CAREFUL WITH THAT CONDUIT Any invasive foreign body can present the risk of infection if it's improperly handled.

Urinary tract infections top the list of the most commonly reported healthcare- acquired bugs, according to the CDC. Approximately 75% of UTI result from catheterization, but they're highly preventable in the outpatient setting. The following precautions, based on guidelines from the CDC, Infectious Diseases Society of America and Society for Healthcare Epidemiology of America, can help you avoid catheter-associated urinary tract infections (CAUTI).

The risk exists
The risk of CAUTI among ambulatory surgery patients isn't as high as it is among acute-care or long-term-care patients. When outpatients get catheters, they're in for a few hours at the most, and often only in the sterile OR.

Still, "we're putting what one might consider a foreign body into the bladder through the urethra," says Robert Manasse, PhD, an infection control consultant at Garrett County Memorial Hospital in Oakland, Md. "Any time we introduce a foreign body, it is a potential point of entry for bacteria."

This point of entry can give bacteria a boost to reach the bladder, ureters or kidney following the patient's discharge, he says.

Appropriate use only
Every CAUTI prevention guideline urges providers, first and foremost, to use catheters only when necessary. "The main issue is overuse or inappropriate use," says Thomas Hooton, MD, a professor at the University of Miami (Fla.) School of Medicine and lead author of the IDSA's 2009 clinical practice guidelines on CAUTI. "It's estimated that 30% to 40% of those who are implanted with a catheter don't need it. In long-term care, for instance, a lot of times a catheter is put in for the convenience of staff."

In the outpatient setting, a catheter might be inserted to facilitate voiding when a surgical site impacts a patient's bladder or affects the ability to urinate, such as in general, GYN and urological surgery. But IDSA guidelines discourage their use for managing incontinence.

Catheters are a go-to solution for treating patients who appear to be suffering from post-op urinary retention, but technology may provide a simpler, less invasive option. Scanning the bladder with a portable ultrasound device can measure urine volume, possibly ruling out retention and needless catheterization. "A bladder scan can help select out who needs to be catheterized," says Dr. Hooton. "It makes sense and is quite useful." It's not a standard of care, but the CDC's guidelines describe bladder-scanning technology as "a promising technology for CAUTI prevention," and a review by Italian researchers in the Nov. 2010 Journal of Clinical Nursing showed its effectiveness.

Keep it clean and closed
You wouldn't think of starting an IV line without washing your hands and prepping the skin. Catheterization also demands aseptic technique to ensure a clean insertion. "The perception may be that if it's not a central line going into the blood, you don't need to take the same care," says Nasia Safdar, MD, PhD, director of infection prevention at the University of Wisconsin Hospital in Madison. "But it's just as critical, if not more so." Considering the organisms and moisture on the skin in the perineal area, she says, hand hygiene, gloving and skin prepping are important steps to take.

Once the catheter is in, proper maintenance is key. The guidelines recommend a closed drainage system with minimal disconnection and minimal manipulation of the catheter, which can introduce bacteria. The collection bag should always be below the bladder to prevent backflow.

Coatings considered
The pre-op antibiotics you're administering to your surgical patients are too narrowly targeted to have any preventive effect against CAUTI, says Dr. Hooton. So catheters treated with silver alloy (noted for its antibacterial properties), antibiotics or other antimicrobial substances would seem to offer a more direct defense. Clinically speaking, however, the jury's still out.

The CDC hasn't endorsed the effectiveness of coated catheters, although it suggests that facilities unable to lower their CAUTI rate through other interventions might consider their use. Additionally, in a study in the Nov. 2, 2012, issue of the journal Lancet, British researchers saw no significant difference in results following their short-term use. "Silver alloy-coated catheters were not effective for reduction of incidence of symptomatic CAUTI," the authors wrote, "The reduction we noted in CAUTI associated with nitrofural-impregnated catheters was less than that regarded as clinically important. Routine use of antimicrobial-impregnated catheters is not supported by this trial."

Then there's the question of cost. A pricier coated catheter may be preferable to treating UTI (which Medicare hasn't reimbursed since 2008), says Dr. Manasse. But in the quick and cost-conscious outpatient OR, is it worth it?

Cost isn't the only concern about coated catheters, though. "One always has to be concerned about exposing organisms to antibiotics, for fear of fostering resistance to a drug, or creating a multi-drug resistant organism," says Dr. Manasse. He suggests the use of condom catheters among male patients, which offer a non-invasive alternative, although not one that can resolve retention.

Removal and reinforcement
Catheter removal, the guidelines agree, should be done as soon as possible. "The longer the catheter's in, the more likely you will see harm from infection," says Dr. Hooton. Instituting a system of removal reminders, through stop orders or EMR alerts, may be advisable. And post-discharge follow-up is mandatory. "You should always know about patients who have a fever after surgery," says Dr. Hooton. "It could be an SSI. Or it could be UTI."

Implementing these precautions will require staff education, and possibly supervisory support. "There are expectations that CAUTI should be largely preventable," says Dr. Safdar. "The critical thing about infection prevention policy is, it needs to come from the top. It takes motion from management to establish a protocol. They have to show up."