Urinary Catheterisation Prophylaxis in Adults - Guideline for Antimicrobial Prophylaxis
|Last review: 26/04/2019|
|Next review: 26/04/2022|
|Approved By: Improving Antimicrobial Prescribing Group|
|Copyright© Leeds Teaching Hospitals NHS Trust 2019|
This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
Guideline for antimicrobial prophylaxis during urinary catheterisation in adults: inpatient guidance
Urinary Catheterisation Prophylaxis in Adults
CSU, catheter specimen of urine; UTI, urinary tract infection;
The aim of this guideline is to standardise the use of antimicrobial prophylaxis for urinary bladder catheterisation.
A review of antimicrobial prophylaxis recommendations for urinary bladder catheterisation in Leeds has been prompted by:
Urinary tract infections (UTI) have previously been reported to account for about 40% of hospital-acquired (nosocomial) infections (HAIs), and about 80% of urinary tract infections acquired in hospital are associated with urinary catheters 4 5. More recent studies have found UTIs to account for 19-24.5% of HAIs6,7.
5.7-9% of hospital-acquired bacteraemias are caused by urinary catheter-associated urinary tract infections (CA-UTI) 8 and attributable mortality has been reported to be 12.7% 9. Relative to the number of catheters inserted, secondary bacteraemia is an uncommon complication occurring in <4% of patients with urinary catheter-associated bacteriuria 10.
Insertion of urethral catheters is a very common procedure, carried out in 11% of inpatients in one European study 11 and has a variety of indications including: peri-operative urine collection, management of urinary incontinence/retention and to measure urine output in acutely unwell patients.
Many factors have been associated with catheter-associated urinary tract infections and there are multiple approaches to reducing these infections but these guidelines are solely concerned with systemic antimicrobial prophylaxis.
Where the recommendations in these guidelines do not seem appropriate for a particular patient, discussion of the patient with a Microbiologist is advised.
In this guideline, the term catheter manipulation refers to either insertion, removal or change of a urinary catheter. This guideline does not cover patients who intermittently self catheterise.
There are relatively few studies of prophylaxis for routine catheter insertion. Most are not powered to detect any statistically significant difference in the rates of infection. A recent Cochrane review only found one study regarding antimicrobial use at catheter changes, and this was underpowered to offer statistically significant result, and predominately looked for catheter colonisation rather than a diagnosis of catheter-associated UTI12. These Leeds guidelines draw on national guidelines where available, a review of available evidence for specific areas of concern/controversy and local consensus.
There is considerable variation in the practise of prophylaxis for urethral catheter insertion in the UK 13. Practise in the UK varies with patient group and between healthcare professionals 14. Gentamicin is commonly used for insertion, change and removal; without a clear evidence base 13. The European Association of Urology guidelines on urological infection have recently recommended against antimicrobial prophylaxis for urinary catheter insertions 15.
Because urinary catheters are used in many different settings with different risks, a blanket approach to systemic antimicrobial prophylaxis would result in many patients receiving antimicrobials unnecessarily. These guidelines therefore deal with the common situations separately. Where a situation is not covered by the guideline or clinical circumstances require a different approach, discussion with Microbiology is recommended.
As a general principle, the risk of bacteraemia associated with catheterisation depends on prior urine colonisation or infection 16.
Recommendation: Patients with urinary tract infections (UTI) who require catheter insertion should be started on antimicrobial treatment prior to catheterisation wherever possible. Follow Guidelines for the diagnosis and treatment of UTI.
Recommendation: Uncatheterised patients known to have asymptomatic bacteriuria who require catheter insertion should be given a dose of antimicrobial prophylaxis prior to catheterisation according to susceptibilities of the urinary isolate.
Recommendation: Catheterised patients with urinary tract infections should be commenced on empirical treatment prior to catheter changes. Guidelines for the diagnosis and treatment of UTI.
Part A. Endocarditis, joint prostheses and other medical implants.
Part B Short term urinary catheters
N.B Early work on urological procedures revealed that bacteraemia rarely occurred when pre-operative urine was sterile.
Part C Long term indwelling urinary catheters.
* Taken from ‘The Green Book: Immunisation against infectious disease’
A recent Cochrane review only found one study regarding antimicrobial use at catheter changes, and this was underpowered to offer statistically significant results, and predominately looked for catheter colonisation rather than a diagnosis of catheter-associated UTI12. Therefore Cochrane states that there is not enough evidence to say whether the use of antibiotics at the time of catheter change to prevent infection is effective12. NICE guidelines recommend that prophylaxis is not required for routine changes of indwelling urethral catheters on the basis of low rates of infective complications coupled with a lack of evidence that prophylaxis is effective3, 12, except where patients have a history of symptomatic urinary tract infection after a catheter change, or where they experience trauma during the procedure (frank haematuria or 2 or more attempts of catheterisation)25.
Part D Urinary tract infection.
|Objective:||To standardise the approach to antimicrobial prophylaxis for urinary catheter manipulation in Leeds.|
|Target patient group:||Any patient undergoing manipulation (insertion/change/removal) of a urinary catheter|
|Target professional group(s):||Secondary Care Doctors
Secondary Care Nurses
- Gould FK, Elliott TS, Foweraker J, Fulford M, Perry JD, Roberts GJ, et al. Guidelines for the prevention of endocarditis: report of the Working Party of the British Society for Antimicrobial Chemotherapy. J Antimicrob Chemother 2006;57(6):1035-42.
- NICE. Prophylaxis against infective endocarditis: antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures. NICE clinical guideline 64: National Institue for Health and Clinical Excellence, 2008. Updated 2015
- NICE. Infection Control clinical guideline 02: National Institute for Health and Clinical Excellence, 2008.
- Meares EM, Jr. Current patterns in nosocomial urinary tract infections. Urology 1991;37(3 Suppl):9-12.
- Niel-Weise BS, van den Broek PJ. Antibiotic policies for short-term catheter bladder drainage in adults. Cochrane database of systematic reviews (Online) 2005(3):CD005428.
- Summary: Point prevalence survey of healthcare-associated infections and antimicrobial use in European hospitals 2011–2012 https://ecdc.europa.eu/sites/portal/files/media/en/healthtopics/Healthcare-associated_infections/point-prevalence-survey/Documents/healthcare-associated-infections-antimicrobial-use-PPS-summary.pdf
- National Point Prevalence Survey of Healthcare Associated Infection and Antimicrobial Prescribing 2016, NHS, National Services Scotland http://www.hps.scot.nhs.uk/resourcedocument.aspx?id=5964
- Anon. Surveillance of hospital acquired bacteraemia in English hospitals 1997-1999. London: Public Health Laboratory Service (PHLS), 2000:1-11.
- Bryan CS, Reynolds KL. Hospital-acquired bacteremic urinary tract infection: epidemiology and outcome. J Urol 1984;132(3):494-8.
- Krieger JN, Kaiser DL, Wenzel RP. Urinary tract etiology of bloodstream infections in hospitalized patients. J Infect Dis 1983;148(1):57-62.
- Stickler DJ, Zimakoff J. Complications of urinary tract infections associated with devices used for long-term bladder management. The Journal of hospital infection 1994;28(3):177-94.
- Cooper FPM, Alexander CE, Sinha S, Omar MI. Policies for replacing long-term indwelling urinary catheters in adults (Review). Cochrane database of systematic reviews 2016, Issue 7. Art No.: CD011115.
- Fraczyk L, Godfrey H. Current practice of antibiotic prophylaxis for catheter procedures. Br J Nurs 2004;13(10):610-7.
- Wazait HD, van der Meullen J, Patel HR, Brown CT, Gadgil S, Miller RA, et al. Antibiotics on urethral catheter withdrawal: a hit and miss affair. J Hosp Infect 2004;58(4):297-302.
- Grabe M, Bishop MC, Bjerklund-Johansen TE, Botto H, Çek M, Lobel B, et al. Guidelines on urological infections.: European Association of Urology, 2009, updated 2015
- Ibrahim AI. Hospital acquired pre-prostatectomy bacteriuria: risk factors and implications. East Afr Med J 1996;73(2):107-10.
- Polastri F, Auckenthaler R, Loew F, Michel JP, Lew DP. Absence of significant bacteremia during urinary catheter manipulation in patients with chronic indwelling catheters. J Am Geriatr Soc 1990;38(11):1203-8.
- Bregenzer T, Frei R, Widmer AF, Seiler W, Probst W, Mattarelli G, et al. Low risk of bacteremia during catheter replacement in patients with long-term urinary catheters. Arch Intern Med 1997;157(5):521-5.
- Garnham F, Smith C, Williams S. Best evidence topic report. Prophylactic antibiotics in urinary catheterisation to prevent infection. Emerg Med J 2006;23(8):649.
- Wazait HD, Patel HR, van der Meulen JH, Ghei M, Al-Buheissi S, Kelsey M, et al. A pilot randomized double-blind placebo-controlled trial on the use of antibiotics on urinary catheter removal to reduce the rate of urinary tract infection: the pitfalls of ciprofloxacin. BJU Int 2004;94(7):1048-50.
- Platt R, Polk BF, Murdock B, Rosner B. Prevention of catheter-associated urinary tract infection: a cost-benefit analysis. Infect Control Hosp Epidemiol 1989;10(2):60-4.
- Wroblewski BM, del Sel HJ. Urethral instrumentation and deep sepsis in total hip replacement. Clin Orthop Relat Res 1980(146):209-12.
- Berbari EF, Hanssen AD, Duffy MC, Steckelberg JM, Ilstrup DM, Harmsen WS, et al. Risk factors for prosthetic joint infection: case-control study. Clin Infect Dis 1998;27(5):1247-54.
- Saint S, Lipsky BA. Preventing catheter-related bacteriuria: should we? Can we? How? Arch Intern Med 1999;159(8):800-8.
- Healthcare-associated infections: prevention and control in primary and community care. Clinical guideline [CG139] Published date: March 2012 Last updated: February 2017 https://www.nice.org.uk/guidance/cg139/evidence/appendix-a-summary-of-new-evidence-pdf-4355390702
- Rutschmann OT, Zwahlen A. Use of norfloxacin for prevention of symptomatic urinary tract infection in chronically catheterized patients. Eur J Clin Microbiol Infect Dis 1995;14(5):441-4.
- Bursle EC, Dyer J, Looke DFM, MacDougall DAJ, Paterson DL & Playford EG. Risk factors for urinary cathether associated bloodstream infection. Journal of infection (2015) 70, 585-591
- Conway LJ, Liu J, Harris AD & Larson EL. Risk factors for bacteraemia in patients with urinary catheter-associated bacteriuria. American Journal of Critical Care Jan 2017, Vol 26, No 1 (43-52).
- Tambyah PA, Halvorson KT, Maki DG. A prospective study of pathogenesis of catheter-associated urinary tract infections. Mayo Clin Proc 1999;74(2):131-6.
- Ashley C, Currie A. The renal drug handbook. 2nd ed: Radcliffe Medical Press Ltd., 2004.
- The Green Book: Immunisation against infectious disease. Public Health Englnad, Published 17 December 2013. Chapter 6, last updated August 2017. Last accessed online on 25/4/2019 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/655225/Greenbook_chapter_6.pdf
Improving Antimicrobial Prescribing Group
LHP version 1.0
2018 Peer Review
Comment: Should the comment regarding previous resistance to prophylactic agents be added to the short term catheter table also?
Response: Amendment to tables to have asterixed comment regarding previous susceptibility to all instances of antibiotics.
Comment: Question regarding use of doxycycline as a suitable agent for preventing gram negative infections
Response: Following further discussion with colleagues it is apparent that doxycycline is a rarely used alternative as it is impracticable time-wise compared to gentamicin, and whilst it has reasonable anti-staphylococcal activity, the local resistance rates for gram negatives are not known as it is not routinely tested. As such doxycycline has been removed from the guideline.
Comment: Consideration that multiple or traumatic catheterisation (attempts) and also those with known asymptomatic bacteriuria (positive urine result with no symptoms) to be included as indications for prophylaxis
Response: Many of these patients may be covered by indications already listed already, such as by age, but that it is reasonable to add them specifically for those who may fall out-with the listed categories. Indications added.
Comment: Suggested removal of the table row regarding infective endocarditis as the text below is deemed sufficient
Response: Table row left in situ as the tables are used for quick reference and the full text is not always viewed; the mention in the table would often be the prompt to view specific text portions.
Comment: Request to give timing for catheter insertion after gentamicin administration.
Response: Already included in the table as <1hr; more detail added to the text regarding peak serum concentrations.
Comment: To add information about doxycycline being unlicensed for this indication.
Response: No longer relevant as doxycycline removed from the guideline.
Following peer review there was further discussion regarding the indications for prophylaxis for the change or removal of long term catheters. The final text represents a local consensus on risk factors.
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