Prevention of catheter-associated urinary tract infection: implementation strategies of international guidelines

Objective to describe strategies used by health professionals on the implementation of the Centers for Disease Control and Prevention guidelines for the prevention of urinary infection related to catheterism. Method systematic review on literature based on data from CINAHL(r), Nursing & Allied Health Collection, Cochrane Plus Collection, MedicLatina, MEDLINE(r), Academic Search Complete, ACS - American Chemical Society, Health Reference Center Academic, Nursing Reference Center, ScienceDirect Journals and Wiley Online Library. A sample of 13 articles was selected. Results studies have highlighted the decrease of urinary tract infection related to catheterism through reminder systems to decrease of people submitted to urinary catheterism, audits about nursing professionals practice and bundles expansion. Conclusion the present review systemizes the knowledge of used strategies by health professionals on introduction to international recommendations, describing a rate decrease of such infection in clinical practice.


Introduction
Catheter-associated urinary tract infection (CAUTI) is frequent on hospitalized people. On infections associated to health care, catheter-associated urinary tract infection corresponds to 40% (1) . About 15% to 25% of hospitalized people are submitted to vesical catheterization (2) . In most cases, this technique is used without proper indication, extending its unnecessary use.
CAUTI is referred to in several studies about increase on mortality and morbidity, as well as hospitalization, and, consequently, associated costs (2) .
However, it is pointed out that when compared to other healthcare-associated infections (HAI), urinary tract infection (UTI) presents a low morbidity. A study carried out in the USA (2) determined that UTI rate was superior to 560 thousands when compared to other HAIs, with a mortality rate of 2.3%, and bacteriuria (which develop bactareamia) cases lower than 5%. UTI is the main cause of infecctions on secondary nosocomial bloodstream, about 17% of nosocomial bactareamia origin from urinary, with an associated mortality of 10%.
Society for Healthcare Epidemology of America (SHEA) estimates between 17% and 69% of CAUTI can be prevented through infection control recommendations, based on evidences (2) . The investigation suggests that CAUTI prevention goes through recommended actions, and based on evidences that lower the rate for this infection. Simple initiatives as hand hygiene, use of a reliable technique, maintenance and the way the catheter is removed can contribute to prevent the associated infection.
An unnecessary urinary catheterism and the period of permanency of catheter influence the infection development, being modifiable factors (2) . Currently, the practice based on evidences is a highlight in a culture that aims a quality standard for safe care. However, it is pointed out that many times professionals face a few embarrassments regarding the connection between results from the most current and practical investigation.
The way actions and/or strategies are applied for implementations, in one document, providing practical changeable tools to readers, based in measurable results. This systematic review supplies the answer to this need, gathering the scattered knowledge on literature and facilitating the access to safe practices based on evidences. The study's goal was to search evidences regarding strategies that health professionals found out on practice to apply/implement of CDC recommendations and CAUTI prevention.

Method
The structure of this systematic review on literature was based on the CAUTI thematic, elaborating the initial  We would like to highlight that the exclusion of articles was also related to lack of information about parameters considered important for the analysis; participants, interventions, results, study's draw.
Facing the studies' diversity and non-relevance to the investigation question, the parameter Comparison [C] was removed. We also considered, when selecting the studies, the bibliographic references mentioned (3) . On the initial phase, 92 articles were obtained, from which, 38 were excluded by their titles. After reading 53 abstracts, 29 articles were rejected. Twenty-five articles were fully analyzed, from which 12 were rejected, according the inclusion/exclusion criteria, leading to 13 articles selected to perform the systematic review on literature.    contribution to the answer to the investigation question.

Author(s) Year/Country Participants Interventions Results Design
Crouzet et al., 2007 (France) (5) Two hundred and thirtyfour clients submitted to urinary catheterism from several services on Besançon Hospial, between January 1 and June 30, 2005.
The nurse reminds the doctor on a daily basis about the urinary catheter removal in people with more than four days of catheterization Decrease on catheterization duration non-significant (p=0.14); however there were a significant decrease on orthopedic and cardiology services. Urinary tract infection incidence associated to catheterism has significantly decreased (p=0.03).

Quantitative study
Apisarnthanarak et al., 2007 (Thailand) (6)  The clients submitted to urinary catheterism were daily assigned in a database by nursing team with the respective catheterization indication. The clients with inappropriate catheterization indications were identified by the nursing team, and through investigation data, they analyzed with doctors the need for urinary catheterism.  (14) A hundred and fifty clients submitted to urinary catheterism in a Surgery unit, and 125 clients submitted to urinary catheterism in a Pulmonology unit -Hospital of the University of Colorado Intervention from a nurse-driven, who absorbs the scientific evidence in practice, taking into consideration the most recent recommendations, Phase 1: data collection about practice alterations and rate of catheter-associated urinary tract infection. Phase 2: House wide intervention, which constituted a review on hospital policies regarding insertion and attention to urinary catheter, conformity evaluation with recommended practices of competence and insertion training and maintenance of the catheter, and evaluation of used products on urinary catheterization Decrease on catheter duration on different phases from 1 to 3 -on Surgery Unit there was a significant decrease (p=0.018); Catheter-associated urinary tract infection rate: Pulmonology Unit has zero incidence before intervention, and kept this same incidence; The Surgery Unit has increased the catheter-associated urinary tract infection incidence on phase 1 to phase 2, and then decreased the incidence on phase 3. 96% of nurses concluded the training.
Quantitative study (the Figure 4 continue  for, at least, seven days) There was an intervention group (with reminder system), and a control group (without a reminder system). The investigative nurse evaluated and identified users with vesical catheterism on daily basis, and in case there was no indication, the nurse responsible for the user was informed, and the doctor was reported about the catheter removal.
Usage rate of urinary catheter decreased 22% on intervention group, when compared to control group. Decrease of average catheterism duration.
The reminder intervention has decreased the catheterassociated urinary tract infection incidence in 48% on intervention group, regarding the control group.
Quantitative study Mori, 2014 (USA) (17) Study performed in a community hospital with 150 beds. All hospitalized users who were submitted to vesical catheterism during hospitalization. The users from the obstetric area were excluded.
A clinical nurse specialist led a team of expert nurses, elements of infection control commission, and doctors, to the development of a practical guideline protocol based on the guidelines of the Centers for Diasease Control and Prevention de 2009, for the need of urinary catheter, as well as the maintenance record of urinary catheterism. This protocol allowed nurses to make decisions autonomously regarding the interruption of catheterism in case proper indications were not known and/or not justified.

Discussion
In the search for better evidence, we concluded that the articles present a high level of evidence for the answer to the matter being investigated. They are in between the levels I and II of evidence (4) , promoting a more consistent validity for the resolution of the problem.
The number of participants in the analyzed studies varied between 50 and 4,963. In two retrospective studies (11)(12) what was defined was the time of development of the studies, and not the number of clients.
Although big difference between the number of participants in different studies, having groups with more than 2,000 (6)(7) , the results were similar in comparison to smaller groups. We determined that, despite the difference in the methodology applied, the results of the studies are analogous. In the majority of them, there was an intervention phase and a post-intervention one (6)(7)(9)(10)(13)(14)17) . Some studies motivate the formation of nurses about the guidelines of prevention of CAUTI, revealing extreme importance in their duties (9, [11][12][13][14][15]17) .
Andrade VLF, Fernandes FAV.  (15)(16)(17) . According to the guidelines of CDC (2) , the early removal of the urinary catheter contributes for the prevention of the infection associated to this device.
One of the strategies used by the nurses was to remind the doctor about the necessity of the urinary catheter (5)(6)10) . The justification used by the nurses was based on appropriate indicators described on scientific evidence, concerning the need of the urinary catheter.
In the cases in which the catheters were not removed, the duration of the catheterization decreased, so did the incidence of CAUTI.
The dominant strategy throughout the studies is the application of bundles of many formats in the prevention of CAUTI (7)(8)(9)(11)(12)(13)(14) . Another identified strategy was the creation of the algorithm for the maintenance of the urinary catheter, based on evidence, whenever really necessary (12,17) . On With the purpose of assessing the necessity of the urinary catheter on clients, the impact of the daily participation of a nurse with management duties (nurse-led) was evaluated in the multidisciplinary visit and the assessment proposing the removal of the catheter (7) .
In this study, there is a decline of the usage and unnecessary usage of the vesical catheter. The decision making is based on evidence of the nurses in suspending the vesical catheterization. The nurses were based on the recommendation of scientific evidence for the making of protocols of performance in the prevention of CAUTI, from its insertion and maintenance, until the evaluation of the necessity of catheterization (9,(13)(14)(16)(17).
In summary, the health professionals, based on CAUTI prevention guidelines, present many methods of implementation, responding, in an efficient way, to this problematic. The attention during the procedure, handling of the vesical catheter, duration of the catheterization and staff training are of extreme importance (19)(20) .
Determining the crucial and decisive role that the health professional play in the prevention and control of urinary infection associated to urinary catheter. The awareness of the professionals for this problematic is a fundamental starting point for this supported practice, seen in some studies (9,(11)(12)(13)(14)(15)17) in which education was one of the tools for the starting point of this change.

Conclusion
The intervention based on evidence can promote the evaluation of the necessity of urinary catheterization and removing the catheter when not necessary and allowing the reduction of the CAUTI rate.
In relation to the goal of this study and in summary, the main strategies of implementation of the guidelines