This document discusses catheterization, including appropriate indications, insertion techniques, complications, and prevention of catheter-associated urinary tract infections (CAUTIs). The key points are: 1) Catheters should only be used for approved indications and removed as soon as possible to prevent CAUTIs. 2) CAUTIs are the most common healthcare-associated infection and have significant costs and patient impacts. 3) Biofilm formation on catheters is a major mechanism of CAUTI development. Strict aseptic insertion and maintenance techniques can reduce risk.

2. Catheter: Basics
Dr Prashant Mulawkar

3. Appropriate
Indications for
Catheters
• Acute Urinary Retention or bladder outlet
obstruction
• Critical output monitoring in critically ill
patients (hourly uop measurement)
• Peri-operatively in selected surgical procedures
– GU tract of its contiguous structures
– Long procedures
– Large volume infusions or diuretics during
surgery
– Intra-operative urinary output monitoring
» Gould CV et al, HICPAC guidelines: 2006,9-13

4. Appropriate
indications for
catheters
• Assist healing of open sacral or perineal
wounds in incontinent patients
• Prolonged immobilization
– Unstable thoracic or lumbar spine
– Multiple traumatic injuries
• Improve comfort for end of life care
» Gould CV et al, HICPAC guidelines: 2006,9-13

5. Non-indwelling catheters
Irrigation
Intravesical antibiotics
Intravesical cytotoxic medications
Urodynamic investigations
Cystograms

6. Contraindications
Traumatic urethral injury
H/o urethral stricture .
Resistance to passage .
Blood at meatus

7. Insertion Technique
Gloves
Cleaning the
genitalia
Draping
Lubrication:
Lot of jelly
WAIT
Aseptic Non-
touch insertion
WAIT for urine
to come
Inflate balloon
with st water

8. Catheterization Procedure
• Short video
• https://www.youtube.com/watch?v=gKWT5DBCQm0
• Long video:
• https://www.youtube.com/watch?v=Kk_ObQOYUYU

9. Choosing the
right catheter
Material
Latex
Silocone elastomer coated
Silver coated
NFT coated
Triclosan Balloon

10. What size?
• Male: 14-16 fr
• Female 12-14 fr
Picture courtesy: Bard training
video; When the balloon goes up

11. How much Balloon?
• Larger balloon, more spasm
• Balloon does not prevent leakage
Picture courtesy: Bard training
video; When the balloon goes up

12. How to Clamp?
• Always clamp the tubing and not the
catheter
Picture courtesy: Bard training
video; When the balloon goes up

13. Let Gravity do the Job
Empty the drainage bag
or urine meter prior to
patient transport or
transfer to prevent
backward flow of urine
into the bladder.
1
Position the drainage
bag at the foot of the
bed and never allow
tubing to kink or loop.
2
Always keep the
drainage bag lower than
the catheter and the
patient’s bladder.
3

14. URINE LEAK BY THE SIDE
OF CATHETER
HOW TO MANAGE?
Case

15. Urine Leak by
the side of
catheter??
Is bladder palpable?
Ascertain patency
Empty bag
Wait
See Output
If yes bladder spasm
Treat with antimuscarinics
If no: catheter is blocked

16. Urine leak by side of Catheter
Never put larger
catheter
Never overinflate
the balloon

17. Removing Catheter
• Identify Patient
• Explain Procedure to him
• Privacy Provide privacy
• Wash your hands and put on exam gloves.
• Empty the balloon
• Pinch off and gently pull on the catheter
• Inspect the catheter to be sure no remnants remained in the bladder.
• Empty the drainage bag. Measure output
• Remove the gloves and wash your hands.
• Discard disposable supplies
• Do not discharge unless he passes urine

18. Sample Collection
• No need to disconnect urine bag
• Take sample with syringe
Picture courtesy: Bard training
video; When the balloon goes up

19. Instructions to the patient
• Ask your doctor/nurse each day if you still need your
catheter
• Make sure your catheter tubing is secured to your abdomen
if possible
• Make sure all hospital staff wash or sanitize their hands
before & after touching your catheter
• Do not tug, pull or twist the catheter tubing
• Always keep your urine drain bag below the level of your
bladder or hips
• Always keep your urine drain bag off of the floor
• Avoid disconnecting the catheter from the drain tube

20. Urethral vs SPC
Urethral SPC P
UTI 27% 6% P<0.001
Post-op hospital stay days 5.7 4.8 P<0.001
Trial of voiding days 4.4 2.7 P<0.001
Wells TH, Steed H, Capstick V, Schepanksy A, Hiltz M, Faught W.Suprapubic or urethral catheter:
what is the optimal method of bladder drainage after radical hysterectomy? J Obstet Gynaecol
Can. 2008 Nov;30(11):1034-8.

21. Intermittent Catheter vs SPC
• The use of intermittent catheterization following
urogynaecological surgery is associated with a more rapid
return to normal micturition and a shorter hospital stay,
although the clinical significance of the difference is perhaps
limited.
» Br J Nurs. 2010 Oct 14-27;19(18):S7-13. RCT of urethral versus suprapubic
catheterization. Dixon L, Dolan LM, Brown K, Hilton P.

22. Non deflating Foley Balloon
RULE OUT STONE
FIRST
Cut the balloon
arm
Ureteric catheter
stylet
Ether : No No Not
at all
Transabdominal
USG guided
puncture: usually
fails
Transrectal USG
guided puncture:
successful
PR guided
puncture
Transurethral
endoscopic
Suprapubic
endoscopic

23. Case 1
• 34 year male, traumatic paraplegia, S1, S2, S3 sensory motor
loss, LNM bladder, Failure to void. Residual urine. Best mode
of voiding
– A: Indwelling Foley
– B: SPC
– C: Creedes
– D: Self catheterization

24. Case 1A: Same patient
• Recovered from spinal shock. Ambulatory. On catheter. Ready
for discharge. How would you manage
– A: Remove Foley and send home
– B: Intermittent clamping and remove Foley
– C: CIC and measure residual
– D: Remove Foley and measure RUV by USG

25. What about bladder reconditioning?
• Should catheter be clamped intermittently before removal from stroke patients?
• NO
– Bladder reconditioning through IUC clamping has no noticeable benefits in
stroke patients and may induce additional problems. These findings suggest
that IUC removal without clamping is superior to IUC clamping for bladder
reconditioning in stroke patients.
» Am J Phys Med Rehabil. 2012 Aug;91(8):681-8. The usefulness of bladder reconditioning before indwelling urethral
catheter removal from stroke patients. Moon HJ, Chun MH, Lee SJ, Kim BR.

26. Should Catheter Washouts be given?
• All randomized and quasi-randomized trials comparing catheter washout
policies
– washout vs. no washout
– different washout solutions
– frequency, duration, volume, concentration, method of administration
– In any setting (i.e., hospital, nursing/residential home, community)
– Indwelling urethral or suprapubic catheter in place for more than 28 days
• The data were sparse and trials were generally of poor quality or poorly
reported.
• The evidence was too scant to conclude whether or not washouts were
beneficial
» Sinclair L, Hagen S, Cross S.Washout policies in long-term indwelling urinary catheterization in adults: a
short version cochrane review. Neurourol Urodyn. 2011 Sep;30(7):1208-12. doi: 10.1002/nau.21063.
Epub 2011 May 11.

27. Non-infectious Complications of Foley Catheter
No % FC days
Pain/ Difficult removal 36 0.6
Gross Hematuria 33 0.5
False passage 11 0.2
Ext trauma (gangrene/ paraphimosis / meatal erosion) 7 0.1
Misplacement: prostatic/intraperitoneal 7 0.1
Catheter removal with balloon inflated 4 0.1
Other 2 0.03
Leuck et al: J urol 2012: 187: 1662-66

28. Healthcare Associated Infections
Category Percent
Urinary Tract Infections UTI 32%
Surgical Site Infections SSI 22%
Lower Respiratory Tract
Infections LRTI
15%
Bloosstream Infec tion BSI 14%
Other 17%
32
22
15
14
17
%
UTI
SSI
LRTI
BSI
OTH
Klevins RM et al: Estimating healthcare associated infections and deaths in US 2002:
Public health reports 2007, March – April : 122: 160-66

29. High cost/
High Volume/
Reasonably
Preventable
conditions
• Catheter associated UTI
• Vascular catheter associated infection
• Retained object during surgery
• Air embolism
• Blood incompatibility
• Pressure ulcers
• Surgical site infections after certain surgical
procedures
• Falls and trauma
• Manifestations of poor glycemic control
• DVT or PE following certain orthopedic
saurgeries
» 42 CFR parts 411,412, 413 and 4898; August 2007::: Saint
S: preventing CAUTI: Translating research into practice:
catheterout.org website, University of Michigen

30. Why Speak of UTI
33 45 108 764
175000
248678
322946
561667
0
100000
200000
300000
400000
500000
600000
Wrong bld
Air embolism
Mediastinitis
Objects left Sx
Injuries from falls
Vascular cath infections
Pressure ulcers
CAUTI
DHHS Med Par data 2006: 42 CFR parts 411,412, 413 and 489: August 2007

31. Why Discuss CAUTI?
• 100,000,000 catheters sold worldwide annually
» Saint S et al, Are physicians aware of which of their patients, have catheters? Am J Med 2000, Oct 15,
109(6) 476-80
• 25% of hospitalised patients receive urinary catheters during their stay
• UTI= up to 40% of all HAI
• Vast majority of HA-UTI are CAUTI
• Not without increased cost and morbidity
» Saint S et al: A reminder reduces urinary catheterization in hospitalised patietns: J on Quality & Pt safety:
2005 (Aug) 31:8: 455-62

32. Scope of CAUTI issue
• Incidence: 3.1-7.5 infections per 1000 catheter days
• Highest rates in Burn ICU, followed by Inpatient medical wards and
Neurosurgical ICUs
• Lowest rates in Medical/Surgical ICUs
» Edwards JR et al: NHSN report: Am J Inf Control: 2007;35: 290-301

33. Clinical impact of CAUTI
• UTIs account for 40% of HAI, and of these 80% are associated with urinary
catheterization
• What CAUTI lack in terms of severity they make up in terms of volume
• UTIs are the second most common cause of bloodstream infections and
due to their frequency and subsequent T/t they are one of the largest
breeding grounds for antibiotic resistant organisms
» HICPAC, Guideline to prevention of CAUTI: 2009

34. Scope of CAUTI issue
26%
• Incidence of Catheter associated bacteruria
is 26% in pt with catheter for 2-10 days
24%
• 24% of those acquiring bacteruria will
advance to CAUTI
3%
• Approx 3% will develop bacteremia of
urinary origin
Greene et al : Guide to elimination of CAUTI: 2008

35. Case 2
• 53 year male, MI >> Catheter >> PCI
• On catheter, ready for discharge
• No urgency, dysuria, Suprapubic pain, costovertebral angle pain or
tenderness, No fever
• Urine culture: E coli, Colony >10^5, Pansensetive strain
• Blood culture : same organism
• TREATMENT??

36. CAUTI: Definition
• SUTI: Symptomatic UTI
– Pt has indwelling catheter at the time of (or within 48 hours prior to) specimen collection
– Pt exhibits at least 1 symptom
– (or) has a positive urinanalysis
– (And) a positive urine culture
• ABUTI: Asymptomatic bacteuria
– Pt is with or without an indwelling catheter
– Pt does not exhibit any signs or symptoms of infection
– Pt has a positive urine culture
– Pt has a positive blood culture
• As per the 2009 NHSN guidelines, Asymptomatic Bacteruria should not be treated
» Greene, L., Marx, J. & Oriola, S. Guide to the Elimination of Catheter-Associated Urinary Tract Infections (CAUTIs).
Publication. Washington D.C.: APIC, 2008.

37. Asymptomatic Bacteruria is often being treated
U-ABU, 48% T-ABU, 34% SUTI, 18%
0% 20% 40% 60% 80% 100%
Types
• U-ABU: Untreated ABU // T-ABU: Treated ABU // SUTI: Symptomatic
• The ABUTI accounted for 70% of the antimicrobial treated
possible UTI episodes
• The inappropriate use of antibiotics increases the risk of
antibiotic resistant infections
» Leuck et al: J Urol 187(2012):1662-666

38. Risk factors for CAUTI
Factor Relative risk
Prolonged catheterization >6 days 5.1-6.8
Female gender 2.3-3.7
Catheter insertion outside OR 2.0-5.3
Urology service 2.0-4.0
Other active sites of infection 2.3-2.4
Diabetes 2.2-2.3
Malnutrition 2.4
Azotemia (creat>2) 2.1-2.6
Ureteral stent 2.5
Monitoring of UOP 2.0
Drainage tube below level of bladder and above the collection bag 1.9
Antimicrobial drug therapy 0.1-0.4
Maki DG et al: 2001

39. CAUTI Pathogens
• Most are caused by urogenital and fecal flora
• Most common
– E. coli
– Enterococcus sp
– Yeast sp
» Saint and Chenowith CE: Biofilms and CAUTI: Inf dis clin North Am: 2003;17: 411-
432

40. Case 3
• 45 y female, Admitted with pyelonephritis, Received C/s
antibiotics
• On catheter, ready for discharge
• No urgency, dysuria, Suprapubic pain, costovertebral angle
pain or tenderness, No fever
• Recent Urine culture: No growth
• Urine R/M : Fungus
• TREATMENT??

41. Mechanism of Infection
• Extraluminal
– Biofilm
– Organism migration
– Perineal flora
– Faecal incontinence
• Intraluminal
– Closed system failure
– Outlet tube contamination
– Biofilm
Extraluminal
Gram positives 79%
Yeasts 69%
Gram Negatives 54%
Total 66%
Intraluminal
Gram Positives 21%
Yeasts 31%
Gram Negatives 46%
Total 34%
Maki DG, Tambyah PA. Engineering out the risk of infections with urinary catheters, Emerging infectious diseases, 2001: March April; 7(2)341-47

42. Ports of Entry

43. Stages of Biofilm formation

44. Prevention
• Make sure the catheter is indicated
• Adhere to general infection control principles
– Aseptic insertion, Proper maintainence, hand hygiene, properly
trained staff, feedback to care providers
• Remove catheter as soon as possible
• Consider alternatives to indwelling catheters
» Gould CV et al, HICPAC guidelines: 2006,9-13

45. Examples of Inappropriate Indwelling Catheter Use
• Incontinence
• Obtaining urine for culture of diagnostic test (when patient can void)
• Prolonged post-operative duration (more than 1 or 2 days)
» Gould CV et al, HICPAC guidelines: 2006,9-13, CMS Specifications manual for National
hospital inpatient quality measures 2009

46. How many Catheters are Inappropriate?
• 10% of the medical admissions had indwelling catheter
placed within 24 hours of admission
• 38% had no justifiable indication
» Munasinghe RL et al Appropriateness of use of indwelling catheters in patients
admitted to the medical service, Infection control and hospital epidemiology :
2001 October 22(10) 647-49

47. How many Catheters are Inappropriate?
• Unfortunately urinary catheters are often used unnecessarily
– 202 hospitalized patients with a urinary catheter studied
– Initial indication for its insertion inappropriate = 21%
– Continued catheterization judged inappropriate = almost 50%
» Saint S et al , AQ reminder reduces urinary catheterization in hospitalized patients:
J on quality and Patient safety. 2005 August 31(8) 455-62

48. What is the risk?
• In patients with indwelling catheters
– Risk of bacteruria increases by 5% everyday the catheter remains
indwelling
– 10-20% of those becoming bacteuric advance to symptomatic
CAUTI
– Around 3% will develop urinary associated bacteremia
» Saint S: Catherout.org website

49. Are physicians aware?
• Survey of 288 physicians
(attending, House staff, interns,
medical students)
• 469 patients
• 25% with catheters
• 31% of catheters were
inappropriate
% UNAWARE
Medical students 21%
Interns 21%
Residents 27%
Attending MD 38%
Saint S et al: are physicians aware which of their
patients have indwelling catheters? Am J Med
2000; 109(6): 476-80

50. Prevention: Popular Interventions
• Improving appropriateness and duration
– Insertion checklist
– Removal reminder systems
– Automatic stop orders
• Results on reminder systems
– CAUTI reduced by 52% (p=<0.001)
– Foley duration decreased by 37% (2.6 fewer days / pt)
– Stop orders were more effective than reminders
– Need for re-catherization not different, control vs intervention
» Meddings J et al, systematic review and meta analysis, reminder systems to reduce
CAUTI and urinary catheter use in hospitalised patients, Clin Infect Dis 2010;51(5) 550-
60

51. Alternatives to Indwelling
Catheters
• Use of portable bladder scanners
• Straight catheterization vs indwelling
• Condom catheter in male patients
• Bladder scan: accurate urine volume,
reduce no of intermittent catheter
– Decrease in UTI 87% >>50%
Saint S et al , Preventing hospital acquired UTI in USA: A

52. By failing to
prepare, you are
preparing to fail
-- Benjamin Franklin, inventor of flexible
urinary catheter (1752)