the earlier guideline.

      4. Definition

      CAUTI refers to UTIs associated with indwelling urinary catheters, which are defined as drainage tubes inserted into the urinary bladder through the urethra, left in place, and connected to a collection system [
      • Gould C.V.
      • Umscheid C.A.
      • Agarwal R.K.
      • Kuntz G.
      • Pegues D.A.
      Guideline for prevention of catheter-associated urinary tract infections 2009.
      ].
      The definition of CAUTI remains controversial, with all guidelines agreeing that symptoms alone are not reliable for the diagnosis of CAUTI [
      • Johansen T.E.B.
      • Botto H.
      • Cek M.
      • Grabe M.
      • Tenke P.
      • Wagenlehner F.M.E.
      • et al.
      Critical review of current definitions of urinary tract infections and proposal of an EAU/ESIU classification system.
      ,
      • Tenke P.
      • Kovacs B.
      • Bjerklund Johansen T.E.
      • Matsumoto T.
      • Tambyah P.A.
      • Naber K.G.
      European and Asian guidelines on management and prevention of catheter-associated urinary tract infections.
      ,
      • Lo E.
      • Nicolle L.E.
      • Coffin S.E.
      • Gould C.
      • Maragakis L.L.
      • Meddings J.
      • et al.
      Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update.
      ,
      • Gould C.V.
      • Umscheid C.A.
      • Agarwal R.K.
      • Kuntz G.
      • Pegues D.A.
      Guideline for prevention of catheter-associated urinary tract infections 2009.
      ,
      • Tambyah P.A.
      • Maki D.G.
      Catheter-associated urinary tract infection is rarely symptomatic: a prospective study of 1,497 catheterized patients.
      ,
      • Tambyah P.A.
      • Oon J.
      Catheter-associated urinary tract infection.
      ,
      • Hooton T.M.
      • Bradley S.F.
      • Cardenas D.D.
      • Colgan R.
      • Geerlings S.E.
      • Rice J.C.
      • 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.
      ,
      • Lo E.
      • Nicolle L.
      • Classen D.
      • Arias K.M.
      • Podgorny K.
      • Anderson D.J.
      • et al.
      Strategies to prevent catheter-associated urinary tract infections in acute care hospitals.
      ] [
      • Johansen T.E.B.
      • Botto H.
      • Cek M.
      • Grabe M.
      • Tenke P.
      • Wagenlehner F.M.E.
      • et al.
      Critical review of current definitions of urinary tract infections and proposal of an EAU/ESIU classification system.
      ,
      • Tenke P.
      • Kovacs B.
      • Bjerklund Johansen T.E.
      • Matsumoto T.
      • Tambyah P.A.
      • Naber K.G.
      European and Asian guidelines on management and prevention of catheter-associated urinary tract infections.
      ,
      • Lo E.
      • Nicolle L.E.
      • Coffin S.E.
      • Gould C.
      • Maragakis L.L.
      • Meddings J.
      • et al.
      Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update.
      ,
      • Gould C.V.
      • Umscheid C.A.
      • Agarwal R.K.
      • Kuntz G.
      • Pegues D.A.
      Guideline for prevention of catheter-associated urinary tract infections 2009.
      ,
      • Tambyah P.A.
      • Maki D.G.
      Catheter-associated urinary tract infection is rarely symptomatic: a prospective study of 1,497 catheterized patients.
      ,
      • Tambyah P.A.
      • Oon J.
      Catheter-associated urinary tract infection.
      ,
      • Hooton T.M.
      • Bradley S.F.
      • Cardenas D.D.
      • Colgan R.
      • Geerlings S.E.
      • Rice J.C.
      • 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.
      ,
      • Lo E.
      • Nicolle L.
      • Classen D.
      • Arias K.M.
      • Podgorny K.
      • Anderson D.J.
      • et al.
      Strategies to prevent catheter-associated urinary tract infections in acute care hospitals.
      ] [
      • Gould C.V.
      • Umscheid C.A.
      • Agarwal R.K.
      • Kuntz G.
      • Pegues D.A.
      Guideline for prevention of catheter-associated urinary tract infections 2009.
      ,
      • Tambyah P.A.
      • Maki D.G.
      Catheter-associated urinary tract infection is rarely symptomatic: a prospective study of 1,497 catheterized patients.
      ] [
      • Johansen T.E.B.
      • Botto H.
      • Cek M.
      • Grabe M.
      • Tenke P.
      • Wagenlehner F.M.E.
      • et al.
      Critical review of current definitions of urinary tract infections and proposal of an EAU/ESIU classification system.
      ,
      • Tenke P.
      • Kovacs B.
      • Bjerklund Johansen T.E.
      • Matsumoto T.
      • Tambyah P.A.
      • Naber K.G.
      European and Asian guidelines on management and prevention of catheter-associated urinary tract infections.
      ,
      • Lo E.
      • Nicolle L.E.
      • Coffin S.E.
      • Gould C.
      • Maragakis L.L.
      • Meddings J.
      • et al.
      Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update.
      ,
      • Gould C.V.
      • Umscheid C.A.
      • Agarwal R.K.
      • Kuntz G.
      • Pegues D.A.
      Guideline for prevention of catheter-associated urinary tract infections 2009.
      ,
      • Tambyah P.A.
      • Maki D.G.
      Catheter-associated urinary tract infection is rarely symptomatic: a prospective study of 1,497 catheterized patients.
      ,
      • Tambyah P.A.
      • Oon J.
      Catheter-associated urinary tract infection.
      ,
      • Hooton T.M.
      • Bradley S.F.
      • Cardenas D.D.
      • Colgan R.
      • Geerlings S.E.
      • Rice J.C.
      • 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.
      ,
      • Lo E.
      • Nicolle L.
      • Classen D.
      • Arias K.M.
      • Podgorny K.
      • Anderson D.J.
      • et al.
      Strategies to prevent catheter-associated urinary tract infections in acute care hospitals.
      ] [
      • Johansen T.E.B.
      • Botto H.
      • Cek M.
      • Grabe M.
      • Tenke P.
      • Wagenlehner F.M.E.
      • et al.
      Critical review of current definitions of urinary tract infections and proposal of an EAU/ESIU classification system.
      ,
      • Tenke P.
      • Kovacs B.
      • Bjerklund Johansen T.E.
      • Matsumoto T.
      • Tambyah P.A.
      • Naber K.G.
      European and Asian guidelines on management and prevention of catheter-associated urinary tract infections.
      ,
      • Lo E.
      • Nicolle L.E.
      • Coffin S.E.
      • Gould C.
      • Maragakis L.L.
      • Meddings J.
      • et al.
      Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update.
      ,
      • Gould C.V.
      • Umscheid C.A.
      • Agarwal R.K.
      • Kuntz G.
      • Pegues D.A.
      Guideline for prevention of catheter-associated urinary tract infections 2009.
      ,
      • Tambyah P.A.
      • Maki D.G.
      Catheter-associated urinary tract infection is rarely symptomatic: a prospective study of 1,497 catheterized patients.
      ,
      • Tambyah P.A.
      • Oon J.
      Catheter-associated urinary tract infection.
      ,
      • Hooton T.M.
      • Bradley S.F.
      • Cardenas D.D.
      • Colgan R.
      • Geerlings S.E.
      • Rice J.C.
      • 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.
      ,
      • Lo E.
      • Nicolle L.
      • Classen D.
      • Arias K.M.
      • Podgorny K.
      • Anderson D.J.
      • et al.
      Strategies to prevent catheter-associated urinary tract infections in acute care hospitals.
      ]. For surveillance purposes, the US CDC's NHSN definitions [
      • Us Centers for Disease Control and Prevention
      Urinary tract infections (UTI) events catheter-associated urinary tract infection (CAUTI) and non-catheter-associated urinary tract infection (UTI) (and other urinary system infection (USI)).
      ] have commonly been accepted and used in most published reports [
      • Saint S.
      • Greene M.T.
      • Kowalski C.P.
      • Watson S.R.
      • Hofer T.P.
      • Krein S.L.
      Preventing catheter-associated urinary tract infection in the United States: a national comparative study.
      ], despite these definitions being difficult to apply in practice [
      • Al-Qas Hanna F.
      • Sambirska O.
      • Iyer S.
      • Szpunar S.
      • Fakih M.G.
      Clinician practice and the National Healthcare Safety Network definition for the diagnosis of catheter-associated urinary tract infection.
      ]. The NHSN definitions are described below in the diagnosis section.
      Alternative urinary drainage methods are available, such as clean intermittent (“in-and-out”) urinary catheterization, external catheters that fit over or adhere to the genitalia (“condom” catheters), suprapubic catheters and nephrostomy tubes. Although UTIs associated with these methods may be considered device-associated, NHSN CAUTI definitions typically refer only to UTIs associated with indwelling urethral catheters. Hence, CAUTI will be taken to refer only to indwelling urethral catheters throughout this guideline.

      5. Epidemiology

      UTIs are a leading cause of nosocomial infections worldwide, and have been estimated to cause approximately 30 % of HCAIs in the acute care setting in the United States [
      • Klevens R.M.
      • Edwards J.R.
      • Richards C.L.
      • Horan T.C.
      • Gaynes R.P.
      • Pollock D.A.
      • et al.
      Estimating health care-associated infections and deaths in U.S. hospitals, 2002.
      ]. Of these, approximately 75 % are associated with an indwelling urinary catheter.
      The impact of CAUTI is likely to be even greater in Asia [
      • Ling M.L.
      • Apisarnthanarak A.
      • Madriaga G.
      The burden of healthcare-associated infections in Southeast Asia: a systematic literature review and meta-analysis.
      ]. A surveillance study was conducted over 6 years by the International Nosocomial Infection Control Consortium in 422 ICUs of 36 countries in Latin America, Asia, Africa, and Europe, of which 57 % were in Asia. The study found developing countries to have a rate of 6.3 CAUTIs per 1000 urinary catheter-days, compared to 3.3 per 1000 catheter-days in comparable US ICUs [
      • Rosenthal V.D.
      • Bijie H.
      • Maki D.G.
      • Mehta Y.
      • Apisarnthanarak A.
      • Medeiros E a
      • et al.
      International nosocomial infection control Consortium (INICC) report, data summary of 36 countries, for 2004-2009.
      ]. CAUTIs in developing countries were also associated with higher rates of antibiotic resistance on microbiological surveillance.
      The sheer frequency of urinary catheter usage in most healthcare settings highlights the impact and significance of CAUTI in the healthcare system globally and in Asia [
      • Gould C.V.
      • Umscheid C.A.
      • Agarwal R.K.
      • Kuntz G.
      • Pegues D.A.
      Guideline for prevention of catheter-associated urinary tract infections 2009.
      ,
      • Ling M.L.
      • Apisarnthanarak A.
      • Madriaga G.
      The burden of healthcare-associated infections in Southeast Asia: a systematic literature review and meta-analysis.
      ,
      • Centers for Disease Control and Prevention
      Catheter-associated urinary tract infections.
      ] [
      • Ling M.L.
      • Apisarnthanarak A.
      • Madriaga G.
      The burden of healthcare-associated infections in Southeast Asia: a systematic literature review and meta-analysis.
      ,
      • Centers for Disease Control and Prevention
      Catheter-associated urinary tract infections.
      ,
      • Umscheid C.A.
      • Mitchell M.D.
      • Doshi J.A.
      • Agarwal R.
      • Williams K.
      • Brennan P.J.
      Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs.
      ,
      • Yi S.H.
      • Baggs J.
      • Gould C.V.
      • Scott R.D.
      • Jernigan J.A.
      Medicare reimbursement attributable to catheter-associated urinary tract infection in the inpatient setting: a retrospective cohort analysis.
      ,
      • Hu B.
      • Tao L.
      • Rosenthal V.D.
      • Liu K.
      • Yun Y.
      • Suo Y.
      • et al.
      Device-associated infection rates, device use, length of stay, and mortality in intensive care units of 4 Chinese hospitals: International Nosocomial Control Consortium findings.
      ,
      • Castle N.
      • Engberg J.B.
      • Wagner L.M.
      • Handler S.
      Resident and facility factors associated with the incidence of urinary tract infections identified in the nursing home minimum data set.
      ,
      • Gould C.V.
      • Umscheid C.A.
      • Agarwal R.K.
      • Kuntz G.
      • Pegues D.A.
      Guideline for prevention of catheter-associated urinary tract infections 2009.
      ] [
      • Ling M.L.
      • Apisarnthanarak A.
      • Madriaga G.
      The burden of healthcare-associated infections in Southeast Asia: a systematic literature review and meta-analysis.
      ,
      • Centers for Disease Control and Prevention
      Catheter-associated urinary tract infections.
      ,
      • Umscheid C.A.
      • Mitchell M.D.
      • Doshi J.A.
      • Agarwal R.
      • Williams K.
      • Brennan P.J.
      Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs.
      ,
      • Yi S.H.
      • Baggs J.
      • Gould C.V.
      • Scott R.D.
      • Jernigan J.A.
      Medicare reimbursement attributable to catheter-associated urinary tract infection in the inpatient setting: a retrospective cohort analysis.
      ,
      • Hu B.
      • Tao L.
      • Rosenthal V.D.
      • Liu K.
      • Yun Y.
      • Suo Y.
      • et al.
      Device-associated infection rates, device use, length of stay, and mortality in intensive care units of 4 Chinese hospitals: International Nosocomial Control Consortium findings.
      ,
      • Castle N.
      • Engberg J.B.
      • Wagner L.M.
      • Handler S.
      Resident and facility factors associated with the incidence of urinary tract infections identified in the nursing home minimum data set.
      ,
      • Gould C.V.
      • Umscheid C.A.
      • Agarwal R.K.
      • Kuntz G.
      • Pegues D.A.
      Guideline for prevention of catheter-associated urinary tract infections 2009.
      ]. However, a recent point-prevalence survey in the US have shown that implementation of evidence-based interventions in programs such as the Comprehensive Unit-based Safety Program, which aims to reduce urinary catheter use, may be effective in reducing the prevalence of CAUTI [
      • Magill S.S.
      • O'Leary E.
      • Janelle S.J.
      • Thompson D.L.
      • Dumyati G.
      • Nadle J.
      • et al.
      Changes in prevalence of health care–associated infections in U.S. Hospitals. N engl J med.
      ].

      6. Pathogenesis and risk factors

      The presence of a urethral catheter will bypass or inhibit natural host defenses, predisposing patients to CAUTIs [
      • Maki D.G.
      • Tambyah P.A.
      Engineering out the risk for infection with urinary catheters.
      ]. This is further exacerbated by the development of biofilm on the urinary catheters, which provides a favorable environment for bacterial proliferation & invasion [
      • Tenke P.
      • Kovacs B.
      • Bjerklund Johansen T.E.
      • Matsumoto T.
      • Tambyah P.A.
      • Naber K.G.
      European and Asian guidelines on management and prevention of catheter-associated urinary tract infections.
      ,
      • Nicolle L.E.
      Urinary catheter-associated infections.
      ].
      Bacteria may be introduced into the urinary tract via several routes, such as:
      • i.
        Inoculation at the time of catheter insertion, especially in patients who have had inadequate disinfection of the perineum prior to catheterization.
      • ii.
        Via intraluminal ascent in the urinary catheter lumen after contamination of the closed urinary catheter system (such as via breaks in aseptic practice during the emptying of the urinary drainage bag, or temporary disconnection of catheters from urinary bags).
      • iii.
        Via extraluminal route of ascent along the external surface of the urinary catheter into the urethra.
      The most common uropathogen isolated from the catheterized urinary tract is Escherichia coli. Other common organisms isolated in patients with short-term catheterization include Pseudomonas, Klebsiella, Proteus, Enterococcus and Candida species. Proteus mirabilis bacteriuria is often associated with catheter obstruction, and polymicrobial bacteriuria is commonly found in patients with long-term catheters [
      • Magill S.S.
      • O'Leary E.
      • Janelle S.J.
      • Thompson D.L.
      • Dumyati G.
      • Nadle J.
      • et al.
      Changes in prevalence of health care–associated infections in U.S. Hospitals. N engl J med.
      ,
      • Warren J.W.
      Catheter-associated urinary tract infections.
      ].
      Risk factors for CAUTI which have been identified in prospective observational studies include [
      • Maki D.G.
      • Tambyah P.A.
      Engineering out the risk for infection with urinary catheters.
      ,
      • Foxman B.
      The epidemiology of urinary tract infection.
      ] [
      • Maki D.G.
      • Tambyah P.A.
      Engineering out the risk for infection with urinary catheters.
      ,
      • Foxman B.
      The epidemiology of urinary tract infection.
      ,
      • Platt R.
      • Polk B.F.
      • Murdock B.
      • Rosner B.
      Risk factors for nosocomial urinary tract infection.
      ,
      • Barbadoro P.
      • Labricciosa F.M.
      • Recanatini C.
      • Gori G.
      • Tirabassi F.
      • Martini E.
      • et al.
      Catheter-associated urinary tract infection: role of the setting of catheter insertion.
      ] [
      • Maki D.G.
      • Tambyah P.A.
      Engineering out the risk for infection with urinary catheters.
      ,
      • Foxman B.
      The epidemiology of urinary tract infection.
      ,
      • Platt R.
      • Polk B.F.
      • Murdock B.
      • Rosner B.
      Risk factors for nosocomial urinary tract infection.
      ,
      • Barbadoro P.
      • Labricciosa F.M.
      • Recanatini C.
      • Gori G.
      • Tirabassi F.
      • Martini E.
      • et al.
      Catheter-associated urinary tract infection: role of the setting of catheter insertion.
      ]:
      • Duration of catheterization
      • Female gender
      • Anatomical or functional abnormalities of the urinary tract
      • Insertion of the catheter outside the operating room
      • Diabetes mellitus
      • Poor catheter care including failure of aseptic technique or breaks in closed drainage

      7. Diagnosis

      7.1 Symptoms (physical examination)

      Among patients without catheters with microbiology confirmed bacteriuria, the presence of symptoms attributable to an infection of the urinary tract has classically differentiated patients with asymptomatic bacteriuria from those with symptomatic UTI. These symptoms include fever, urgency, dysuria, hematuria, suprapubic pain and costovertebral angle tenderness [
      • Conway L.J.
      • Larson E.L.
      Guidelines to prevent catheter-associated urinary tract infection: 1980 to 2010.
      ,
      • Beveridge L.A.
      • Davey P.G.
      • Phillips G.
      • McMurdo M.E.T.
      Optimal management of urinary tract infections in older people.
      ,
      • Loeb M.
      • Brazil K.
      • Lohfeld L.
      • McGeer A.
      • Simor A.
      • Stevenson K.
      • et al.
      Effect of a multifaceted intervention on number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes: cluster randomised controlled trial.
      ] [
      • Conway L.J.
      • Larson E.L.
      Guidelines to prevent catheter-associated urinary tract infection: 1980 to 2010.
      ,
      • Beveridge L.A.
      • Davey P.G.
      • Phillips G.
      • McMurdo M.E.T.
      Optimal management of urinary tract infections in older people.
      ,
      • Loeb M.
      • Brazil K.
      • Lohfeld L.
      • McGeer A.
      • Simor A.
      • Stevenson K.
      • et al.
      Effect of a multifaceted intervention on number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes: cluster randomised controlled trial.
      ] [
      • Conway L.J.
      • Larson E.L.
      Guidelines to prevent catheter-associated urinary tract infection: 1980 to 2010.
      ,
      • Beveridge L.A.
      • Davey P.G.
      • Phillips G.
      • McMurdo M.E.T.
      Optimal management of urinary tract infections in older people.
      ,
      • Loeb M.
      • Brazil K.
      • Lohfeld L.
      • McGeer A.
      • Simor A.
      • Stevenson K.
      • et al.
      Effect of a multifaceted intervention on number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes: cluster randomised controlled trial.
      ].
      However, this distinction may be difficult in some patients with chronic indwelling catheters, such as in patients with spinal cord injury, and patients who are unable to communicate due to illness, comorbidities or extremes of age [
      • Lo E.
      • Nicolle L.E.
      • Coffin S.E.
      • Gould C.
      • Maragakis L.L.
      • Meddings J.
      • et al.
      Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update.
      ,
      • Foxman B.
      The epidemiology of urinary tract infection.
      ,
      • Beveridge L.A.
      • Davey P.G.
      • Phillips G.
      • McMurdo M.E.T.
      Optimal management of urinary tract infections in older people.
      ,
      • Wagenlehner F.M.E.
      • Cek M.
      • Naber K.G.
      • Kiyota H.
      • Bjerklund-Johansen T.E.
      Epidemiology, treatment and prevention of healthcare-associated urinary tract infections.
      ,
      • Buhr G.T.
      • Genao L.
      • White H.K.
      Urinary tract infections in long-term care residents.
      ]. In particular, symptoms referable to the urinary tract have been found to be uncommon in patients with CAUTI for whom the catheter alone may be a source of symptoms, and have poor predictive value for differentiating CAUTIs from CAASBs [
      • Tambyah P.A.
      • Maki D.G.
      Catheter-associated urinary tract infection is rarely symptomatic: a prospective study of 1,497 catheterized patients.
      ]. It is thus recommended for clinicians to evaluate patients carefully for the likelihood of UTI/CAUTI against alternative sources of infection, and only obtain urine cultures when suspicion of UTI/CAUTI is high. This is to avoid inadvertent misdiagnosis of CAUTIs in cases of CAASB, resulting in unnecessary antimicrobial use [
      • Agency for Healthcare Research and Quality
      Preventing CAUTI: focus on culturing stewardship.
      ].

      7.2 Criteria and classification

      The criteria and classifications of CAUTI and CAASB, as adapted from the US NHSN [
      • Us Centers for Disease Control and Prevention
      Urinary tract infections (UTI) events catheter-associated urinary tract infection (CAUTI) and non-catheter-associated urinary tract infection (UTI) (and other urinary system infection (USI)).
      ], are as detailed below in Table 1. There are other more complex classification criteria which have been developed [
      • Johansen T.E.B.
      • Botto H.
      • Cek M.
      • Grabe M.
      • Tenke P.
      • Wagenlehner F.M.E.
      • et al.
      Critical review of current definitions of urinary tract infections and proposal of an EAU/ESIU classification system.
      ] for research purposes, but the NHSN criteria are most practical in the setting of surveillance and clinical decision making. Criteria for the categories of presence of indwelling urinary catheter, symptoms and positive microbiology must all be met to qualify for the diagnosis of CAUTI (see Fig. 1). Culture of indwelling urinary catheter is not recommended.
      Table 1Criteria and classification of CAUTI and CAASB.
      Indwelling urinary catheter criteriaSymptoms criteriaMicrobiological criteria
      CAUTIIn place for >2 consecutive days, and catheter present for any portion of the date of development of CAUTIAt least 1 of the following:
      • Fever >38 °C
      • Suprapubic tenderness
      • Costovertebral angle pain or tenderness
      Positive urine culture with no more than 2 species of microorganisms identified (excluding Candida species, yeast, mold, dimorphic fungi and parasites), at least one of which is ≥ 105 CFU/ml.
      In place for >2 consecutive days, but removed the day before the development of CAUTIAt least 1 of the following:
      • Urgency, frequency or dysuria with no other cause
      • Fever >38 °C
      • Suprapubic tenderness
      • Costovertebral angle pain or tenderness
      Positive urine culture with no more than 2 species of microorganisms identified (excluding Candida species, yeast, mold, dimorphic fungi and parasites), at least one of which is ≥ 105 CFU/ml.
      CAASBIn place for >2 days, and either in place on the date of assessment, OR removed on the day of or the day before assessmentNo symptoms of UTI, including:
      • Urgency, frequency or dysuria
      • Fever
      • Suprapubic tenderness
      • Costovertebral angle pain or tenderness
      Positive urine culture of ≥105 CFU/ml.
      Routine urine cultures in asymptomatic catheterized patients are not recommended.

      8. Treatment

      The treatment, management and prevention of CAUTIs are as follows:

      8.1 Medication/Drug therapy

      Significantly higher rates of antibiotic resistance have been found in Asia as compared to Europe and North America [
      • Morrissey I.
      • Hackel M.
      • Badal R.
      • Bouchillon S.
      • Hawser S.
      • Biedenbach D.
      A review of ten years of the study for monitoring antimicrobial resistance trends (SMART) from 2002 to 2011.
      ]. In addition, clinical prescribing practices and availability of antibiotics differ between countries and healthcare facilities. Hence, no single set of recommendation for empiric antibiotics can be made for the treatment of CAUTIs in Asia. Recommendations with regards to selection of antibiotics are detailed in Table 2. There is considerable controversy regarding the duration of treatment, the need to treat bacteriuria once catheters are removed [
      • Harding G.K.
      • Nicolle L.E.
      • Ronald A.R.
      • Preiksaitis J.K.
      • Forward K.R.
      • Low D.E.
      • et al.
      How long should catheter-acquired urinary tract infection in women be treated? A randomized controlled study.
      ], and the role of periodic treatment in spinal cord injured patients [
      • Salomon J.
      • Denys P.
      • Merle C.
      • Chartier-Kastler E.
      • Perronne C.
      • Gaillard J.-L.
      • et al.
      Prevention of urinary tract infection in spinal cord-injured patients: safety and efficacy of a weekly oral cyclic antibiotic (WOCA) programme with a 2 year follow-up -- an observational prospective study.
      ]. No general recommendation can be made for these situations.
      Table 2Principles to guide selection of antibiotics.
      RecommendationLE/GR
      1.Monitoring of local antibiotic resistance patterns in uropathogens.4/C
      2.Urine cultures, preferably before initiation of antibiotic therapy, to guide choice of definitive antibiotic therapy.4/C
      3.Empiric antimicrobial therapy could be guided by recent prior urine culture results, where possible [
      • MacFadden D.R.
      • Ridgway J.P.
      • Robicsek A.
      • Elligsen M.
      • Daneman N.
      The predictive utility of prior positive urine cultures.
      ].
      2 b/C
      4.Early de-escalation of antibiotic therapy, as guided by urine culture results, to the narrowest spectrum antibiotic available.4/C
      5.Shorter 5 day course of antibiotics with catheter exchange may be considered in the treatment of CAUTI in patients with spinal cord injury [
      • Darouiche R.O.
      • Al Mohajer M.
      • Siddiq D.M.
      • Minard C.G.
      Short versus long course of antibiotics for catheter-associated urinary tract infections in patients with spinal cord injury: a randomized controlled noninferiority trial.
      ].
      1 b/B
      6.CAASB should not be routinely treated with antibiotics [
      • Lo E.
      • Nicolle L.E.
      • Coffin S.E.
      • Gould C.
      • Maragakis L.L.
      • Meddings J.
      • et al.
      Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update.
      ,
      • Warren J.W.
      • Anthony W.C.
      • Hoopes J.M.
      • Muncie H.L.
      Cephalexin for susceptible bacteriuria in afebrile, long-term catheterized patients.
      ].
      1 b/B

      8.2 Procedures and interventions

      Asepsis of the urinary catheter system is vital for the prevention of CAUTI. Interventions towards this end have been recently been focused on the use of modified catheters, as well as aseptic insertion and maintenance of urinary catheters. Recommendations regarding the use of catheters are detailed in Table 3.
      Table 3Recommendations on the use of urinary catheters.
      RecommendationLE/GR
      1.1 b/C
      2.Alternative methods of bladder drainage with external and suprapubic catheters may be considered, but evidence of efficacy in preventing CAUTI remains limited [
      • Hunter K.F.
      • Bharmal A.
      • Moore K.N.
      Long-term bladder drainage: suprapubic catheter versus other methods: a scoping review.
      ,
      • Healy E.F.
      • Walsh C.A.
      • Cotter A.M.
      • Walsh S.R.
      Suprapubic compared with transurethral bladder catheterization for gynecologic surgery: a systematic review and meta-analysis.
      ].
      1 b/C
      3.Consider changing long-term indwelling urinary catheters prior to initiating antimicrobial therapy [
      • Raz R.
      • Schiller D.
      • Nicolle L.E.
      Chronic indwelling catheter replacement before antimicrobial therapy for symptomatic urinary tract infection.
      ].
      1 b/B

      8.3 Prophylaxis, prevention and monitoring

      Principles for prevention of CAUTI may be broadly classified under the following categories:
      • Avoiding unnecessary urinary catheterization [
        • Ma Y.
        • Lu X.
        Indwelling catheter can increase postoperative urinary tract infection and may not be required in total joint arthroplasty: a meta-analysis of randomized controlled trial.
        ] and minimizing duration of catheterization via close surveillance and reminder systems.
      • Preserving closed drainage of urinary catheter system and strict aseptic technique during insertion and maintenance.
      • Implementation of urinary catheter care bundles and infection control programs.
      Specific recommendations are detailed in Table 4.
      Table 4Recommendations for the prevention of CAUTIs.
      RecommendationLE/GR
      1.Early removal of indwelling urinary catheters reduces the risks of subsequent CAUTI [
      • Wald H.L.
      • Ma A.
      • Bratzler D.W.
      • Kramer A.M.
      Indwelling urinary catheter use in the postoperative period: analysis of the national surgical infection prevention project data.
      ,
      • Okrainec A.
      • Aarts M.A.
      • Conn L.G.
      • McCluskey S.
      • McKenzie M.
      • Pearsall E.A.
      • et al.
      Compliance with urinary catheter removal guidelines leads to improved outcome in enhanced recovery after surgery patients.
      ] and other complications [
      • West D.A.
      • Cummings J.M.
      • Longo W.E.
      • Virgo K.S.
      • Johnson F.E.
      • Parra R.O.
      Role of chronic catheterization in the development of bladder cancer in patients with spinal cord injury.
      ].
      2 b/B
      2.Heath care workers are often unaware about the presence of an indwelling catheter in patients [
      • Saint S.
      • Wiese J.
      • Amory J.K.
      • Bernstein M.L.
      • Patel U.D.
      • Zemencuk J.K.
      • et al.
      Are physicians aware of which of their patients have indwelling urinary catheters?.
      ]. This should be addressed, so as to minimize inappropriate use of indwelling catheters and reduce duration of catheterization.
      3/B
      3.Nurse generated or electronic-based reminder and stop-order systems for the removal of urinary catheters reduce utilization of indwelling catheters and rates of CAUTIs [
      • Meddings J.
      • Rogers M.A.M.
      • Macy M.
      • Saint S.
      Systematic review and meta-analysis: reminder systems to reduce catheter-associated urinary tract infections and urinary catheter use in hospitalized patients.
      ,
      • Apisarnthanarak A.
      • Thongphubeth K.
      • Sirinvaravong S.
      • Kitkangvan D.
      • Yuekyen C.
      • Warachan B.
      • et al.
      Effectiveness of multifaceted hospitalwide quality improvement programs featuring an intervention to remove unnecessary urinary catheters at a tertiary care center in Thailand.
      ,
      • Crouzet J.
      • Bertrand X.
      • Venier A.G.
      • Badoz M.
      • Husson C.
      • Talon D.
      Control of the duration of urinary catheterization: impact on catheter-associated urinary tract infection.
      ,
      • Robinson S.
      • Allen L.
      • Barnes M.R.
      • Berry T.A.
      • Foster T.A.
      • Friedrich L.A.
      • et al.
      Development of an evidence-based protocol for reduction of indwelling urinary catheter usage.
      ,
      • Huang W.-C.
      • Wann S.-R.
      • Lin S.-L.
      • Kunin C.M.
      • Kung M.-H.
      • Lin C.-H.
      • et al.
      Catheter-associated urinary tract infections in intensive care units can be reduced by prompting physicians to remove unnecessary catheters.
      ,
      • Bruminhent J.
      • Keegan M.
      • Lakhani A.
      • Roberts I.M.
      • Passalacqua J.
      Effectiveness of a simple intervention for prevention of catheter-associated urinary tract infections in a community teaching hospital.
      ,
      • Elpern E.H.
      • Killeen K.
      • Ketchem A.
      • Wiley A.
      • Patel G.
      • Lateef O.
      Reducing use of indwelling urinary catheters and associated urinary tract infections.
      ,
      • Fakih M.G.
      • Dueweke C.
      • Meisner S.
      • Berriel-Cass D.
      • Savoy-Moore R.
      • Brach N.
      • et al.
      Effect of nurse-led multidisciplinary rounds on reducing the unnecessary use of urinary catheterization in hospitalized patients.
      ,
      • Chen Y.-Y.
      • Chi M.-M.
      • Chen Y.-C.
      • Chan Y.-J.
      • Chou S.-S.
      • Wang F.-D.
      Using a criteria-based reminder to reduce use of indwelling urinary catheters and decrease urinary tract infections.
      ,
      • Cornia P.B.
      • Amory J.K.
      • Fraser S.
      • Saint S.
      • Lipsky B.A.
      Computer-based order entry decreases duration of indwelling urinary catheterization in hospitalized patients.
      ,
      • Nagle D.
      • Curran T.
      • Anez-Bustillo L.
      • Poylin V.
      Reducing urinary tract infections in colon and rectal surgery.
      ,
      • Topal J.
      • Conklin S.
      • Camp K.
      • Morris V.
      • Balcezak T.
      • Herbert P.
      Prevention of nosocomial catheter-associated urinary tract infections through computerized feedback to physicians and a nurse-directed protocol.
      ,
      • Loeb M.
      • Hunt D.
      • O'Halloran K.
      • Carusone S.C.
      • Dafoe N.
      • Walter S.D.
      Stop orders to reduce inappropriate urinary catheterization in hospitalized patients: a randomized controlled trial.
      ,
      • Dumigan D.G.
      • Kohan C.A.
      • Reed C.R.
      • Jekel J.F.
      • Fikrig M.K.
      Utilizing national nosocomial infection surveillance system data to improve urinary tract infection rates in three intensive-care units.
      ,
      • Fakih M.G.
      • Heavens M.
      • Ratcliffe C.J.
      • Hendrich A.
      First step to reducing infection risk as a system: evaluation of infection prevention processes for 71 hospitals.
      ,
      • Magers T.L.
      Using evidence-based practice to reduce catheter-associated urinary tract infections.
      ,
      • Parry M.F.
      • Grant B.
      • Sestovic M.
      Successful reduction in catheter-associated urinary tract infections: focus on nurse-directed catheter removal.
      ,
      • Mori C.
      A-voiding catastrophe: implementing a nurse-driven protocol.
      ,
      • Rothfeld A.F.
      • Stickley A.
      A program to limit urinary catheter use at an acute care hospital.
      ]
      1a/B
      4.Urinary catheter care bundles and infection control programs reduce rates of CAUTI [
      • Lo E.
      • Nicolle L.E.
      • Coffin S.E.
      • Gould C.
      • Maragakis L.L.
      • Meddings J.
      • et al.
      Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update.
      ,
      • Saint S.
      • Greene M.T.
      • Kowalski C.P.
      • Watson S.R.
      • Hofer T.P.
      • Krein S.L.
      Preventing catheter-associated urinary tract infection in the United States: a national comparative study.
      ,
      • Miller B.L.
      • Krein S.L.
      • Fowler K.E.
      • Belanger K.
      • Zawol D.
      • Lyons A.
      • et al.
      A multimodal intervention to reduce urinary catheter use and associated infection at a Veterans Affairs Medical Center.
      ] [
      • Saint S.
      • Greene M.T.
      • Kowalski C.P.
      • Watson S.R.
      • Hofer T.P.
      • Krein S.L.
      Preventing catheter-associated urinary tract infection in the United States: a national comparative study.
      ,
      • Lo E.
      • Nicolle L.E.
      • Coffin S.E.
      • Gould C.
      • Maragakis L.L.
      • Meddings J.
      • et al.
      Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update.
      ,
      • Titsworth W.L.
      • Hester J.
      • Correia T.
      • Reed R.
      • Williams M.
      • Guin P.
      • et al.
      Reduction of catheter-associated urinary tract infections among patients in a neurological intensive care unit: a single institution's success.
      ,
      • Andreessen L.
      • Wilde M.H.
      • Herendeen P.
      Preventing catheter-associated urinary tract infections in acute care: the bundle approach.
      ,
      • Kanj S.S.
      • Zahreddine N.
      • Rosenthal V.D.
      • Alamuddin L.
      • Kanafani Z.
      • Molaeb B.
      Impact of a multidimensional infection control approach on catheter-associated urinary tract infection rates in an adult intensive care unit in Lebanon: International Nosocomial Infection Control Consortium (INICC) findings.
      ,
      • Navoa-Ng J.A.
      • Berba R.
      • Rosenthal V.D.
      • Villanueva V.D.
      • Tolentino M.C.V.
      • Genuino G.A.S.
      • et al.
      Impact of an International Nosocomial Infection Control Consortium multidimensional approach on catheter-associated urinary tract infections in adult intensive care units in the Philippines: International Nosocomial Infection Control Consortium findings.
      ,
      • Rosenthal V.D.
      • Todi S.K.
      • Álvarez-Moreno C.
      • Pawar M.
      • Karlekar A.
      • Zeggwagh A.A.
      • et al.
      Impact of a multidimensional infection control strategy on catheter-associated urinary tract infection rates in the adult intensive care units of 15 developing countries: findings of the International Nosocomial Infection Control Consortium (INICC).
      ,
      • Marra A.R.
      • Sampaio Camargo T.Z.
      • Gonçalves P.
      • Sogayar A.M.C.B.
      • Moura D.F.
      • Guastelli L.R.
      • et al.
      Preventing catheter-associated urinary tract infection in the zero-tolerance era.
      ,
      • Clarke K.
      • Tong D.
      • Pan Y.
      • Easley K.A.
      • Norrick B.
      • Ko C.
      • et al.
      Reduction in catheter-associated urinary tract infections by bundling interventions.
      ,
      • Leblebicioglu H.
      • Ersoz G.
      • Rosenthal V.D.
      • Nevzat-Yalcin A.
      • Akan O.A.
      • Sirmatel F.
      • et al.
      Impact of a multidimensional infection control approach on catheter-associated urinary tract infection rates in adult intensive care units in 10 cities of Turkey: International Nosocomial Infection Control Consortium findings (INICC).
      ,
      • Miller B.L.
      • Krein S.L.
      • Fowler K.E.
      • Belanger K.
      • Zawol D.
      • Lyons A.
      • et al.
      A multimodal intervention to reduce urinary catheter use and associated infection at a Veterans Affairs Medical Center.
      ,
      • Fakih M.G.
      • George C.
      • Edson B.S.
      • Goeschel C.A.
      • Saint S.
      Implementing a national program to reduce catheter-associated urinary tract infection: a quality improvement collaboration of state hospital associations, academic medical centers, professional societies, and governmental agencies.
      ,
      • Saint S.
      • Olmsted R.N.
      • Fakih M.G.
      • Kowalski C.P.
      • Watson S.R.
      • Sales A.E.
      • et al.
      Translating health care-associated urinary tract infection prevention research into practice via the bladder bundle.
      ,
      • Meddings J.
      • Saint S.
      • Krein S.L.
      • Gaies E.
      • Reichert H.
      • Hickner A.
      • et al.
      Systematic review of interventions to reduce urinary tract infection in nursing home residents.
      ,
      • Mody L.
      • Greene M.T.
      • Meddings J.
      • Krein S.L.
      • McNamara S.E.
      • Trautner B.W.
      • et al.
      A national implementation project to prevent catheter-Associated urinary tract infection in nursing home residents.
      ] [
      • Titsworth W.L.
      • Hester J.
      • Correia T.
      • Reed R.
      • Williams M.
      • Guin P.
      • et al.
      Reduction of catheter-associated urinary tract infections among patients in a neurological intensive care unit: a single institution's success.
      ,
      • Mody L.
      • Greene M.T.
      • Meddings J.
      • Krein S.L.
      • McNamara S.E.
      • Trautner B.W.
      • et al.
      A national implementation project to prevent catheter-Associated urinary tract infection in nursing home residents.
      ] [
      • Saint S.
      • Greene M.T.
      • Kowalski C.P.
      • Watson S.R.
      • Hofer T.P.
      • Krein S.L.
      Preventing catheter-associated urinary tract infection in the United States: a national comparative study.
      ,
      • Lo E.
      • Nicolle L.E.
      • Coffin S.E.
      • Gould C.
      • Maragakis L.L.
      • Meddings J.
      • et al.
      Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update.
      ,
      • Titsworth W.L.
      • Hester J.
      • Correia T.
      • Reed R.
      • Williams M.
      • Guin P.
      • et al.
      Reduction of catheter-associated urinary tract infections among patients in a neurological intensive care unit: a single institution's success.
      ,
      • Andreessen L.
      • Wilde M.H.
      • Herendeen P.
      Preventing catheter-associated urinary tract infections in acute care: the bundle approach.
      ,
      • Kanj S.S.
      • Zahreddine N.
      • Rosenthal V.D.
      • Alamuddin L.
      • Kanafani Z.
      • Molaeb B.
      Impact of a multidimensional infection control approach on catheter-associated urinary tract infection rates in an adult intensive care unit in Lebanon: International Nosocomial Infection Control Consortium (INICC) findings.
      ,
      • Navoa-Ng J.A.
      • Berba R.
      • Rosenthal V.D.
      • Villanueva V.D.
      • Tolentino M.C.V.
      • Genuino G.A.S.
      • et al.
      Impact of an International Nosocomial Infection Control Consortium multidimensional approach on catheter-associated urinary tract infections in adult intensive care units in the Philippines: International Nosocomial Infection Control Consortium findings.
      ,
      • Rosenthal V.D.
      • Todi S.K.
      • Álvarez-Moreno C.
      • Pawar M.
      • Karlekar A.
      • Zeggwagh A.A.
      • et al.
      Impact of a multidimensional infection control strategy on catheter-associated urinary tract infection rates in the adult intensive care units of 15 developing countries: findings of the International Nosocomial Infection Control Consortium (INICC).
      ,
      • Marra A.R.
      • Sampaio Camargo T.Z.
      • Gonçalves P.
      • Sogayar A.M.C.B.
      • Moura D.F.
      • Guastelli L.R.
      • et al.
      Preventing catheter-associated urinary tract infection in the zero-tolerance era.
      ,
      • Clarke K.
      • Tong D.
      • Pan Y.
      • Easley K.A.
      • Norrick B.
      • Ko C.
      • et al.
      Reduction in catheter-associated urinary tract infections by bundling interventions.
      ,
      • Leblebicioglu H.
      • Ersoz G.
      • Rosenthal V.D.
      • Nevzat-Yalcin A.
      • Akan O.A.
      • Sirmatel F.
      • et al.
      Impact of a multidimensional infection control approach on catheter-associated urinary tract infection rates in adult intensive care units in 10 cities of Turkey: International Nosocomial Infection Control Consortium findings (INICC).
      ,
      • Miller B.L.
      • Krein S.L.
      • Fowler K.E.
      • Belanger K.
      • Zawol D.
      • Lyons A.
      • et al.
      A multimodal intervention to reduce urinary catheter use and associated infection at a Veterans Affairs Medical Center.
      ,
      • Fakih M.G.
      • George C.
      • Edson B.S.
      • Goeschel C.A.
      • Saint S.
      Implementing a national program to reduce catheter-associated urinary tract infection: a quality improvement collaboration of state hospital associations, academic medical centers, professional societies, and governmental agencies.
      ,
      • Saint S.
      • Olmsted R.N.
      • Fakih M.G.
      • Kowalski C.P.
      • Watson S.R.
      • Sales A.E.
      • et al.
      Translating health care-associated urinary tract infection prevention research into practice via the bladder bundle.
      ,
      • Meddings J.
      • Saint S.
      • Krein S.L.
      • Gaies E.
      • Reichert H.
      • Hickner A.
      • et al.
      Systematic review of interventions to reduce urinary tract infection in nursing home residents.
      ,
      • Mody L.
      • Greene M.T.
      • Meddings J.
      • Krein S.L.
      • McNamara S.E.
      • Trautner B.W.
      • et al.
      A national implementation project to prevent catheter-Associated urinary tract infection in nursing home residents.
      ] [
      • Saint S.
      • Greene M.T.
      • Kowalski C.P.
      • Watson S.R.
      • Hofer T.P.
      • Krein S.L.
      Preventing catheter-associated urinary tract infection in the United States: a national comparative study.
      ,
      • Lo E.
      • Nicolle L.E.
      • Coffin S.E.
      • Gould C.
      • Maragakis L.L.
      • Meddings J.
      • et al.
      Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update.
      ,
      • Titsworth W.L.
      • Hester J.
      • Correia T.
      • Reed R.
      • Williams M.
      • Guin P.
      • et al.
      Reduction of catheter-associated urinary tract infections among patients in a neurological intensive care unit: a single institution's success.
      ,
      • Andreessen L.
      • Wilde M.H.
      • Herendeen P.
      Preventing catheter-associated urinary tract infections in acute care: the bundle approach.
      ,
      • Kanj S.S.
      • Zahreddine N.
      • Rosenthal V.D.
      • Alamuddin L.
      • Kanafani Z.
      • Molaeb B.
      Impact of a multidimensional infection control approach on catheter-associated urinary tract infection rates in an adult intensive care unit in Lebanon: International Nosocomial Infection Control Consortium (INICC) findings.
      ,
      • Navoa-Ng J.A.
      • Berba R.
      • Rosenthal V.D.
      • Villanueva V.D.
      • Tolentino M.C.V.
      • Genuino G.A.S.
      • et al.
      Impact of an International Nosocomial Infection Control Consortium multidimensional approach on catheter-associated urinary tract infections in adult intensive care units in the Philippines: International Nosocomial Infection Control Consortium findings.
      ,
      • Rosenthal V.D.
      • Todi S.K.
      • Álvarez-Moreno C.
      • Pawar M.
      • Karlekar A.
      • Zeggwagh A.A.
      • et al.
      Impact of a multidimensional infection control strategy on catheter-associated urinary tract infection rates in the adult intensive care units of 15 developing countries: findings of the International Nosocomial Infection Control Consortium (INICC).
      ,
      • Marra A.R.
      • Sampaio Camargo T.Z.
      • Gonçalves P.
      • Sogayar A.M.C.B.
      • Moura D.F.
      • Guastelli L.R.
      • et al.
      Preventing catheter-associated urinary tract infection in the zero-tolerance era.
      ,
      • Clarke K.
      • Tong D.
      • Pan Y.
      • Easley K.A.
      • Norrick B.
      • Ko C.
      • et al.
      Reduction in catheter-associated urinary tract infections by bundling interventions.
      ,
      • Leblebicioglu H.
      • Ersoz G.
      • Rosenthal V.D.
      • Nevzat-Yalcin A.
      • Akan O.A.
      • Sirmatel F.
      • et al.
      Impact of a multidimensional infection control approach on catheter-associated urinary tract infection rates in adult intensive care units in 10 cities of Turkey: International Nosocomial Infection Control Consortium findings (INICC).
      ,
      • Miller B.L.
      • Krein S.L.
      • Fowler K.E.
      • Belanger K.
      • Zawol D.
      • Lyons A.
      • et al.
      A multimodal intervention to reduce urinary catheter use and associated infection at a Veterans Affairs Medical Center.
      ,
      • Fakih M.G.
      • George C.
      • Edson B.S.
      • Goeschel C.A.
      • Saint S.
      Implementing a national program to reduce catheter-associated urinary tract infection: a quality improvement collaboration of state hospital associations, academic medical centers, professional societies, and governmental agencies.
      ,
      • Saint S.
      • Olmsted R.N.
      • Fakih M.G.
      • Kowalski C.P.
      • Watson S.R.
      • Sales A.E.
      • et al.
      Translating health care-associated urinary tract infection prevention research into practice via the bladder bundle.
      ,
      • Meddings J.
      • Saint S.
      • Krein S.L.
      • Gaies E.
      • Reichert H.
      • Hickner A.
      • et al.
      Systematic review of interventions to reduce urinary tract infection in nursing home residents.
      ,
      • Mody L.
      • Greene M.T.
      • Meddings J.
      • Krein S.L.
      • McNamara S.E.
      • Trautner B.W.
      • et al.
      A national implementation project to prevent catheter-Associated urinary tract infection in nursing home residents.
      ]. These bundles and programs may include the following components:
      • Educational and training interventions on catheter indications [
        • Jain M.
        • Dogra V.
        • Mishra B.
        • Thakur A.
        • Loomba P.S.
        Knowledge and attitude of doctors and nurses regarding indication for catheterization and prevention of catheter-associated urinary tract infection in a tertiary care hospital.
        ,
        • Hu F.-W.
        • Chang C.-M.
        • Tsai C.-H.
        • Chen C.-H.
        Exploring initial inappropriate use of urinary catheters among hospitalised older patients in Taiwan.
        ], insertion techniques, care and management.
      • Avoidance of indwelling catheter use, and the use of alternatives to indwelling urinary catheters where appropriate.
      • Aseptic catheter insertion technique by trained personnel, with all necessary supplies needed being made conveniently available. Records and indications for catheter insertion should be maintained.
      • Attention to hand hygiene practices
      • Surveillance and performance feedback systems.
      2a/B
      5.Secure and maintain integrity of closed urinary catheter systems, and prevent flow obstruction [
      • Lo E.
      • Nicolle L.E.
      • Coffin S.E.
      • Gould C.
      • Maragakis L.L.
      • Meddings J.
      • et al.
      Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update.
      ].
      3/B
      6.No recommendation can be made for the routine use of antibiotic prophylaxis for the prevention of CAUTI:
      • The use of antibiotic prophylaxis during short-term urinary catheterization of up to 14 days in adult patients was reviewed in several randomized controlled trials. Meta-analysis showed only limited evidence in reduction of rates of bacteriuria, pyuria and febrile morbidity in surgical patients post-operatively, and reduction of symptomatic UTIs with antibiotic prophylaxis at the time of catheter removal [
        • Salomon J.
        • Denys P.
        • Merle C.
        • Chartier-Kastler E.
        • Perronne C.
        • Gaillard J.-L.
        • et al.
        Prevention of urinary tract infection in spinal cord-injured patients: safety and efficacy of a weekly oral cyclic antibiotic (WOCA) programme with a 2 year follow-up -- an observational prospective study.
        ,
        • Lusardi G.
        • Lipp A.
        • Shaw C.
        Antibiotic prophylaxis for short-term catheter bladder drainage in adults.
        ,
        • Marschall J.
        • Carpenter C.R.
        • Fowler S.
        • Trautner B.W.
        Antibiotic prophylaxis for urinary tract infections after removal of urinary catheter: meta-analysis.
        ].
      • Meta-analysis on the use of antibiotic prophylaxis in patients requiring long-term intermittent or indwelling urinary catheterization showed inconsistent and limited evidence of efficacy [
        • Niël-Weise B.S.
        • van den Broek P.J.
        • da Silva E.M.K.
        • Silva L.A.
        Urinary catheter policies for long-term bladder drainage.
        ].
      • The decision to use antibiotic prophylaxis must consider local microbial prevalence and antibiotic resistance patterns, as well as risk-benefit ratio and cost considerations of the antibiotic. In Asia, it is unlikely that prophylaxis will be effective in view of high rates of antimicrobial resistance, and it might have the unintended consequence of selecting for even more resistant pathogens.
      1a/D

      9. Further research

      Studies on the impact of hydrophilic catheters [
      • Rognoni C.
      • Tarricone R.
      Intermittent catheterisation with hydrophilic and non-hydrophilic urinary catheters: systematic literature review and meta-analyses.
      ], chlorhexidine baths [
      • Strouse A.C.
      Appraising the literature on bathing practices and catheter-associated urinary tract infection prevention.
      ,
      • Reagan K.A.
      • Chan D.M.
      • Vanhoozer G.
      • Stevens M.P.
      • Doll M.
      • Godbout E.J.
      • et al.
      You get back what you give: decreased hospital infections with improvement in CHG bathing, a mathematical modeling and cost analysis.
      ,
      • Pallotto C.
      • Fiorio M.
      • De Angelis V.
      • Ripoli A.
      • Franciosini E.
      • Quondam Girolamo L.
      • et al.
      Daily bathing with 4% chlorhexidine gluconate in intensive care settings: a randomized controlled trial.
      ,
      • Frost S.A.
      • Hou Y.C.
      • Lombardo L.
      • Metcalfe L.
      • Lynch J.M.
      • Hunt L.
      • et al.
      Evidence for the effectiveness of chlorhexidine bathing and health care-associated infections among adult intensive care patients: a trial sequential meta-analysis 11 Medical and Health Sciences 1103 Clinical Sciences 11 Medical and Health Sciences 1117 Public Health and Health Services.
      ] and nurse-driven catheter management protocols [
      • Durant D.J.
      Nurse-driven protocols and the prevention of catheter-associated urinary tract infections: a systematic review.
      ] remain small and not strong enough for generalized recommendations. Further studies into the utility, efficacy and cost-effectiveness of these preventive strategies, as well as other novel diagnostic stewardship [
      • Watson K.J.
      • Trautner B.
      • Russo H.
      • Phe K.
      • Lasco T.
      • Pipkins T.
      • et al.
      Using clinical decision support to improve urine culture diagnostic stewardship, antimicrobial stewardship, and financial cost: a multicenter experience.
      ,
      • Dougherty D.F.
      • Rickwa J.
      • Guy D.
      • Keesee K.
      • Martin B.J.
      • Smith J.
      • et al.
      Reducing inappropriate urine cultures through a culture standardization program.
      ,
      • Frontera J.A.
      • Wang E.
      • Phillips M.
      • Radford M.
      • Sterling S.
      • Delorenzo K.
      • et al.
      Protocolized urine sampling is associated with reduced catheter-associated urinary tract infections: a pre- and postintervention study.
      ] [
      • Watson K.J.
      • Trautner B.
      • Russo H.
      • Phe K.
      • Lasco T.
      • Pipkins T.
      • et al.
      Using clinical decision support to improve urine culture diagnostic stewardship, antimicrobial stewardship, and financial cost: a multicenter experience.
      ,
      • Dougherty D.F.
      • Rickwa J.
      • Guy D.
      • Keesee K.
      • Martin B.J.
      • Smith J.
      • et al.
      Reducing inappropriate urine cultures through a culture standardization program.
      ,
      • Frontera J.A.
      • Wang E.
      • Phillips M.
      • Radford M.
      • Sterling S.
      • Delorenzo K.
      • et al.
      Protocolized urine sampling is associated with reduced catheter-associated urinary tract infections: a pre- and postintervention study.
      ] [
      • Watson K.J.
      • Trautner B.
      • Russo H.
      • Phe K.
      • Lasco T.
      • Pipkins T.
      • et al.
      Using clinical decision support to improve urine culture diagnostic stewardship, antimicrobial stewardship, and financial cost: a multicenter experience.
      ,
      • Dougherty D.F.
      • Rickwa J.
      • Guy D.
      • Keesee K.
      • Martin B.J.
      • Smith J.
      • et al.
      Reducing inappropriate urine cultures through a culture standardization program.
      ,
      • Frontera J.A.
      • Wang E.
      • Phillips M.
      • Radford M.
      • Sterling S.
      • Delorenzo K.
      • et al.
      Protocolized urine sampling is associated with reduced catheter-associated urinary tract infections: a pre- and postintervention study.
      ] and surveillance measures are needed [
      • Fakih M.G.
      • Gould C.V.
      • Trautner B.W.
      • Meddings J.
      • Olmsted R.N.
      • Krein S.L.
      • et al.
      Beyond infection: device utilization ratio as a performance measure for urinary catheter harm.
      ,
      • Livorsi D.J.
      • Perencevich E.N.
      CAUTI surveillance: opportunity or opportunity cost?.
      ,
      • Trautner B.W.
      • Morgan D.J.
      ].

      Declaration of competing interest

      PAT has received research support from GlaxoSmithKline , Sanofi , Roche , Johnson and Johnson and Arcturus . LC declares no conflict of interest.

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