Hospital-onset urinary tract infections remain a common complication of inpatient care, and prevention strategies should address both catheter-associated and non–catheter-associated infections, according to new consensus recommendations published in Open Forum Infectious Diseases.

The recommendations were developed through a modified Delphi process involving a multidisciplinary panel of 17 US experts in infectious diseases, infection prevention and control, epidemiology, urology, urogynecology, clinical microbiology, nursing, and quality improvement. The researchers sought to address gaps in prevention guidance for non–catheter-associated hospital-onset urinary tract infections (UTIs), which lack standardized surveillance definitions and targeted interventions.

Recent surveillance data cited in the study show that catheter-associated urinary tract infection (CAUTI) rates declined by 11% between 2022 and 2023. However, non-CAUTI hospital-onset UTIs (HOUTIs) were reported to occur more frequently and were associated with three times the number of secondary hospital-onset bacteremia and fungemia events compared with CAUTIs.

Delphi Process and Consensus Thresholds

The panel conducted three Delphi rounds informed by a systematic literature review covering observational studies, randomized trials, and meta-analyses published since 2013.

The process included:

• An initial anonymous online survey

• A hybrid in-person and virtual meeting

• A final online survey to refine recommendations

Consensus thresholds were predefined. Strong consensus required agreement from at least 88% of panel members, while moderate consensus required agreement from at least 76%.

The panel ultimately reached strong consensus on 37 prevention statements spanning eight domains:

• Surveillance

• Intervention selection

• Intervention strategies

• Intervention maintenance

• Related care interventions

• Specimens and cultures

• Provider training

• Outcome assessment

Eight of the 37 recommendations were identified by the authors as unique recommendations not addressed in most existing prevention frameworks.

Surveillance and Diagnostic Stewardship

Panelists reached strong consensus that hospitals should define and track infection rates for both CAUTI and non-CAUTI HOUTIs using standardized surveillance definitions. Monthly reporting of non-CAUTI infection rates was recommended to support internal quality improvement efforts, although the researchers noted that these data should not be reported externally until surveillance definitions are validated and standardized.

The panel also highlighted the importance of using electronic health record systems rather than manual methods for infection surveillance, provided that key clinical data elements are consistently documented.

Researchers recommended documenting bladder management devices, insertion rationale, and symptom criteria within electronic systems to support surveillance and facilitate transitions to less invasive bladder management strategies.

Device Selection and Minimizing Catheter Use

Several consensus recommendations focused on reducing unnecessary catheterization.

The panel recommended using the least invasive devices possible to measure bladder output and progressively transitioning patients to less invasive approaches as clinical conditions permit. Bladder scanners should be used to evaluate suspected urinary retention before catheter insertion.

For male patients aged older than 55 with enlarged prostate, benign prostatic hyperplasia, or a history of difficult catheterization, the panel recommended considering Coudé-tip catheters to reduce insertion trauma.

Additional strategies to minimize infection risk included:

• Nurse-driven catheter management protocols

• Clinical decision support tools

• Tailoring bladder management devices to patient-specific factors such as urine output needs or incontinence

Infection Prevention and Maintenance Practices

The panel reaffirmed several established CAUTI prevention practices and extended them to all HOUTIs.

These included strict hand hygiene adherence by both patients and health care professionals and aseptic technique during urinary device insertion.

Strong consensus also supported the use of sealed, pre-connected closed catheter systems to maintain sterile drainage and reduce the risk of catheter-associated bacteriuria. If hourly urine output monitoring is anticipated, panelists recommended selecting a closed urinary system with a urometer at the outset to avoid breaking the closed system later.

Daily reassessment of bladder management strategies was recommended to determine whether continued catheter use remains necessary. Care team rounds or “huddles” were identified as an effective mechanism to review device necessity and facilitate timely transitions to less invasive options.

Culture Stewardship and Diagnostic Practices

The panel emphasized urine culture stewardship as an important component of antimicrobial stewardship and infection control.

Recommendations included:

• Requiring documentation of clinical symptoms prior to ordering urine cultures

• Using clean-catch, aseptic, or sterile collection techniques to reduce contamination

• Ensuring clinicians understand appropriate indications for urine testing

Urine culture stewardship may reduce inappropriate treatment of asymptomatic bacteriuria and support appropriate antibiotic use, the researchers noted.

Training and Outcome Monitoring

Panelists highlighted the role of clinician education and interdisciplinary training in infection prevention.

Recommended training areas included:

• Selection and placement of urinary devices

• Ongoing device assessment and removal

• Diagnostic stewardship and infection prevention principles

Training should extend beyond physicians and nurses to personnel who may manipulate bladder management systems, including transport staff.

Hospitals were also encouraged to monitor broader outcomes related to urinary device use, including length of hospital stay, antimicrobial exposure, device-related trauma, and transitions to less invasive devices.

Research Gaps

Despite reaching consensus on many recommendations, the panel identified several areas requiring additional research. These included hydration protocols, antiseptic cleansing of the urethral meatus prior to catheter insertion, use of antimicrobial catheters, molecular diagnostic testing for urinary pathogens, and surveillance reporting of non-CAUTI infections.

The lack of standardized diagnostic criteria and prevention strategies for non-CAUTI infections remains a major barrier to effective prevention, the researchers wrote. The framework is intended to help reduce the dual burden of CAUTI and non-CAUTI HOUTIs in adult hospitalized patients.

The hybrid meeting in Chicago was supported by Becton, Dickinson and Company, which covered travel expenses and provided meeting space and refreshments. The researchers reported that no sponsor, professional society, or external organization influenced the recommendations. All panel members participated in writing and editing the manuscript. Edward J. Septimus, MD, contributed to the conceptualization of the Delphi panel and received honoraria as meeting chair. Robert Garcia reported consulting for Bravida Inc., and Kathleen Vollman reported consulting for Stryker Sage.

Source: Open Forum Infectious Diseases