Pilot Study of Avoidance of Bladder Catheters in Stroke Patients to Avoid Urinary Tract Infections

Medical complications, both minor and serious, play a large role in post-stroke management
and outcome. Infection, especially pneumonia and urinary tract infections (UTI), is one of
the most common medical complications of stroke. In addition, immunosuppression secondary to
stroke may increase the risk of infection after stroke, and fever secondary to infection may
result in poor outcomes. UTIs occur in 3 to 16% of patients within the first week to month
after a cerebrovascular event. Compared with patients who do not develop post-stroke UTIs,
those who do have a UTI have poorer outcomes; such patients have an approximately 3-fold
increased odds of a higher mRS, and a 4.5-fold higher odds for the combined endpoint of
death or disability.

Between 15% and 25% of all hospitalized patients receive short-term indwelling urinary
catheters, often unnecessarily. In the general medical population, the risk of UTI ranges
from 3%-10% per day of catheterization, and approaches 100% after 30 continuous days.
Catheter-associated UTI (CAUTI) is the second most commonly reported healthcare-associated
infection in acute care hospitals, accounting for approximately one-third of all infections
reported to the National Healthcare Safety Network in 2006-2007, and is the leading cause of
secondary nosocomial bloodstream infections. CAUTIs have been estimated to cost $589 to
$758 per infection, and between 17 and 69% may be preventable.

The recently released draft guidelines from the Centers for Disease Control and Prevention
(CDC) for prevention of CAUTI suggest appropriate indications for indwelling urethral
catheter use, including acute urinary retention or obstruction, need for accurate
measurements of urinary output in critically ill patients, and prolonged immobilization, but
an estimated 20 to 50% of hospitalized patients have urinary catheters placed without clear
indications.

We will conduct a pilot RCT to determine the tolerability and efficacy of a protocol to
avoid catheter placement in patients admitted to the UCSF neurovascular service with
ischemic stroke or intracerebral hemorrhage. There are two study arms: a usual care control
group will have catheter placement on admission, and the intervention group will not have a
catheter placed on admission. The intervention arm will be treated using a protocol,
developed with a multidisciplinary team, and instituted by nurses to avoid the need for
catheter placement. The sample will be followed during hospital admission, with the main
outcome measures being the tolerability of the protocol by the nursing staff, patient
comfort and the incidence of UTI during hospitalization. The subjects will be followed
during their hospitalization and a follow-up telephone call will be made to them at 90-days
post-stroke.

We hypothesize that limiting the use of Foley catheters to the medical indications noted in
the CDC guidelines, which is not current standard practice, will decrease the number of
catheters placed, and thereby reduce the number of UTIs in stroke patients. The ultimate
goal of this study is to improve clinical outcomes, decrease hospital length of stay, cost
of care, and time to rehabilitation among patients who suffer a stroke.

Inclusion Criteria:

- Adults aged ≥18

- Admission to the neurovascular service at UCSF (from the ED or from an outside
hospital)

- Diagnosis of acute stroke or intracerebral hemorrhage

Exclusion Criteria:

- Glasgow Coma Scale (GCS) <9

- Need for intubation or sedation

- An active medical problem requiring the use of a bladder catheter (e.g., congestive
heart failure exacerbation, acute bladder outlet obstruction)

- Subarachnoid hemorrhage

- Patients who are asymptomatic or have minimal symptoms from stroke

- Bladder catheter already in place for >12 hours

- Contraindication for bladder catheterization

- Evidence of UTI on admission