2009 CAUTI guidelines - Centers for Disease Control and Prevention

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I. Executive SummaryThis guideline updates and expands the original Centers for Disease Control and Prevention(CDC) Guideline for Prevention of Catheter-associated Urinary Tract Infections (CAUTI)published in 1981. Several developments necessitated revision of the 1981 guideline, includingnew research and technological advancements for preventing CAUTI, increasing need toaddress patients in non-acute care settings and patients requiring long-term urinarycatheterization, and greater emphasis on prevention initiatives as well as better defined goalsand metrics for outcomes and process measures. In addition to updating the previousguideline, this revised guideline reviews the available evidence on CAUTI prevention forpatients requiring chronic indwelling catheters and individuals who can be managed withalternative methods of urinary drainage (e.g., intermittent catheterization). The revised guidelinealso includes specific recommendations for implementation, performance measurement, andsurveillance. Although the general principles of CAUTI prevention have not changed from theprevious version, the revised guideline provides clarification and more specific guidance basedon a defined, systematic review of the literature through July 2007. For areas where knowledgegaps exist, recommendations for further research are listed. Finally, the revised guidelineoutlines high-priority recommendations for CAUTI prevention in order to offer guidance forimplementation.This document is intended for use by infection prevention staff, healthcare epidemiologists,healthcare administrators, nurses, other healthcare providers, and persons responsible fordeveloping, implementing, and evaluating infection prevention and control programs forhealthcare settings across the continuum of care. The guideline can also be used as a resourcefor societies or organizations that wish to develop more detailed implementation guidance forprevention of CAUTI.Our goal was to develop a guideline based on a targeted systematic review of the best availableevidence, with explicit links between the evidence and recommendations. To accomplish this,we used an adapted GRADE system approach for evaluating quality of evidence anddetermining strength of recommendations. The methodology, structure, and components of thisguideline are approved by HICPAC and will be used for subsequent guidelines issued byHICPAC. A more detailed description of our approach is available in the Methods section.To evaluate the evidence on preventing CAUTI, we examined data addressing three keyquestions and related subquestions:1. Who should receive urinary catheters?A. When is urinary catheterization necessary?B. What are the risk factors for CAUTI?C. What populations are at highest risk of mortality related to urinary catheters?2. For those who may require urinary catheters, what are the best practices?Specifically, what are the risks and benefits associated with:A. Different approaches to catheterization?B. Different catheters or collecting systems?C. Different catheter management techniques?D. Different systems interventions (i.e., quality improvement programs)?3. What are the best practices for preventing CAUTI associated with obstructed urinarycatheters?8
Evidence addressing the key questions was used to formulate recommendations, and explicitlinks between the evidence and recommendations are available in the Evidence Review in thebody of the guideline and Evidence Tables and GRADE Tables in the Appendices. It isimportant to note that Category I recommendations are all considered strongrecommendations and should be equally implemented; it is only the quality of the evidenceunderlying the recommendation that distinguishes between levels A and B. Category ICrecommendations are required by state or federal regulation and may have any level ofsupporting evidence.The categorization scheme used in this guideline is presented in Table 1 in the Summary ofRecommendations and described further in the Methods section.The Summary of Recommendations is organized as follows: 1) recommendations for whoshould receive indwelling urinary catheters (or, for certain populations, alternatives to indwellingcatheters); 2) recommendations for catheter insertion; 3) recommendations for cathetermaintenance; 4) quality improvement programs to achieve appropriate placement, care, andremoval of catheters; 5) administrative infrastructure required; and 6) surveillance strategies.The Implementation and Audit section includes a prioritization of recommendations (i.e., highpriorityrecommendations that are essential for every healthcare facility), organized by modules,in order to provide facilities more guidance on implementation of these guidelines. A list ofrecommended performance measures that can potentially be used for internal reportingpurposes is also included.Areas in need of further research identified during the evidence review are outlined in theRecommendations for Further Research. This section includes guidance for specificmethodological approaches that should be used in future studies.Readers who wish to examine the primary evidence underlying the recommendations arereferred to the Evidence Review in the body of the guideline, and the Evidence Tables andGRADE Tables in the Appendices. The Evidence Review includes narrative summaries of thedata presented in the Evidence Tables and GRADE Tables. The Evidence Tables include allstudy-level data used in the guideline, and the GRADE Tables assess the overall quality ofevidence for each question. The Appendices also contain a clearly delineated search strategythat will be used for periodic updates to ensure that the guideline remains a timely resource asnew information becomes available.9
Page 4 and 5: AcknowledgementHICPAC thanks the fo
Page 6 and 7: AbbreviationsADLAPACHE IIASAASBBUNC
Page 10 and 11: II. Summary of RecommendationsTable
Page 12 and 13: II. Proper Techniques for Urinary C
Page 14 and 15: 1. If obstruction is anticipated, c
Page 16 and 17: a. Procedure-specific guidelines fo
Page 18 and 19: III. Implementation and AuditPriori
Page 20 and 21: IV. Recommendations for Further Res
Page 22 and 23: V. BackgroundUrinary tract infectio
Page 24 and 25: acteriuria inevitably occurs over t
Page 26 and 27: VII. MethodsThis guideline was base
Page 28 and 29: Figure 2: Results of the Study Sele
Page 30 and 31: After determining the GRADE of the
Page 32 and 33: Category I recommendations are defi
Page 34 and 35: VIII. Evidence ReviewQ1. Who should
Page 36 and 37: Evidence Review Table 1B. What are
Page 38 and 39: Very low-quality evidence suggested
Page 40 and 41: Q2B.2. Hydrophilic catheters vs. st
Page 42 and 43: For all comparisons, we considered
Page 44 and 45: a. Clamping vs. free drainage prior
Page 46 and 47: studies. 3,25,260-276 The findings
Page 48 and 49: 2D.5. Maintain unobstructed urine f
Page 50 and 51: 15. Jain P, Parada JP, David A, Smi
Page 52 and 53: 44. Chaudhuri P, Vengadasalam D. Ur
Page 54 and 55: 71. Kelleher RE, Meeropol E, Parks
Page 56 and 57: 101. Hirsh DD, Fainstein V, Musher
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132. Van Nagell, JR, Penny RM, Rodd
Page 60 and 61:
163. Lai KK, Fontecchio SA, Lai KK,
Page 62 and 63:
193. Waites KB, Canupp KC, Armstron
Page 64 and 65:
222. Cohen A. A microbiological com
Page 66 and 67:
253. Chavigny KH. The use of polymi
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2009 CAUTI guidelines - Centers for Disease Control and Prevention

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