Adherence to Guidelines for Preventing Catheter-Associated Urinary Tract Infections in Hospitalized Patients in a Tertiary Teaching Hospital

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Adhering to CDC guidelines is vital to prevent inappropriate use and reduce infection rates. This study evaluated compliance with these guidelines in hospitalized patients at a tertiary hospital in 2024. Methodology: A cross-sectional study assessed compliance with CDC guidelines for preventing catheter-associated urinary tract infections (CAUTIs) in hospitalized patients at Al-Zahra Hospital, Isfahan. Data were gathered through patient observation and chart reviews, evaluating demographics, catheter indications, retention duration, and guideline adherence. Department-specific compliance rates were also analyzed. Standardized checklists ensured consistent data recording. Results: Of 1262 patients evaluated, 477 (37.8%) underwent urinary catheterization, with a 57.3% adherence rate to CDC guidelines. The most common appropriate indication was acute urinary retention (15.4%), followed by urine output monitoring in critically ill patients (14.5%) and intraoperative monitoring (11.1%). Adherence was highest in cardiology and urology, while gynecology, rheumatology, plastic surgery, and vascular surgery had the lowest rates. The emergency department showed only 27.8% adherence. Conclusion: The findings highlight a suboptimal adherence rate to CDC guidelines in urinary catheterization, emphasizing the need for targeted interventions to improve compliance. Strategic interventions can enhance adherence and subsequently reduce catheter-associated urinary tract infections. Ethics approval and consent to participate This study was approved by the Ethics Committee of Isfahan University of Medical Sciences (Ethics approval code: IR.MUI.MED.REC.1401.326). All procedures involving human participants were conducted in accordance with the ethical standards of the institutional and/or national research committee and adhered to the principles outlined in the Declaration of Helsinki. Urinary Tract Infections Urinary Catheters Adolescent Hospitalized Figures Figure 1 Figure 2 Figure 3 Summary Statement What is already known about this topic? Catheter-associated urinary tract infections (CAUTIs) account for a significant proportion of healthcare-associated infections, with approximately 36% of such infections linked to urinary catheters. Previous studies have reported varying rates of inappropriate catheter placements across different settings, such as 39% in Chinese hospitals and 64.9% in U.S. emergency departments. Adherence to catheterization guidelines, such as those from the Centers for Disease Control and Prevention (CDC), is essential to reduce CAUTIs and associated complications, including urethral trauma and antimicrobial resistance. What this paper adds: The study revealed a 57.3% adherence rate to CDC guidelines for catheter placement in hospitalized patients at a tertiary teaching hospital. Acute urinary retention and monitoring of urine output in critically ill patients were the most frequent appropriate indications for catheter use, whereas substitution for nursing care in incontinent patients was a common inappropriate reason. Adherence rates varied significantly across hospital departments, with the cardiology department achieving full compliance and gynecology recording the lowest adherence. The implications of this paper: How can these findings influence clinical practice? Implementing regular training sessions and audits can enhance healthcare providers' adherence to catheterization guidelines, thereby reducing inappropriate catheter use. How can this research guide future interventions? Focused interventions targeting departments with low adherence rates, such as gynecology and the emergency room, could significantly improve patient outcomes and reduce CAUTI rates. What role can policy play in addressing the identified issues? Hospitals could adopt policy changes that mandate real-time feedback and automated reminders for timely catheter removal, ensuring compliance with established guidelines. Introduction Urinary tract infections (UTIs) are among the most common bacterial infections affecting humans and pose a significant burden on healthcare systems globally (A. Flores-Mireles et al., 2019; A. L. Flores-Mireles et al., 2015). These infections are broadly classified into uncomplicated and complicated UTIs, with catheter-associated urinary tract infections (CAUTIs) being a major contributor to the latter (A. Flores-Mireles et al., 2019; Tambyah & Oon, 2012). Distinct differences exist between uncomplicated UTIs and CAUTIs in terms of clinical presentation, causative organisms, and pathophysiology (A. Flores-Mireles et al., 2019; A. L. Flores-Mireles et al., 2015; Tambyah & Oon, 2012). Alarmingly, CAUTIs account for 36% of healthcare-associated infections, of which nearly 80% are linked to indwelling urinary catheters (Parker et al., 2017). Inappropriate catheter use, either without proper indication or in violation of established guidelines, is widespread (Parker et al., 2017). Studies have shown that in some regions, up to 39% of catheter placements in hospitalized patients in China (Jiang et al., 2020) and 64.9% in emergency departments in the United States did not meet appropriate criteria(Schuur et al., 2014). Such practices not only increase the risk of CAUTIs but also expose patients to other complications, including urethral trauma and long-term urethral stricture, particularly when catheters are not inserted correctly or by skilled personnel (Morozov A et al., 2024). Furthermore, the rising antimicrobial resistance associated with CAUTIs exacerbates the public health challenge posed by these infections (Lakoh et al., 2023). Also prolonged urinary catheterization has been identified as a significant factor contributing to the development of urethral strictures (Drinka, 2006). These complications are more likely when catheters are left in place beyond the recommended duration, emphasizing the importance of adhering to established guidelines for catheter use and timely removal to minimize associated risks. Several preventive strategies have been proposed to mitigate the risks associated with CAUTIs, including adherence to sterile catheter insertion techniques, the use of well-defined guidelines for catheter indications, and prompt removal of catheters as soon as clinically appropriate (Saint et al., 2016). Among these, the CDC has published a comprehensive guideline that, if adhered to, can significantly reduce the burden of CAUTIs on healthcare systems (Gould et al., 2019). Interventions aimed at improving compliance with such guidelines have demonstrated remarkable success, with studies showing reductions of up to 50% in inappropriate catheter placements (Fakih et al., 2014; Jaggi & Sissodia, 2012). Despite the critical importance of this issue, data on adherence to catheterization guidelines, particularly at local referral hospitals, remain scarce. This lack of evidence underscores the need for systematic research to assess current practices and identify areas for improvement. This study was designed to address this gap by evaluating the adherence to CDC guidelines for catheter placement indications in hospitalized patients. By systematically collecting and analyzing data on the frequency, appropriateness, and timing of catheter placements, this research aims to provide actionable insights to enhance guideline adherence and improve patient outcomes. The findings will serve as a foundation for targeted interventions and policy changes to address this pressing healthcare challenge in the region. Methods This descriptive cross-sectional study was conducted at Al-Zahra Hospital, a tertiary referral hospital in Isfahan, Iran in September and October 2024. The study protocol received approval from the institutional ethics board (IR.MUI.MED.REC.1401.326). Informed consent was obtained from all participants, and strict confidentiality measures were implemented to anonymize all identifiable data during analysis. The study population comprised randomly selected patients hospitalized during the study period. Inclusion criteria encompassed all hospitalized patients within the defined timeframe. Patients were excluded if they declined consent for catheterization, were under 18 years of age, or had pre-existing urinary catheters prior to admission. Additionally, patients in labor, pediatric wards, ICU, CCU, and day surgery units were excluded to ensure consistency and relevance. The required sample size was calculated as 351 patients using a margin of error of 5% and a 95% confidence level. Data Collection Procedures Data collection was performed through systematic visits to randomly selected hospital wards at intervals of at least four days. During each visit, researchers assessed every patient in the ward for inclusion in the study. As part of the process, bedside observations were conducted to document the presence or absence of urinary catheters and record patient demographic data, including age, gender, and length of hospitalization. For patients without current catheters, their medical records were reviewed to identify any history of catheterization during hospitalization. Data collected included admission and catheterization dates from physician orders, as well as indications for catheterization based on Centers for Disease Control and Prevention (CDC) guidelines for preventing catheter-associated urinary tract infections (CAUTI) which especially discusses the adult patients. Adherence Assessment Catheter placements were classified as either appropriate or inappropriate. Appropriate catheterization was determined by specific clinical needs, including (Gould et al., 2019): Acute urinary retention or bladder outlet obstruction Requirement for accurate urine output measurement in critically ill patients Perioperative use for certain surgical procedures: Urological surgery or other procedures involving structures adjacent to the genitourinary tract Anticipation of prolonged surgery duration (the catheter should be removed upon patient recovery from anesthesia) Anticipation of significant fluid or diuretic administration during surgery Need for intraoperative urine output monitoring Facilitation of healing for open sacral or perineal wounds in incontinent patients Prolonged immobility (e.g., unstable thoracic or lumbar spine injuries, multiple traumatic injuries such as pelvic fractures) Enhancing patient comfort in end-of-life care, if necessary Critically ill patients were identified as coma, cardiac arrest, respiratory failure, shock, endotracheal tube placement, ICU admission, and monitoring in cardiac catheterization units (Gould et al., 2019). Inappropriate catheter use was defined as: Substitution for nursing care in incontinent patients. Obtaining urine samples for diagnostic tests when patients could urinate voluntarily. Extended postoperative use without clear indications (e.g., structural repair, prolonged epidural anesthesia). For patients with appropriate placement the removal earliest opportunity was recoded if possible. Data Entry and Validation A web-based checklist was implemented to minimize errors during data transfer from forms to SPSS. Data were double-checked for completeness and accuracy, and a random subset of 10% of entries underwent cross-validation to ensure reliability. Data Analysis Qualitative variables were summarized using frequencies and percentages, while quantitative variables were described using means and standard deviations or median and interquartile range. The demographic variables were also compared between appropriate and inappropriately placed catheters. Results A total of 351 patients were included in the study. The demographic details of the study population, including age, gender distribution, and hospitalization duration, are summarized in Table 1. The mean age of participants was 57.7 years (SD= 20.1), with 63.7% identified as male and 36.3% as female. The average length of hospitalization was 8.96 (SD=10.1) days, ranging from 1 to 100 days. A total of 1262 patients were checked for inclusion 37.8% of which have experienced urinary characterization in their stay and 34.5% were included (Figure 1) Adherence to CDC Guidelines Overall, 57.3% of catheter placements adhered to the CDC guidelines, while 42.7% were classified as inappropriate. Among the appropriate indications for catheter placement, the most frequent reason was acute urinary retention or bladder outlet obstruction, accounting for 15.4% of cases (26.8% of appropriate placements), followed by monitoring accurate urine output in critically ill patients at 14.5% and monitoring urine output during surgery at 11.1% (Figure 2). Inappropriate indications were primarily due to substitution for nursing care in incontinent patients, and monitoring urine output in patients who are not considered critically ill. Departmental Variations Adherence rates varied across hospital Specialties (Figure 3). For example, Cardiology exhibited the highest adherence rate (100%), while Gynecology had the lowest (0%). Between the wards, besides gynecology with the highest rate of inappropriate catheter placements, plastic surgery ward and Emergency department had very high rates. For example, 72.2% of catheters in ER were inappropriate. Timing of Catheter Removal The mean duration of catheterization for cases with appropriate indications was 5.3 days, with a median of 4.5 days. For inappropriate indications, the mean duration was 4.25 days, with a median of 4 days. The mean delay time in removal of appropriate catheterizations was 1.9 days. Delays in removal were most commonly associated with urine output monitoring in patients who were not considered as severely ill any more. Discussion Our study found that only 57.3% of catheter placements adhered to CDC guidelines, with acute urinary retention or bladder outlet obstruction and monitoring accurate urine output in critically ill patients being the most common appropriate reasons respectively. The primary inappropriate reasons were substitution for nursing care in incontinent patients followed by monitoring urine output in non-critically ill patients. Adherence varied notably by ward, ranging from 100% in the cardiology ward to significantly lower adherence rates in gynecology and the emergency room, with the latter recording inappropriate catheterization in 72.2% of cases. The comparison of demographic variables between patients appropriately and inappropriately catheterized showed no significant difference which ensures proper randomization and also is in favor of age, gender and hospitalization duration of patients not being important factors in guideline adherence (Table 1). UTIs are most common hospital-acquired infections and they are associated with urinary catheters but limited studies have been conducted to assess adherence to guidelines aimed at preventing catheter-associated UTIs. The adherence rate in our study aligns with findings from other studies. For instance, Jeremiah D. Schuur et al. reported 35.1% adherence in ER, comparable to our findings (Schuur et al., 2014). Also Wei Jiang et al. reported 61% adherence in patients admitted to the Second Affiliated Hospital of Chongqing Medical University(Jiang et al., 2020) which is also comparable to our 57.3%. The high prevalence of inappropriate catheter use (42.7%) underscores the necessity for enhanced educational initiatives targeting healthcare staff. Implementing routine audits, incorporating feedback systems, and emphasizing compliance during training sessions could significantly improve adherence. Studies have shown that multifaceted interventions, such as combining staff training, real-time feedback, and guideline reminders, can effectively increase adherence rates to catheterization guidelines. These approaches could be particularly impactful in wards with the lowest adherence rates, such as the emergency room and gynecology, where targeted efforts could significantly reduce inappropriate catheter use. Reducing inappropriate catheterization not only aligns with evidence-based practices but also mitigates risks associated with catheter-associated urinary tract infections (CAUTIs), including patient morbidity, prolonged hospital stays, and increased healthcare costs. There are studies showing the adherence in different specialties for example Okrainec et al. showed overall 53.2% compliance with guidelines after surgeries (Okrainec et al., 2017). However, a wider investigation has not been conducted. The urology ward’s highest adherence rate highlights their expertise and understanding of catheterization guidelines. This insight underscores the potential value of leveraging their practices and knowledge to enhance adherence across other medical departments. Sharing their best practices through targeted training sessions, interdisciplinary case presentations, and collaborative teamwork could help improve adherence in other departments. By fostering a culture of shared learning, hospitals can more effectively bridge gaps in guideline adherence. One might say a reason for higher adherence in some Specialties is the higher prevalence of urinary catheter placements. Although this could be true especially for Specialties like urology but such statement needs much more evidence regarding the Specialties with as many as catheterized patients like the neurology service with moderate adherence and nephrology with low adherence (Table 2, Figure 3). Preventing delay in removing urinary catheter is also critical in controlling UTIs in the hospital, because keeping the catheters increase the UTI risk 3% to7% each day (CDC, 2024). Limited data collection was possible for the appropriate removal timing which may undermine the reliability of the result of this part but double checking the necessity of urinary catheters when patient is transferred from ICU to ward and also focusing on the fact that catheterization is only indicated for severely ill patients would make a clear difference. The low adherence in ER ward necessitates especial attention to this point in the ER both for the emergency medicine service and other Specialties before transferring admitted patients from ER to their own ward. As also mentioned by Schuur et al urinary catheter placement in ER should needs special attention to stick to guides (Schuur et al., 2014). Regarding our results both surgical and non-surgical specialties can have adherence challenges in this matter. We should emphasize on the fact that physicians should pay enough attention to the orders every day, especially when repeating the previous orders, which could result in less focused ordering. This study benefits from a robust methodology, including a well-defined sample size of 351 patients and the use of systematic bedside observations. Additionally, adherence was assessed against established CDC guidelines, ensuring consistency and reliability. However, certain limitations must be acknowledged. Incomplete or inconsistent documentation in medical records posed challenges in verifying the timing of catheter placements and determining the earliest possible time for removal. Moreover, the findings are specific to a single tertiary hospital, which may limit generalizability to other settings. Future studies should aim to include multiple institutions to provide a broader understanding of adherence patterns. Future research should focus on evaluating the impact of targeted interventions on adherence rates and patient outcomes. Longitudinal studies examining trends in catheter use and CAUTI rates following intervention implementation would be valuable. Additionally, qualitative studies exploring barriers to guideline adherence among healthcare providers could offer actionable insights to refine training and policy initiatives. Investigating the role of technological solutions, such as electronic reminders and decision-support systems, may also prove beneficial in promoting adherence. Conclusion Adherence to urinary catheterization guidelines at the tertiary hospital has been low. There is a significant variation in adherence rates across different hospital departments, with the lowest compliance observed in the gynecology, rheumatology, vascular and plastic surgery departments. Future studies should aim to identify the underlying causes of these discrepancies and develop targeted strategies to reduce unnecessary catheterization. Abbreviations CAUTIs: Catheter-associated urinary tract infections CDC: Centers for Disease Control and Prevention UTIs: Urinary tract infections SD: Standard deviation Declarations Ethics approval and consent to participate: Ethics approval code is IR.MUI.MED.REC.1401.326 Clinical Trial: not applicable Consent for publication: All authors are in agreement with the content of the manuscript and give consent for publication. Availability of data and material: All data is available upon request. Competing interests: None of the authors have any conflict of interests. Funding: There’s no funding source in this research. Authors' contributions: Mohammad Shahdadian: Contributed to data collection, performed data analysis, and took the lead in writing the manuscript. Farshad Gholipour: Played a key role in identifying and verifying the study's scope, contributed to manuscript editing, and provided critical revisions. Ali Azadian, Parsa Elyasi Bakhtiari, and Ali Khalilianpour: Participated in the collection and organization of study data. Amir Javid: Provided expert guidance and contributed to critical revision of the manuscript, ensuring its accuracy and coherence. Acknowledgements: not applicable References CDC. (2024, April 15). Indwelling Urinary Catheter Culture Stewardship: Overview . Urinary Tract Infection. https://www.cdc.gov/uti/hcp/clinical-guidance/index.html Drinka PJ. Complications of chronic indwelling urinary catheters. J Am Med Dir Assoc. 2006;7(6):388–92. https://doi.org/10.1016/j.jamda.2006.01.020 . Fakih MG, Heavens M, Grotemeyer J, Szpunar SM, Groves C, Hendrich A. Avoiding potential harm by improving appropriateness of urinary catheter use in 18 emergency departments. Ann Emerg Med. 2014;63(6):761–e7681. https://doi.org/10.1016/j.annemergmed.2014.02.013 . Flores-Mireles A, Hreha TN, Hunstad DA. Pathophysiology, Treatment, and Prevention of Catheter-Associated Urinary Tract Infection. Top Spinal Cord Injury Rehabilitation. 2019;25(3):228–40. https://doi.org/10.1310/sci2503-228 . Flores-Mireles AL, Walker JN, Caparon M, Hultgren SJ. Urinary tract infections: Epidemiology, mechanisms of infection and treatment options. Nat Rev Microbiol. 2015;13(5):269–84. https://doi.org/10.1038/nrmicro3432 . Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA. (2019). Guideline for Prevention of Catheter-Associated Urinary Tract Infections (2009) . 61. Jaggi N, Sissodia P. Multimodal Supervision Programme to Reduce Catheter Associated Urinary Tract Infections and Its Analysis to Enable Focus on Labour and Cost Effective Infection Control Measures in a Tertiary Care Hospital in India. J Clin Diagn Research: JCDR. 2012;6(8):1372–6. https://doi.org/10.7860/JCDR/2012/4229.2362 . Jiang W, Song Y, Zhang H, Huang R, Yin Y, Tan B. Inappropriate initial urinary catheter placement among older Chinese hospital inpatients: An observational study. Int J Nurs Pract. 2020;26(2). https://doi.org/10.1111/ijn.12791 . Lakoh S, Yi L, Russell JBW, Zhang J, Sevalie S, Zhao Y, Kanu JS, Liu P, Conteh SK, Williams CEE, Barrie U, Adekanmbi O, Jiba DF, Kamara MN, Sesay D, Deen GF, Okeibunor JC, Yendewa GA, Guo X, Firima E. High incidence of catheter-associated urinary tract infections and related antibiotic resistance in two hospitals of different geographic regions of Sierra Leone: A prospective cohort study. BMC Res Notes. 2023;16(1):301. https://doi.org/10.1186/s13104-023-06591-w . Morozov A, Khabib O, Yandiev DS S, A., Gazimiev M. A. (2024). [Catheter-associated iatrogenic urethral injuries and methods to prevent them]. Urologiia (Moscow, Russia: 1999) , 2 , 100–104. Okrainec A, Aarts M-A, Conn LG, McCluskey S, McKenzie M, Pearsall EA, Rotstein O, Victor JC, McLeod RS, members of the iERAS Group. Compliance with Urinary Catheter Removal Guidelines Leads to Improved Outcome in Enhanced Recovery After Surgery Patients. J Gastrointest Surgery: Official J Soc Surg Aliment Tract. 2017;21(8):1309–17. https://doi.org/10.1007/s11605-017-3434-x . Parker V, Giles M, Graham L, Suthers B, Watts W, O’Brien T, Searles A. Avoiding inappropriate urinary catheter use and catheter-associated urinary tract infection (CAUTI): A pre-post control intervention study. BMC Health Serv Res. 2017;17:314. https://doi.org/10.1186/s12913-017-2268-2 . Saint S, Greene MT, Krein SL, Rogers MAM, Ratz D, Fowler KE, Edson BS, Watson SR, Meyer-Lucas B, Masuga M, Faulkner K, Gould CV, Battles J, Fakih MG. A Program to Prevent Catheter-Associated Urinary Tract Infection in Acute Care. N Engl J Med. 2016;374(22):2111–9. https://doi.org/10.1056/NEJMoa1504906 . Schuur JD, Chambers JG, Hou PC. Urinary catheter use and appropriateness in U.S. emergency departments, 1995–2010. Acad Emerg Medicine: Official J Soc Acad Emerg Med. 2014;21(3):292–300. https://doi.org/10.1111/acem.12334 . Tambyah PA, Oon J. Catheter-associated urinary tract infection. Curr Opin Infect Dis. 2012;25(4):365–70. https://doi.org/10.1097/QCO.0b013e32835565cc . Tables Table 1. Patient’s charecteristics. Appropriately Catheterized (N=201) Inappropriately Catheterized (N=150) Total (N=351) P-value Age(years), means (SD) 59.67 (20.81) 55.21 (18.97) 57.76 (20.136) 0.32 a Gender (male) 136 (67.6%) 87(58%) 223 (63.5%) 0.54 b Hospitalization Duration(days), median[Q1-Q3] 6 [4-10] 6 [3-10] 6 [3-10] 0.17 c a. T test, b. Chi-square, c. Mann-Whitney U test Table 2. prevalence of catheterization in each specialty Specialty Total Catheterized (%) Urology 154 80 (52) Neurosurgery 100 49 (49) Pulmonology 96 42 (44) Gastroenterology 52 22 (42) General Surgery 88 36 (41) Internal Medicine 78 32 (41) Neurology 143 59 (41) Nephrology 135 51 (38) Infectious Disease 78 25 (32) Thoracic Surgery 46 14 (30) Vascular Surgery 46 13 (28) Orthopedics 56 15 (27) Gynecology 46 12 (26) Hematology 53 11 (21) Endocrinology 23 4 (17) Plastic Surgery 42 3 (7) Missing 26 9 (34) Total non-missing 1262 477 (37) Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 04 Nov, 2025 Read the published version in BMC Infectious Diseases → Version 1 posted Editorial decision: Revision requested 25 Aug, 2025 Reviews received at journal 23 Aug, 2025 Reviewers agreed at journal 23 Aug, 2025 Reviews received at journal 22 Aug, 2025 Reviews received at journal 22 Aug, 2025 Reviews received at journal 21 Aug, 2025 Reviewers agreed at journal 21 Aug, 2025 Reviewers agreed at journal 19 Aug, 2025 Reviewers agreed at journal 19 Aug, 2025 Reviewers invited by journal 19 Aug, 2025 Editor assigned by journal 19 Aug, 2025 Editor invited by journal 18 Aug, 2025 Submission checks completed at journal 14 Aug, 2025 First submitted to journal 14 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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09:08:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7225268/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7225268/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12879-025-11928-w","type":"published","date":"2025-11-04T15:58:10+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":90299156,"identity":"9909864b-c86f-442e-9b98-fa4343bfea94","added_by":"auto","created_at":"2025-09-01 08:49:45","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":45268,"visible":true,"origin":"","legend":"\u003cp\u003ePatient Inclusion Funnel Chart\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7225268/v1/74baf9fe7b0830701476dc37.png"},{"id":90299158,"identity":"def97710-1c60-477d-8567-12d8cf418329","added_by":"auto","created_at":"2025-09-01 08:49:45","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":147775,"visible":true,"origin":"","legend":"\u003cp\u003eBar chart showing the prevalence of each appropriate and inappropriate indication for catheter placement\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7225268/v1/76543b7362be7d63dc2d113b.png"},{"id":90299159,"identity":"31305dc9-118e-45ea-8f2d-03b9aa9556d7","added_by":"auto","created_at":"2025-09-01 08:49:45","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":163976,"visible":true,"origin":"","legend":"\u003cp\u003eComparing adherence rates to CDC guidelines across different hospital Specialties\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7225268/v1/9708853c765ed0a385bb94a4.png"},{"id":95564703,"identity":"c87622b3-d219-4aa9-a915-bb8c5021dfe0","added_by":"auto","created_at":"2025-11-10 16:10:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1020724,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7225268/v1/9d355661-91ff-4440-953e-1c3ec39a4ab2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Adherence to Guidelines for Preventing Catheter-Associated Urinary Tract Infections in Hospitalized Patients in a Tertiary Teaching Hospital","fulltext":[{"header":"Summary Statement","content":"\u003cp\u003e\u003cstrong\u003eWhat is already known about this topic?\u003c/strong\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eCatheter-associated urinary tract infections (CAUTIs) account for a significant proportion of healthcare-associated infections, with approximately 36% of such infections linked to urinary catheters.\u003c/li\u003e\n \u003cli\u003ePrevious studies have reported varying rates of inappropriate catheter placements across different settings, such as 39% in Chinese hospitals and 64.9% in U.S. emergency departments.\u003c/li\u003e\n \u003cli\u003eAdherence to catheterization guidelines, such as those from the Centers for Disease Control and Prevention (CDC), is essential to reduce CAUTIs and associated complications, including urethral trauma and antimicrobial resistance.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eWhat this paper adds:\u003c/strong\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eThe study revealed a 57.3% adherence rate to CDC guidelines for catheter placement in hospitalized patients at a tertiary teaching hospital.\u003c/li\u003e\n \u003cli\u003eAcute urinary retention and monitoring of urine output in critically ill patients were the most frequent appropriate indications for catheter use, whereas substitution for nursing care in incontinent patients was a common inappropriate reason.\u003c/li\u003e\n \u003cli\u003eAdherence rates varied significantly across hospital departments, with the cardiology department achieving full compliance and gynecology recording the lowest adherence.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eThe implications of this paper:\u003c/strong\u003e\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003e\u003cstrong\u003eHow can these findings influence clinical practice?\u003c/strong\u003e\n \u003cul type=\"circle\"\u003e\n \u003cli\u003eImplementing regular training sessions and audits can enhance healthcare providers' adherence to catheterization guidelines, thereby reducing inappropriate catheter use.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eHow can this research guide future interventions?\u003c/strong\u003e\n \u003cul type=\"circle\"\u003e\n \u003cli\u003eFocused interventions targeting departments with low adherence rates, such as gynecology and the emergency room, could significantly improve patient outcomes and reduce CAUTI rates.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eWhat role can policy play in addressing the identified issues?\u003c/strong\u003e\n \u003cul type=\"circle\"\u003e\n \u003cli\u003eHospitals could adopt policy changes that mandate real-time feedback and automated reminders for timely catheter removal, ensuring compliance with established guidelines.\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Introduction","content":"\u003cp\u003eUrinary tract infections (UTIs) are among the most common bacterial infections affecting humans and pose a significant burden on healthcare systems globally (A. Flores-Mireles et al., 2019; A. L. Flores-Mireles et al., 2015). These infections are broadly classified into uncomplicated and complicated UTIs, with catheter-associated urinary tract infections (CAUTIs) being a major contributor to the latter (A. Flores-Mireles et al., 2019; Tambyah \u0026amp; Oon, 2012). Distinct differences exist between uncomplicated UTIs and CAUTIs in terms of clinical presentation, causative organisms, and pathophysiology (A. Flores-Mireles et al., 2019; A. L. Flores-Mireles et al., 2015; Tambyah \u0026amp; Oon, 2012). Alarmingly, CAUTIs account for 36% of healthcare-associated infections, of which nearly 80% are linked to indwelling urinary catheters (Parker et al., 2017).\u003c/p\u003e\n\u003cp\u003eInappropriate catheter use, either without proper indication or in violation of established guidelines, is widespread (Parker et al., 2017). Studies have shown that in some regions, up to 39% of catheter placements in hospitalized patients in China (Jiang et al., 2020) and 64.9% in emergency departments in the United States did not meet appropriate criteria(Schuur et al., 2014). Such practices not only increase the risk of CAUTIs but also expose patients to other complications, including urethral trauma and long-term urethral stricture, particularly when catheters are not inserted correctly or by skilled personnel (Morozov A et al., 2024). Furthermore, the rising antimicrobial resistance associated with CAUTIs exacerbates the public health challenge posed by these infections (Lakoh et al., 2023). Also prolonged urinary catheterization has been identified as a significant factor contributing to the development of urethral strictures (Drinka, 2006). These complications are more likely when catheters are left in place beyond the recommended duration, emphasizing the importance of adhering to established guidelines for catheter use and timely removal to minimize associated risks.\u003c/p\u003e\n\u003cp\u003eSeveral preventive strategies have been proposed to mitigate the risks associated with CAUTIs, including adherence to sterile catheter insertion techniques, the use of well-defined guidelines for catheter indications, and prompt removal of catheters as soon as clinically appropriate (Saint et al., 2016). Among these, the CDC has published a comprehensive guideline that, if adhered to, can significantly reduce the burden of CAUTIs on healthcare systems (Gould et al., 2019). Interventions aimed at improving compliance with such guidelines have demonstrated remarkable success, with studies showing reductions of up to 50% in inappropriate catheter placements (Fakih et al., 2014; Jaggi \u0026amp; Sissodia, 2012).\u003c/p\u003e\n\u003cp\u003eDespite the critical importance of this issue, data on adherence to catheterization guidelines, particularly at local referral hospitals, remain scarce. This lack of evidence underscores the need for systematic research to assess current practices and identify areas for improvement. This study was designed to address this gap by evaluating the adherence to CDC guidelines for catheter placement indications in hospitalized patients. By systematically collecting and analyzing data on the frequency, appropriateness, and timing of catheter placements, this research aims to provide actionable insights to enhance guideline adherence and improve patient outcomes. The findings will serve as a foundation for targeted interventions and policy changes to address this pressing healthcare challenge in the region.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis descriptive cross-sectional study was conducted at Al-Zahra Hospital, a tertiary referral hospital in Isfahan, Iran in September and October 2024.\u003c/p\u003e\n\u003cp\u003eThe study protocol received approval from the institutional ethics board (IR.MUI.MED.REC.1401.326). Informed consent was obtained from all participants, and strict confidentiality measures were implemented to anonymize all identifiable data during analysis.\u003c/p\u003e\n\u003cp\u003eThe study population comprised\u0026nbsp;randomly selected patients hospitalized during the study period. Inclusion criteria encompassed all hospitalized patients within the defined timeframe. Patients were excluded if they declined consent for catheterization, were under 18 years of age, or had pre-existing urinary catheters prior to admission. Additionally, patients in labor, pediatric wards, ICU, CCU, and day surgery units were excluded to ensure consistency and relevance.\u003c/p\u003e\n\u003cp\u003eThe required sample size was calculated as 351 patients using a margin of error of 5% and a 95% confidence level.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection Procedures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData collection was performed through systematic visits to randomly selected hospital wards at intervals of at least four days. During each visit, researchers assessed every patient in the ward for inclusion in the study.\u003c/p\u003e\n\u003cp\u003eAs part of the process, bedside observations were conducted to document the presence or absence of urinary catheters and record patient demographic data, including age, gender, and length of hospitalization. For patients without current catheters, their medical records were reviewed to identify any history of catheterization during hospitalization. Data collected included admission and catheterization dates from physician orders, as well as indications for catheterization based on Centers for Disease Control and Prevention (CDC) guidelines for preventing catheter-associated urinary tract infections (CAUTI) which especially discusses the adult patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAdherence Assessment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCatheter placements were classified as either appropriate or inappropriate. Appropriate catheterization was determined by specific clinical needs, including (Gould et al., 2019):\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eAcute urinary retention or bladder outlet obstruction\u003c/li\u003e\n \u003cli\u003eRequirement for accurate urine output measurement in critically ill patients\u003c/li\u003e\n \u003cli\u003ePerioperative use for certain surgical procedures:\u003cul type=\"circle\"\u003e\n \u003cli\u003eUrological surgery or other procedures involving structures adjacent to the genitourinary tract\u003c/li\u003e\n \u003cli\u003eAnticipation of prolonged surgery duration (the catheter should be removed upon patient recovery from anesthesia)\u003c/li\u003e\n \u003cli\u003eAnticipation of significant fluid or diuretic administration during surgery\u003c/li\u003e\n \u003cli\u003eNeed for intraoperative urine output monitoring\u003c/li\u003e\n \u003c/ul\u003e\n \u003c/li\u003e\n \u003cli\u003eFacilitation of healing for open sacral or perineal wounds in incontinent patients\u003c/li\u003e\n \u003cli\u003eProlonged immobility (e.g., unstable thoracic or lumbar spine injuries, multiple traumatic injuries such as pelvic fractures)\u003c/li\u003e\n \u003cli\u003eEnhancing patient comfort in end-of-life care, if necessary\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eCritically ill patients were identified as coma, cardiac arrest, respiratory failure, shock, endotracheal tube placement, ICU admission, and monitoring in cardiac catheterization units (Gould et al., 2019).\u003c/p\u003e\n\u003cp\u003eInappropriate catheter use was defined as:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eSubstitution for nursing care in incontinent patients.\u003c/li\u003e\n \u003cli\u003eObtaining urine samples for diagnostic tests when patients could urinate voluntarily.\u003c/li\u003e\n \u003cli\u003eExtended postoperative use without clear indications (e.g., structural repair, prolonged epidural anesthesia).\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eFor patients with appropriate placement the removal earliest opportunity was recoded if possible.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Entry and Validation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA web-based checklist was implemented to minimize errors during data transfer from forms to SPSS. Data were double-checked for completeness and accuracy, and a random subset of 10% of entries underwent cross-validation to ensure reliability.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQualitative variables were summarized using frequencies and percentages, while quantitative variables were described using means and standard deviations or median and interquartile range.\u003c/p\u003e\n\u003cp\u003eThe demographic variables were also compared between appropriate and inappropriately placed catheters.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 351 patients were included in the study. The demographic details of the study population, including age, gender distribution, and hospitalization duration, are summarized in Table 1. The mean age of participants was 57.7 years (SD= 20.1), with 63.7% identified as male and 36.3% as female. The average length of hospitalization was 8.96 (SD=10.1) days, ranging from 1 to 100 days.\u003c/p\u003e\n\u003cp\u003eA total of 1262 patients were checked for inclusion 37.8% of which have experienced urinary characterization in their stay and 34.5% were included (Figure 1)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAdherence to CDC Guidelines\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOverall, 57.3% of catheter placements adhered to the CDC guidelines, while 42.7% were classified as inappropriate. Among the appropriate indications for catheter placement, the most frequent reason was acute urinary retention or bladder outlet obstruction, accounting for 15.4% of cases (26.8% of appropriate placements), followed by monitoring accurate urine output in critically ill patients at 14.5% and monitoring urine output during surgery at 11.1% (Figure 2). Inappropriate indications were primarily due to substitution for nursing care in incontinent patients, and monitoring urine output in patients who are not considered critically ill.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDepartmental Variations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAdherence rates varied across hospital Specialties (Figure 3). For example, Cardiology exhibited the highest adherence rate (100%), while Gynecology had the lowest (0%).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBetween the wards, besides gynecology with the highest rate of inappropriate catheter placements, plastic surgery ward and Emergency department had very high rates. For example, 72.2% of catheters in ER were inappropriate. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTiming of Catheter Removal\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe mean duration of catheterization for cases with appropriate indications was 5.3 days, with a median of 4.5 days. For inappropriate indications, the mean duration was 4.25 days, with a median of 4 days. The mean delay time in removal of appropriate catheterizations was 1.9 days. Delays in removal were most commonly associated with urine output monitoring in patients who were not considered as severely ill any more.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study found that only 57.3% of catheter placements adhered to CDC guidelines, with acute urinary retention or bladder outlet obstruction and monitoring accurate urine output in critically ill patients being the most common appropriate reasons respectively. The primary inappropriate reasons were substitution for nursing care in incontinent patients followed by monitoring urine output in non-critically ill patients. Adherence varied notably by ward, ranging from 100% in the cardiology ward to significantly lower adherence rates in gynecology and the emergency room, with the latter recording inappropriate catheterization in 72.2% of cases.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe comparison of demographic variables between patients appropriately and inappropriately catheterized showed no significant difference which ensures proper randomization and also is in favor of age, gender and hospitalization duration of patients not being important factors in guideline adherence (Table 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUTIs are most common hospital-acquired infections and they are associated with urinary catheters but limited studies have been conducted to assess adherence to guidelines aimed at preventing catheter-associated UTIs. The adherence rate in our study aligns with findings from other studies. For instance, Jeremiah D. Schuur et al. reported 35.1% adherence in ER, comparable to our findings (Schuur et al., 2014). Also Wei Jiang et al. reported 61% adherence in patients admitted to the Second Affiliated Hospital of Chongqing Medical University(Jiang et al., 2020) which is also comparable to our 57.3%.\u003c/p\u003e\n\u003cp\u003eThe high prevalence of inappropriate catheter use (42.7%) underscores the necessity for enhanced educational initiatives targeting healthcare staff. Implementing routine audits, incorporating feedback systems, and emphasizing compliance during training sessions could significantly improve adherence. Studies have shown that multifaceted interventions, such as combining staff training, real-time feedback, and guideline reminders, can effectively increase adherence rates to catheterization guidelines. These approaches could be particularly impactful in wards with the lowest adherence rates, such as the emergency room and gynecology, where targeted efforts could significantly reduce inappropriate catheter use. Reducing inappropriate catheterization not only aligns with evidence-based practices but also mitigates risks associated with catheter-associated urinary tract infections (CAUTIs), including patient morbidity, prolonged hospital stays, and increased healthcare costs.\u003c/p\u003e\n\u003cp\u003eThere are studies showing the adherence in different specialties for example Okrainec et al. showed overall 53.2% compliance with guidelines after surgeries (Okrainec et al., 2017). However, a wider investigation has not been conducted. The urology ward’s highest adherence rate highlights their expertise and understanding of catheterization guidelines. This insight underscores the potential value of leveraging their practices and knowledge to enhance adherence across other medical departments. Sharing their best practices through targeted training sessions, interdisciplinary case presentations, and collaborative teamwork could help improve adherence in other departments. By fostering a culture of shared learning, hospitals can more effectively bridge gaps in guideline adherence.\u003c/p\u003e\n\u003cp\u003eOne might say a reason for higher adherence in some Specialties \u0026nbsp; \u0026nbsp;is the higher prevalence of urinary catheter placements. Although this could be true especially for Specialties \u0026nbsp; \u0026nbsp;like urology but such statement needs much more evidence regarding the Specialties \u0026nbsp; \u0026nbsp;with as many as catheterized patients like the neurology service with moderate adherence and nephrology with low adherence (Table 2, Figure 3).\u003c/p\u003e\n\u003cp\u003ePreventing delay in removing urinary catheter is also critical in controlling UTIs in the hospital, because keeping the catheters increase the UTI risk 3% to7% each day (CDC, 2024). Limited data collection was possible for the appropriate removal timing which may undermine the reliability of the result of this part but double checking the necessity of urinary catheters when patient is transferred from ICU to ward and also focusing on the fact that catheterization is only indicated for severely ill patients would make a clear difference.\u003c/p\u003e\n\u003cp\u003eThe low adherence in ER ward necessitates especial attention to this point in the ER both for the emergency medicine service and other Specialties before transferring admitted patients from ER to their own ward. As also mentioned by Schuur et al urinary catheter placement in ER should needs special attention to stick to guides (Schuur et al., 2014).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRegarding our results both surgical and non-surgical specialties can have adherence challenges in this matter. We should emphasize on the fact that physicians should pay enough attention to the orders every day, especially when repeating the previous orders, which could result in less focused ordering.\u003c/p\u003e\n\u003cp\u003eThis study benefits from a robust methodology, including a well-defined sample size of 351 patients and the use of systematic bedside observations. Additionally, adherence was assessed against established CDC guidelines, ensuring consistency and reliability. However, certain limitations must be acknowledged. Incomplete or inconsistent documentation in medical records posed challenges in verifying the timing of catheter placements and determining the earliest possible time for removal. Moreover, the findings are specific to a single tertiary hospital, which may limit generalizability to other settings. Future studies should aim to include multiple institutions to provide a broader understanding of adherence patterns.\u003c/p\u003e\n\u003cp\u003eFuture research should focus on evaluating the impact of targeted interventions on adherence rates and patient outcomes. Longitudinal studies examining trends in catheter use and CAUTI rates following intervention implementation would be valuable. Additionally, qualitative studies exploring barriers to guideline adherence among healthcare providers could offer actionable insights to refine training and policy initiatives. Investigating the role of technological solutions, such as electronic reminders and decision-support systems, may also prove beneficial in promoting adherence.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAdherence to urinary catheterization guidelines at the tertiary hospital has been low. There is a significant variation in adherence rates across different hospital departments, with the lowest compliance observed in the gynecology, rheumatology, vascular and plastic surgery departments. Future studies should aim to identify the underlying causes of these discrepancies and develop targeted strategies to reduce unnecessary catheterization.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cul\u003e\n \u003cli\u003eCAUTIs: Catheter-associated urinary tract infections\u003c/li\u003e\n \u003cli\u003eCDC: Centers for Disease Control and Prevention\u003c/li\u003e\n \u003cli\u003eUTIs:\u0026nbsp;Urinary tract infections\u003c/li\u003e\n \u003cli\u003eSD: Standard deviation\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate:\u003c/p\u003e\n\u003cp\u003eEthics approval code is IR.MUI.MED.REC.1401.326\u003c/p\u003e\n\u003cp\u003eClinical Trial: not applicable\u003c/p\u003e\n\u003cp\u003eConsent for publication:\u003c/p\u003e\n\u003cp\u003eAll authors are in agreement with the content of the manuscript and give consent for publication.\u003c/p\u003e\n\u003cp\u003eAvailability of data and material:\u003c/p\u003e\n\u003cp\u003eAll data is available upon request.\u003c/p\u003e\n\u003cp\u003eCompeting interests:\u003c/p\u003e\n\u003cp\u003eNone of the authors have any conflict of interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFunding:\u003c/p\u003e\n\u003cp\u003eThere\u0026rsquo;s no funding source in this research.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eMohammad Shahdadian:\u003c/strong\u003e Contributed to data collection, performed data analysis, and took the lead in writing the manuscript.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eFarshad Gholipour:\u003c/strong\u003e Played a key role in identifying and verifying the study\u0026apos;s scope, contributed to manuscript editing, and provided critical revisions.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAli Azadian, Parsa Elyasi Bakhtiari, and Ali Khalilianpour:\u003c/strong\u003e Participated in the collection and organization of study data.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAmir Javid:\u003c/strong\u003e Provided expert guidance and contributed to critical revision of the manuscript, ensuring its accuracy and coherence.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eAcknowledgements: not applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCDC. (2024, April 15). \u003cem\u003eIndwelling Urinary Catheter Culture Stewardship: Overview\u003c/em\u003e. Urinary Tract Infection. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.cdc.gov/uti/hcp/clinical-guidance/index.html\u003c/span\u003e\u003cspan address=\"https://www.cdc.gov/uti/hcp/clinical-guidance/index.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDrinka PJ. Complications of chronic indwelling urinary catheters. 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Pathophysiology, Treatment, and Prevention of Catheter-Associated Urinary Tract Infection. Top Spinal Cord Injury Rehabilitation. 2019;25(3):228\u0026ndash;40. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1310/sci2503-228\u003c/span\u003e\u003cspan address=\"10.1310/sci2503-228\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFlores-Mireles AL, Walker JN, Caparon M, Hultgren SJ. Urinary tract infections: Epidemiology, mechanisms of infection and treatment options. 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J Gastrointest Surgery: Official J Soc Surg Aliment Tract. 2017;21(8):1309\u0026ndash;17. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s11605-017-3434-x\u003c/span\u003e\u003cspan address=\"10.1007/s11605-017-3434-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eParker V, Giles M, Graham L, Suthers B, Watts W, O\u0026rsquo;Brien T, Searles A. Avoiding inappropriate urinary catheter use and catheter-associated urinary tract infection (CAUTI): A pre-post control intervention study. BMC Health Serv Res. 2017;17:314. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12913-017-2268-2\u003c/span\u003e\u003cspan address=\"10.1186/s12913-017-2268-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSaint S, Greene MT, Krein SL, Rogers MAM, Ratz D, Fowler KE, Edson BS, Watson SR, Meyer-Lucas B, Masuga M, Faulkner K, Gould CV, Battles J, Fakih MG. A Program to Prevent Catheter-Associated Urinary Tract Infection in Acute Care. N Engl J Med. 2016;374(22):2111\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1056/NEJMoa1504906\u003c/span\u003e\u003cspan address=\"10.1056/NEJMoa1504906\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSchuur JD, Chambers JG, Hou PC. Urinary catheter use and appropriateness in U.S. emergency departments, 1995\u0026ndash;2010. Acad Emerg Medicine: Official J Soc Acad Emerg Med. 2014;21(3):292\u0026ndash;300. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/acem.12334\u003c/span\u003e\u003cspan address=\"10.1111/acem.12334\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTambyah PA, Oon J. Catheter-associated urinary tract infection. Curr Opin Infect Dis. 2012;25(4):365\u0026ndash;70. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/QCO.0b013e32835565cc\u003c/span\u003e\u003cspan address=\"10.1097/QCO.0b013e32835565cc\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1. Patient’s charecteristics.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eAppropriately Catheterized (N=201)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eInappropriately Catheterized (N=150)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eTotal (N=351)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAge(years), means (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e59.67 (20.81)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e55.21 (18.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e57.76 (20.136)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.32\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGender (male)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e136 (67.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e87(58%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e223 (63.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.54\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHospitalization Duration(days), median[Q1-Q3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6 [4-10]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6 [3-10]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6 [3-10]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.17\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003e\n \u003cp\u003ea. T test, b. Chi-square, c. Mann-Whitney U test\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 2. prevalence of catheterization in each specialty\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSpecialty\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCatheterized (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eUrology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e154\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e80 (52)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNeurosurgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e49 (49)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePulmonology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e42 (44)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGastroenterology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e22 (42)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGeneral Surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e36 (41)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eInternal Medicine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e32 (41)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNeurology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e143\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e59 (41)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNephrology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e135\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e51 (38)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eInfectious Disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e25 (32)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eThoracic Surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14 (30)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eVascular Surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13 (28)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eOrthopedics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15 (27)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGynecology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12 (26)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHematology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e11 (21)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eEndocrinology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4 (17)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePlastic Surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 (7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMissing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9 (34)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTotal non-missing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e1262\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e477\u0026nbsp; (37)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Urinary Tract Infections, Urinary Catheters, Adolescent, Hospitalized","lastPublishedDoi":"10.21203/rs.3.rs-7225268/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7225268/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eAim:\u003c/strong\u003e\u003cbr\u003e\nUrinary catheterization contributes significantly to hospital-acquired infections. Adhering to CDC guidelines is vital to prevent inappropriate use and reduce infection rates. This study evaluated compliance with these guidelines in hospitalized patients at a tertiary hospital in 2024.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethodology:\u003c/strong\u003e\u003cbr\u003e\nA cross-sectional study assessed compliance with CDC guidelines for preventing catheter-associated urinary tract infections (CAUTIs) in hospitalized patients at Al-Zahra Hospital, Isfahan. Data were gathered through patient observation and chart reviews, evaluating demographics, catheter indications, retention duration, and guideline adherence. Department-specific compliance rates were also analyzed. Standardized checklists ensured consistent data recording.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003cbr\u003e\nOf 1262 patients evaluated, 477 (37.8%) underwent urinary catheterization, with a 57.3% adherence rate to CDC guidelines. The most common appropriate indication was acute urinary retention (15.4%), followed by urine output monitoring in critically ill patients (14.5%) and intraoperative monitoring (11.1%). Adherence was highest in cardiology and urology, while gynecology, rheumatology, plastic surgery, and vascular surgery had the lowest rates. The emergency department showed only 27.8% adherence.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003cbr\u003e\nThe findings highlight a suboptimal adherence rate to CDC guidelines in urinary catheterization, emphasizing the need for targeted interventions to improve compliance. Strategic interventions can enhance adherence and subsequently reduce catheter-associated urinary tract infections.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of Isfahan University of Medical Sciences (Ethics approval code: IR.MUI.MED.REC.1401.326). All procedures involving human participants were conducted in accordance with the ethical standards of the institutional and/or national research committee and adhered to the principles outlined in the Declaration of Helsinki.\u003c/p\u003e","manuscriptTitle":"Adherence to Guidelines for Preventing Catheter-Associated Urinary Tract Infections in Hospitalized Patients in a Tertiary Teaching Hospital","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-01 08:49:40","doi":"10.21203/rs.3.rs-7225268/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-25T07:05:37+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-23T08:02:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"270888984639352313913044350879011900066","date":"2025-08-23T07:15:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-22T18:34:14+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-22T09:22:49+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-21T10:36:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"222477874818501769333085988758929853441","date":"2025-08-21T10:18:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"164047153335004919042957624406953273352","date":"2025-08-19T09:38:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"22263220076591523690152105298232201867","date":"2025-08-19T08:50:21+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-19T08:19:47+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-19T07:48:03+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-18T04:02:38+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-14T11:47:24+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Infectious Diseases","date":"2025-08-14T11:44:56+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e33aa19c-226f-41ea-93aa-38329ee4191d","owner":[],"postedDate":"September 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-10T16:09:06+00:00","versionOfRecord":{"articleIdentity":"rs-7225268","link":"https://doi.org/10.1186/s12879-025-11928-w","journal":{"identity":"bmc-infectious-diseases","isVorOnly":false,"title":"BMC Infectious Diseases"},"publishedOn":"2025-11-04 15:58:10","publishedOnDateReadable":"November 4th, 2025"},"versionCreatedAt":"2025-09-01 08:49:40","video":"","vorDoi":"10.1186/s12879-025-11928-w","vorDoiUrl":"https://doi.org/10.1186/s12879-025-11928-w","workflowStages":[]},"version":"v1","identity":"rs-7225268","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7225268","identity":"rs-7225268","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}