The Centers for Disease Control and Prevention (CDC) released in May its Guide to Infection Prevention in Outpatient Settings: Minimum Expectations for Safe Care. Specific sections of the publication, with links to full guidelines and source documents, are devoted to needed resources including staff education and training as well as standards for the monitoring and reporting of infections. Existing standard precautions are, of course, included, such as hand hygiene, personal protective equipment, injection safety, and cleaning and disinfection of environment and medical equipment.
Outpatient settings are the CDC’s focus because of the rapid shift from inpatient to ambulatory care settings. Three-quarters of all surgeries in the U.S. are now performed on an outpatient basis, and more than a million cancer patients receive outpatient chemotherapy, radiation therapy or both. Kidney dialysis is outpatient and so is a significant portion of all diagnostic procedures across service lines.
One such section is a separate guideline for prevention of catheter-associated urinary tract infections (CAUTI). The document updates and expands the original CDC Guideline published in 1981. To evaluate the evidence in the intervening 28 years on preventing CAUTI, the authors examined data addressing three key questions and related sub-questions:
- Who should receive urinary catheters? When is catheterization necessary and who is at risk for CAUTI?
- For those who may require urinary catheters, what are the best practices in terms of approaches, types of catheters and collection systems, management techniques, and quality improvement programs?
- What are the best practices for preventing CAUTI associated with obstructed urinary catheters?
Providers in the acute care hospital setting are strictly instructed to insert urinary catheters using aseptic technique and sterile equipment. Routine use of antiseptic lubricants is not necessary. However, in the non-acute care setting, clean (i.e., non-sterile) technique for intermittent catheterization is considered an acceptable and more practical alternative to sterile technique for patients requiring chronic intermittent catheterization, although the CDC recommendations state that further research is needed on optimal cleaning and storage methods for catheters re-used for clean intermittent catheterization. This recommendation is based on category level IA evidence (p. 12). Hydrophilic catheters are considered preferable to standard catheters for patients requiring intermittent catheterization, although this was based on very low level evidence. Silicone might be preferable to other catheter materials, although this statement is not definitive.
Although there is not a cross reference found in the CDC’s publication to the 2009 policy change announced by the Centers for Medicare and Medicaid (CMS) commencing coverage for single use, sterile catheters, it is this patient advocate’s opinion that those at highest risk of infection and those already witnessing recurrent UTIs (four or more a year) should be provided access with insurance coverage to sterile devices regardless of the CDC’s recommendations.
Practical instructions are included as well. Unobstructed urine flow is to be maintained by keeping the catheter and collecting tube free from kinking and keeping the collecting bag below the level of the bladder at all times. The bag should not be rested on the floor to avoid contamination. The collection bag should be emptied regularly using a separate, clean collecting container for each patient and splashing should be avoided. The drainage spigot should not be put in contact with the non-sterile collection container.
The CDC publication also attempts to dispel myths and unsupported actions. For example, routine irrigation of the bladder with antimicrobials is not recommended, nor is routine instillation of antiseptic or antimicrobial solutions into urinary drainage bags (p. 14). Nor should the periurethral area be cleaned with antiseptics with the goal of preventing CAUTI while the catheter is in place. Routine hygiene during daily bathing or showering, including cleansing of the meatal surface, is appropriate and considered standard care (p. 13).
Particularly for men with serious urine retention resulting from a distended bladder caused by an enlarged prostate gland blocking urine flow through the urethra, these latest guidelines are worthy of study so that advice and product guidance from providers is consistent with these recommendations. Those facing catheterization while hospitalized should be sure the facility’s practices are compliant with this CDC publication. Every provider should practice with quality improvement programs that include a system of alerts and reminders to patients assessing the need for continued catheterization, guidelines and protocols for nurses to remove unnecessary urinary catheters, education and performance feedback on hygienic practices, and guidelines in place for catheter management after placement.