Although guidelines differ in the amount of detail provided and their focus of efforts to prevent CAUTI (eg, the EAU/UAA guidelines discuss antimicrobial prophylaxis in detail, whereas the WOCN guidelines address catheter type and size in detail), the consistency of recommendations across 30 years is remarkable. Several of the most frequent and strongest recommendations were present in the 1981 guidelines. This consistency would most obviously be attributable to a strong body of evidence for the recommendations. Although this is true for some recommendations to prevent CAUTI (eg, the research into closed vs. open drainage systems is conclusive), for others, wide agreement exists only in theory (eg, the use of the smallest bore catheter possible). In fact, the authors of several guidelines state that the weight of evidence for many recommendations is scant.13,14,19
Lo et al noted that Cochrane reviews of CAUTI interventions consistently observed a “limited number of studies addressing any specific question, small study numbers, low quality of most studies, and heterogeneity in results, particularly when morbidity is addressed.”14
In fact, of the many strategies listed in the SHEA/IDSA guideline, only 3 positive recommendations and 4 proscriptions are based on good evidence from ≥1 properly randomized, controlled trial.
An alternate explanation for the consistency may involve the use by most guidelines of other guidelines as part of their evidence base. Although authors of guidelines need to appraise all evidence and review previous guidelines for gaps in recommendations, this cross-pollination may lend undue weight to some recommendations (especially those based on expert opinion). When good quality evidence was available, this threat was minimized. For example, after appraising new evidence, and in contrast to earlier guidelines, the IDSA recommended that the presence of a sacral ulcer did not provide an appropriate indication for catheter placement, and the WOCN recommended the routine use of silver alloy or antimicrobial catheters in select patients.
Although the guidelines are relatively consistent, different grading systems for quality of evidence and strength of recommendation make comparisons difficult. Moreover, what the recommendations purport to prevent remains unclear. With the exception of EAU/UAA and IDSA, these recommendations do not distinguish between the prevention of symptomatic CAUTI and the prevention of catheter-associated asymptomatic bacteriuria. This lack of clarity occurs because the majority of studies regarding CAUTI use outcome measures that do not make this distinction. Instead, investigators use varying levels of bacteriuria as the outcome of interest. For clinicians seeking to prevent CAUTI, the distinction is a moot point, because all symptomatic CAUTI begins as asymptomatic bacteriuria. However, for clinicians making treatment decisions, the distinction between CAUTI and bacteriuria is important and much debated.27
Separate guidelines address the management of asymptomatic bacteriuria.28
One notable change in recommendations has occurred in the area of catheter selection. Emerging evidence29,30
has led to tentative recommendations for the use of silver alloy and antimicrobial-impregnated catheters, an issue that was previously unresolved. A second change has involved the addition of quality measures. Since 2001, all but 1 of the CAUTI guidelines included recommendations for internal processes or outcome measures to guide efforts at prevention (eg, audit catheter care practices and feedback CAUTI incidence rates to clinical staff). In addition, the 2008 SHEA/IDSA and 2010 HICPAC guidelines provided detailed recommendations for the surveillance of CAUTIs, and advised the internal reporting of 3 outcome measures, ie, the incidence rates of CAUTIs using catheter days as the denominator, bacteremia attributable to CAUTI, and the proportion of appropriate urinary catheter use. Gaps exist, however, in guideline recommendations for strategies that promote the early removal of catheters. Specific advice is needed regarding the context in which automatic stop orders or nurse-directed protocols reduce catheter days or decrease rates of CAUTI.
The temporal relationship between the spike in guideline development and national quality/regulatory initiatives is in keeping with one of the purposes of developing guidelines: “they are to serve as a foundation for instruments to evaluate practitioner and health system performance,”9
and a goal of quality organizations such as the IHI involves “ensuring the broadest possible adoption of best practices.”31
The broad agreement of quality initiatives with guideline recommendations is reassuring, in that clinicians are not forced to choose between practices that benefit patients vs. those that benefit the institution.
Studies suggest that the strategies recommended in these guidelines to prevent CAUTI have not been widely adopted. In 2005, Saint et al surveyed the practices for preventing CAUTI in 719 acute-care American hospitals.32
Although >70% of participating hospitals monitored rates of CAUTI, only 44% monitored which patients had urinary catheters in place, and 26% monitored duration of catheterization. No single, widely used strategy to prevent CAUTI was evident. A small proportion of hospitals reported the regular use of antimicrobial catheters or portable bladder ultrasound (30%), condom catheters in men (14%), or catheter reminders or stop-orders (9%). A more recent national study resulted in similar findings.33
Further research is needed to elucidate why these recommendations are not adopted.
This study is subject to some limitations. Other than applying the 4 inclusion criteria, this review does not offer a critical appraisal of the methodological quality of the clinical practice guidelines included. Therefore, it cannot be used as a primary resource to guide policy or practice. Also, the review is subject to English-language bias, although one European guideline was included. Lastly, a single reviewer compared the guidelines, although the reviewer’s education and experience in the field of preventing infection served to reduce possible information bias. This summary provides a broad overview of recommendations over time; the reader is referred to individual guidelines for important caveats and nuances that accompany the recommendations.
Implications for Practice
The results of this review suggest that clinicians seeking to reduce rates of CAUTI at their hospitals should focus on 2 strategies that are strongly recommended according to good quality evidence: limit the use and duration of urinary catheterization, and maintain a closed, sterile drainage system. Good evidence supports daily reviews or automatic stop orders for identifying and removing catheters that are no longer necessary. Catheter maintenance practices that are well-justified with good evidence include hand hygiene immediately before or after any manipulation of the catheter or apparatus, obtaining small-volume urine samples aseptically from a sampling port, keeping the drainage bag below the level of the bladder, avoiding routine irrigation, and performing routine daily bathing rather than special urethral meatal care. Strong evidence exists that routinely treating asymptomatic bacteriuria, giving systemic antimicrobial prophylaxis, and placing antiseptics in the urine collection bag do not reduce rates of CAUTI.
A hospital committee tasked with setting institutional policies for preventing CAUTI will find either the 2010 IDSA or 2010 HICPAC guidelines most helpful. Both provide discussions of the evidence for each recommendation, along with extensive reference to the medical literature. Both are comprehensive. However, the HICPAC guideline addresses catheter insertion, maintenance, and quality measures in more detail, and includes a prioritization of recommendations.