This is the current release of the guideline.

This guideline updates a previous version: Catheter-associated UTIs. In: Grabe M, Bishop MC, Bjerklund-Johansen TE, Botto H, Çek M, Lobel B, Naber KG, Palou J, Tenke P, Wagenlehner F. Guidelines on urological infections. Arnhem, The Netherlands: European Association of Urology (EAU); 2009 Mar. p. 65-7. [1 reference]

Catheter-associated urinary tract infections

Patients with urinary catheters

Diagnosis

1. Urine culture (not recommended routinely in asymptomatic catheterised patients)
2. Blood cultures in septic patients
3. Examination for other causes of fever

Management/Treatment

1. Antimicrobial treatment, as indicated
2. Antifungal therapy (not recommended in asymptomatic patients)
3. Catheter removal
4. Post-removal management
5. Use of alternative drainage systems

Prevention/Screening

1. Antiseptic conditions when introducing an indwelling catheter
2. Minimise urethral trauma with use of lubricant and size/type of catheter
3. Drainage bag placement below level of the bladder
4. Minimal duration of catherisation
5. Bladder cancer screening for long-term catheterised patients

General Search Strategy

A structured literature search is performed for all guidelines but this search is limited to randomized controlled trials and meta-analyses, covering at least the past three years, or up until the date of the latest text update if this exceeds the three-year period. Other excellent sources to include are other high-level evidence, Cochrane review and available high-quality guidelines produced by other expert groups or organizations. If there are no high-level data available, the only option is to include lower-level data. The choice of literature is guided by the expertise and knowledge of the Guidelines Working Group.

Specific Strategy for This Guideline

The guideline working group surveyed extensive literature regarding the development, therapy, and prevention of catheter-associated UTIs (CAUTIs). They systematically searched for meta-analyses of randomised controlled trials available in Medline, and gave preference to the Cochrane Central Register of Controlled Trials, and also considered other relevant publications, rating them on the basis of their quality. Studies were identified through a PubMed search. The recommendations of the studies, rated according to a modification of the US Department of Health and Human Services (1992), give a close-to-evidence-based guideline for all medical disciplines, with special emphasis on urology, in which catheter care is an important issue.

Not stated

Levels of Evidence

1a Evidence obtained from meta-analysis of randomised trials

1b Evidence obtained from at least one randomised trial

2a Evidence obtained from one well-designed controlled study without randomisation

2b Evidence obtained from at least one other type of well-designed quasi-experimental study

3 Evidence obtained from well-designed non-experimental studies, such as comparative studies, correlation studies, and case reports

4 Evidence obtained from expert committee reports or opinions or clinical experience of respected authorities

Not stated

Methods Used to Formulate the Recommendations

• The first step in the European Association of Urology (EAU) guidelines procedure is to define the main topic.
• The second step is to establish a working group. The working groups comprise about 4-8 members, from several countries. Most of the working group members are academic urologists with a special interest in the topic. Specialists from other medical fields (radiotherapy, oncology, gynaecology, anaesthesiology etc.) are included as full members of the working groups as needed. In general, general practitioners or patient representatives are not part of the working groups. Each member is appointed for a four-year period, renewable once. A chairman leads each group.
• The third step is to collect and evaluate the underlying evidence from the published literature.
• The fourth step is to structure and present the information. All main recommendations are summarized in boxes and the strength of the recommendation is clearly marked in three grades (A-C), depending on the evidence source upon which the recommendation is based. Every possible effort is made to make the linkage between the level of evidence and grade of recommendation as transparent as possible.

The members of the Urinary Tract Infection (UTI) Working Group of the European Association of Urologists (EAU) Health Care Office established the first version of these guidelines in several consensus conferences. A second Working Group updated the guidelines and added several chapters. The first draft of each chapter was sent to the committee members asking for comments, which were then considered, discussed and incorporated accordingly.

Specific Methods Used for This Guideline

The text presents the findings of a comprehensive update produced as a collaborative effort by the European Society for Infection in Urology (ESIU) (the ESIU is a full EAU section office), the Urological Association of Asia, the Asian Association of UTI/Sexually Transmitted Disease (STD), the Western Pacific Society for Chemotherapy, the Federation of European Societies for Chemotherapy and Infection, and the International Society of Chemotherapy for Infection and Cancer.

Grades of Recommendation

1. Based on clinical studies of good quality and consistency addressing the specific recommendations and including at least one randomised trial
2. Based on well-conducted clinical studies, but without randomised clinical trials
3. Made despite the absence of directly applicable clinical studies of good quality

It should be noted that when recommendations are graded, the link between the level of evidence and grade of recommendation is not directly linear. Availability of randomised controlled trials (RCTs) may not necessarily translate into a grade A recommendation where there are methodological limitations or disparity in published results. Alternatively, absence of high level evidence does not necessarily preclude a grade A recommendation, if there is overwhelming clinical experience and consensus.

A formal cost analysis was not performed and published cost analyses were not reviewed.

The formal agreement to each updated chapter was achieved by the European Association of Urology (EAU) working group in a series of meetings.

There is no formal external review prior to publication.

The Appraisal of Guidelines for Research and Evaluation (AGREE) instrument was used to analyse and assess a range of specific attributes contributing to the validity of a specific clinical guideline.

The AGREE instrument, to be used by two to four appraisers, was developed by the AGREE collaboration (www.agreetrust.org ) using referenced sources for the evaluation of specific guidelines (see the "Availability of Companion Documents" field for further methodology information).

Note from the European Association of Urology (EAU) and the National Guideline Clearinghouse (NGC): The following recommendations were current as of March 2011. However, because the European Association of Urology updates their guidelines frequently, users may wish to consult the European Association of Urology Web site  for the most current version available.

Grades of recommendation (A-C) are defined at the end of the "Major Recommendations" field.

General Aspects

• Written catheter care protocols are necessary. (B)
• Health care workers should observe protocols on hand hygiene and the need to use disposable gloves between catheterised patients. (A)

Catheter Insertion and Choice of Catheter

• An indwelling catheter should be introduced under antiseptic conditions. (B)
• Urethral trauma should be minimised by the use of adequate lubricant and the smallest possible catheter calibre. (B)
• Antibiotic-impregnated catheters may decrease the frequency of asymptomatic bacteriuria within 1 week. There is, however, no evidence they decrease symptomatic infection. Therefore, they cannot be recommended routinely. (B)
• Silver alloy catheters significantly reduce the incidence of asymptomatic bacteriuria, but only for <1 week. There was some evidence of reduced risk for symptomatic urinary tract infection (UTI). Therefore, they may be useful in some settings. (B)

Prevention

• The catheter system should remain closed. (A)
• The duration of catheterisation should be minimal. (A)
• Topical antiseptics or antibiotics applied to the catheter, urethra, or meatus are not recommended. (A)
• Benefits from prophylactic antibiotics and antiseptic substances have never been established; therefore, they are not recommended. (A)
• Removal of the indwelling catheter after non-urological operation before midnight might be beneficial. (B)
• Long-term indwelling catheters should be changed in intervals adapted to the individual patient, but must be changed before blockage is likely to occur; however, there is no evidence for the exact intervals of changing catheters. (B)
• Chronic antibiotic suppressive therapy is generally not recommended. (A)
• The drainage bag should always be kept below the level of the bladder and the connecting tube. (B)

Diagnostics

• Routine urine culture in asymptomatic catheterised patients is not recommended. (B)
• Urine, and in septic patients also blood for culture, must be taken before any antimicrobial therapy is started. (C)
• Febrile episodes are only found in <10% of catheterised patients living in a long-term facility. It is therefore extremely important to rule out other sources of fever. (A)

Treatment

• While the catheter is in place, systemic antimicrobial treatment of asymptomatic catheter-associated bacteriuria is not recommended, except in certain circumstances, especially before traumatic urinary tract interventions. (A)
• In case of asymptomatic candiduria, neither systemic nor local antifungal therapy is indicated, but removal of the catheter or stent should be considered. (A/C)
• Antimicrobial treatment is recommended only for symptomatic infection. (B)
• In case of symptomatic catheter associated UTI (CAUTI) it might be reasonable to replace or remove the catheter before starting antimicrobial therapy if the indwelling catheter has been in place for >7 days. (B)
• For empirical therapy, broad-spectrum antibiotics should be given based on local susceptibility patterns. (C)
• After culture results are available antibiotic therapy has to be adjusted according to sensitivities of the pathogen sensitivity. (B)
• In case of candiduria associated with urinary symptoms, or if candiduria is the sign of a systemic infection, systemic therapy with antifungals is indicated. (B)
• Elderly female patients may need treatment if bacteriuria does not resolve spontaneously after catheter removal. (C)

Alternative Drainage Systems

• There is limited evidence that postoperative intermittent catheterisation reduces the risk of bacteriuria compared with indwelling catheters. No recommendation can be made. (C)
• In appropriate patients, a suprapubic, condom drainage system or intermittent catheter is preferable to an indwelling urethral catheter. (B)
• There is little evidence to suggest that antibiotic prophylaxis decreases bacteriuria in patients using intermittent catheterisation; therefore, it is not recommended. (B)

Long-Term Follow Up

• Patients with urethral catheters in place for ≥10 years should be screened for bladder cancer. (C)

Definitions:

Grades of Recommendation

1. Based on clinical studies of good quality and consistency addressing the specific recommendations and including at least one randomised trial
2. Based on well-conducted clinical studies, but without randomised clinical trials
3. Made despite the absence of directly applicable clinical studies of good quality

None provided

The type of supporting evidence is graded for each recommendation (see the "Major Recommendations" field).

Appropriate management and prevention of catheter-associated urinary tract infections (UTIs)

Not stated

The European Association of Urology (EAU) Guidelines long version (containing all 19 guidelines) is reprinted annually in one book. Each text is dated. This means that if the latest edition of the book is read, one will know that this is the most updated version available. The same text is also made available on a CD (with hyperlinks to PubMed for most references) and posted on the EAU websites Uroweb and Urosource (http://www.uroweb.org/guidelines/online-guidelines/  & http://www.urosource.com/diseases/ ).

Condensed pocket versions, containing mainly flow-charts and summaries, are also printed annually. All these publications are distributed free of charge to all (more than 10,000) members of the Association. Abridged versions of the guidelines are published in European Urology as original papers. Furthermore, many important websites list links to the relevant EAU guidelines sections on the association websites and all, or individual, guidelines have been translated to some 15 languages.

This guideline is adapted from the following source:

• Tenke P, Kovacs B, Bjerklund Johansen TE, Matsumoto T, Tambyah PA, Naber KG. European and Asian guidelines on management and prevention of catheter-associated urinary tract infections. Int J Antimicrob Agents 2008;31S: S68-S78.

European Association of Urology

Urinary Tract Infection Guidelines Working Group

Group Members: M. Grabe (Chairman); T.E. Bjerklund-Johansen; H. Botto; B. Wullt; M. Çek; K.G. Naber; R.S. Pickard; P. Tenke; F. Wagenlehner

All members of the Urological Infections guidelines writing panel have provided disclosure statements of all relationships which they have and which may be perceived as a potential source of conflict of interest. This information is kept on file in the European Association of Urology (EAU) Central Office database. This guidelines document was developed with the financial support of the EAU. No external sources of funding and support have been involved. The EAU is a non-profit organisation and funding is limited to administrative assistance and travel and meeting expenses. No honoraria or other reimbursements have been provided.

This is the current release of the guideline.

This guideline updates a previous version: Catheter-associated UTIs. In: Grabe M, Bishop MC, Bjerklund-Johansen TE, Botto H, Çek M, Lobel B, Naber KG, Palou J, Tenke P, Wagenlehner F. Guidelines on urological infections. Arnhem, The Netherlands: European Association of Urology (EAU); 2009 Mar. p. 65-7. [1 reference]

Electronic copies: Available in Portable Document Format (PDF) from the European Association of Urology Web site . Also available in Russian  and Spanish .

Print copies: Available from the European Association of Urology, PO Box 30016, NL-6803, AA ARNHEM, The Netherlands.

The following are available:

• Guidelines on urological infections. Pocket guideline. Arnhem, The Netherlands: European Association of Urology (EAU); 2010 Apr. 17 p. Electronic copies: Available in English , Spanish , Portuguese , and Russian  from the European Association of Urology Web site.
• EAU guidelines office template. Arnhem. The Netherlands: European Association of Urology (EAU); 2007. 4 p.
• The European Association of Urology (EAU) guidelines methodology: a critical evaluation. Arnhem, The Netherlands: European Association of Urology (EAU); 2009. 6 p. Electronic copies: Available from the European Association of Urology Web site .

Print copies: Available from the European Association of Urology, PO Box 30016, NL-6803, AA ARNHEM, The Netherlands.

Also, Chapter 2 of the original guideline document  presents a system of classification for urinary tract infection (UTI) being proposed by the EAU/International Consultation on Urological Diseases (ICUD) based on anatomical level of infection, grade of severity of infection, underlying risk factors, and microbiological findings.

None available

This NGC summary was completed by ECRI Institute on September 8, 2008. The information was verified by the guideline developer on December 8, 2008. This summary was updated by ECRI Institute on January 8, 2010. This NGC summary was updated by ECRI Institute on November 17, 2011. The updated information was verified by the guideline developer on December 23, 2011.

This summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Downloads are restricted to one download and print per user, no commercial usage or dissemination by third parties is allowed.