The Use of an Indwelling Catheter Protocol to Reduce Rates
of Postoperative Urinary Tract Infections
AFFAN UMER, MD, DAVID S. SHAPIRO, MD, CHRIS HUGHES, MD,
CYNTHIA ROSS-RICHARDSON, RN, AND SCOTT ELLNER, DO, MPH
ABSTRACT – Background: Catheter-associated
urinary tract infections (CAUTI) have been associ-
ated with increases in morbidity and mortality as
well as increased costs of hospitalization. At our in-
stitution, we implemented a protocol for indwelling
catheter use, maintenance, and removal based on
Center for Medicare and Medicaid Services (CMS)
guidelines, in efforts to reduce CAUTI rates.
Methods: A hospital committee of quality stewards
focused on several measures which included staff
education, modification of existing systems to en-
sure compliance, and auditing of patient care areas
for catheter utilization before implementation of
the protocol. Pre- and postintervention postopera-
tive cohorts were then identified through American
College of Surgeons National Surgical Quality
Improvement Program (ACS NSQIP) for preva-
lence of CAUTI. Data were collected through chart
review and postdischarge patient interviews.
AFFAN UMER, MD, Research Scientist, Department of
Surgery, Saint Francis Hospital and Medical Center, Hartford;
DAVID S. SHAPIRO, MD, Chief, Surgical Critical Care,
Chair, Medical Staff Oversight Group, Saint Francis Hospital
and Medical Center, Hartford, University of Connecticut Health
Center, Farmington; CHRIS HUGHES, MD, MPH, Chief
Resident, Department of Surgery, Saint Francis Hospital and
Medical Center, Hartford, University of Connecticut Health
Center, Farmington; CYNTHIA ROSS-RICHARDSON,
RN, NSQIP Surgical Clinical Analyst, Department of Surgery,
The Hospital of Central Connecticut, New Britain; SCOTT
ELLNER, DO, MPH, President, Saint Francis Medical Group,
Vice Chairman, Department of Surgery, Director of Surgical
Quality, Saint Francis Hospital and Medical Center, Hartford.
Corresponding author: AFFAN UMER, MD, affan.umer.83@
gmail.com
VOLUME 80, NO. 4
Results: A total of 3873 patients were identified be-
tween September 2007 and December 2010. Thirty-
six patients (2.6%) were diagnosed with a CAUTI in
the preintervention group (N = 1404) compared to 38
(1.5%) patients who were diagnosed with a CAUTI
in the postintervention group (N = 2469). There was
a 1.1% decrease in CAUTI rate after protocol imple-
mentation (P < .028). This reduction in rates resulted
in annual estimated savings of $81,840 to $320,540
annually.
Conclusion: A simple, multifaceted approach con-
sisting of staff education and changing existing pro-
cesses to reflect best care practices has the potential
to significantly reduce the incidence of postoperative
CAUTI.
Key words: CAUTI , postoperative urinary retention,
straight catheterization, indwelling urinary cath-
eter, bladder scanner, general surgery complication
Introduction
U
rinary tract infections (UTI) account for ap-
proximately 40% of hospital-acquired infec-
tions. The majority of hospital-acquired UTIs
are associated with the use of indwelling urinary cath-
eters (IUC), termed catheter-associated urinary tract
infections.1,2 The risk of bacterial colonization of the
urinary tract increases by approximately 5% every day
after 48 hours of catheterization. Infection rates vary
between 10% and 25% among those patients who
are colonized.3 The most successful hospital-based
measures for reducing CAUTI rates have been those
which reduce the frequency and duration of catheter
placement.3–5
197
 In recent years, value has been redefined in the Study population: Patients included in the study
health care setting.6,7 In October 2008, CMS intro- were from a single institution and selected through
duced regulations restricting reimbursement to hos- the ACS NSQIP database from September 22, 2007
pitals for treatment of eight preventable conditions through December 31, 2010. All patients with an ad-
– including CAUTI – if they were acquired during mission to the operating room for vascular, bariatric,
patients’ hospitalizations.8 In response to this, hospi- colorectal, or general surgery procedures were includ-
tals have begun to adopt simple interventions demon- ed, regardless of ambulatory procedures or those pro-
strated to reduce or eliminate CAUTI by decreasing cedures requiring an inpatient stay.
the use of IUC.4,5 The cost for treatment or prevention Data collection: A single surgical clinical nurse re-
of CAUTI has been frequently addressed in literature, viewer collected data on 135 variables for each patient
with studies conservatively estimating a financial bur- per ACS NSQIP requirements, including preopera-
den between $1200 and $4700 per infection.9–12 tive risk factors, intraoperative variables, and 30-day
Since 2007, our hospital has been a participating postoperative mortality and morbidity outcomes.13
institution in the ACS NSQIP, which utilizes risk- The data were collected by chart review and routine
adjusted hospital data to determine the incidence of follow-up patient interviews.
several postoperative complications.13 In 2008, the Planning the intervention: In August 2008, a
data indicated our institution was a high outlier for hospital committee of quality stewards was convened
the incidence of postoperative CAUTI (Figure 1). to address the problem of postoperative CAUTI. The
This subsequently prompted a committee of clinicians committee was comprised of 20 individuals including
to reevaluate the institutional protocols regarding the operating room staff, physicians from the Departments
use of IUC and implement best practice guidelines to of Emergency Medicine, Surgery, Infectious Disease,
reduce the risk of postoperative CAUTI. and Critical Care, and nurses from both the surgi-
The objectives of this study include determining the cal floor and the intensive care unit. This multidisci-
clinical significance of an intervention bundle dedi- plinary group developed evidence-based guidelines for
cated to the reduction of postoperative CAUTI and perioperative catheter use, addressing insertion, main-
evaluating the financial impact of its implementation. tenance, and removal of indwelling urinary catheters
in accordance with CMS Surgical Care Improvement
Methods
Project Core Measure Nine.14 The protocol established
Setting: Saint Francis Hospital and Medical specific criteria for continued urinary catheter use
Center (SFHMC) is a tertiary care center in Hartford, and permitted nursing providers to remove a catheter
Connecticut, USA with an annual subtotal case vol- without a physician order on postoperative day two if
ume of 6200 operations in four categories: vascular, the criteria-driven protocol was utilized (Figure 2).
bariatric, colorectal, and general surgery.
A multifaceted approach was utilized in the edu-
cation of physicians, nurses, and staff involved in the
care of surgical patients. Web-
Figure 1. Reintervention NSQIP Data Showing our Hospital as a High
Outlier for CAUTI. The solid black line is the reference line. Each vertical line based learning modules were
transecting it depicts a 95% confidence interval for CAUTI rates. The small dot used to educate the frontline staff
on each vertical line depicts the odds ratio estimate for each institution. regarding proper insertion tech-
niques, maintenance, and removal
of catheters. Concurrent with ed-
ucation, but prior to the initiation
of the intervention, a 30-day audit
of urinary catheter use on surgical
floors was conducted to assess uti-
lization. In addition, the SFHMC
electronic health record (GE
Centricity™, Buckinghamshire,
UK) was modified to require or-
dering physicians to choose from
a menu of predetermined accept-
able indications when ordering
urinary catheter insertion.

198 CONNECTICUT MEDICINE, APRIL 2016

Figure 2. Indwelling Urinary Catheter Protocol
1. Indwelling urinary catheters will be inserted only when necessary.
2. When ordering an indwelling urinary catheter, the physician or APP (Advanced Practice Practitioner)
will document the necessity for the catheter by using the insertion criteria listed.
3. Clinicians inserting and maintaining a catheter should have knowledge of aseptic technique and procedures
for catheter and drainage system maintenance.
4. Consideration should be given to alternatives to indwelling catheters, such as condom catheters or
intermittent catheterization.
5. A daily assessment of catheter necessity should be performed and the catheter should be removed as soon
as possible.
6. In the event of postoperative urinary retention (POUR), bladder scanning should be performed and the results
reported to the physician/APP. Intermittent catheterization should be considered.
7. If physician/APP states the urinary catheter cannot be removed, the rationale or need for urinary catheter
must be documented by the MD/APP.
8. A physician/APP order for indwelling catheter removal is not needed for removal of catheter on postoperative
day 2 unless the patient still meets one of the insertion criteria.
Insertion Criteria:
9. Patient requiring physiologic monitoring for shock, sepsis, or hypovolemia.
10. Patient with bladder outlet obstruction or known retention.
11. Patient requiring protection of low pelvic colon anastomosis.
Removal Criteria:
12. Urinary catheters will be removed on POD 2 if none of the 3 insertion criteria are met.

In January 2009, the protocol was implemented
to regulate urinary catheter use in surgical patients.
Patients who had surgery prior to January 1, 2009
were assigned to the preintervention cohort, while
those patients with procedures occurring on or af-
ter that date were assigned to the postintervention
group. The primary outcome measure was postop-
erative CAUTI rate. Patients could meet one of two
definitions for CAUTI. The first was a positive urine
culture with > 100 000 colony-forming units (CFU),
but with no more than two distinct organisms, and
either a fever or at least one CAUTI symptom (Figure
3). Some patients did not meet the criteria but were
documented with a diagnosis of CAUTI based upon
the ACS NSQIP screening criteria, including a posi-
tive leukocyte esterase on urinalysis (demonstrating
Figure 3. Criteria for Diagnosing Catheter-Associated
Urinary Tract Infection
• Positive urine culturea,b
• With fever or
Urinary • One UTI symptomc
Tract
Infection • Positive Leukocyte Esterase
• Documentation of UTI in Chart
• Two UTI symptomsc
a Urine culture is positive if it grows > 100 000 cfu.
b
Urinary culture is considered positive if it grew no more
than two bacterial species.
c Frequency, urgency, and burning with urination were
considered UTI symptoms.
pyuria), documentation of CAUTI in their health re-
cord, and two of the listed symptoms. Urine cultures
were ordered for indication of fever, urinary urgency,
and frequency of urination or dysuria. Any catheter-
related urinary infection after protocol implementa-
tion was subjected to an internal audit to determine
whether there were any lapses in compliance.
Statistical Analysis
All analyses were conducted using SAS Software™
Version 9.4 (SAS Institute Inc., Cary, NC). Statistical
significance was determined by a P value of < .05.
Fisher’s exact test (two-tailed) with a 2 x 2 contingen-
cy was used for categorical data, including comparing
CAUTI rates between our pre- and postintervention
groups. Chi-squared two-tailed test was used to com-
pare differences in patient characteristics.
Results
We collected information on 3873 patients over the
course of this study. There were no significant differ-
ences found with respect to patient characteristics be-
tween the pre- and postintervention groups (Table 1).
Of the 1404 patients who were identified for anal-
ysis prior to January 2009, 36 patients (2.6%) met
our definition of a CAUTI. After the protocol was
established, 38 of the 2469 patients (1.5%) met our
definition of a CAUTI (Table 2). This decrease was
statistically significant with a P value of < .05. Post-
intervention ACS NSQIP data showing reduction in
hospital rates is shown in Figure 4.

VOLUME 80, NO. 4 199
Table 1. Comparison of Patient Characteristics in Pre- and Postintervention Groups
Pre-intervention % Post-intervention % P value
N = 1404 N = 2469
Average Age (years) 53.2 56.6 .14
Average BMI 29.8 29.5 .37
Male 575 40.1 986 39.9 .40
Race
Caucasian 1079 76.9 1868 75.7 .61
Black 231 16.5 403 16.4 .61
Other a 94 6.7 193 7.8 .61
Inpatient 851 60.6 1501 60.8 .94
Diabetes 212 15.1 377 15.3 .72
Smoker Within 1 Year 246 17.5 467 18.9 .53
Independent Functional Status 1297 92.4 2266 91.8
ASA=1 136 9.7 233 9.5 .35
ASA=2 698 49.7 1281 51.9 .35
ASA=3 454 32.4 810 32.8 .35
ASA=4 95 6.7 133 5.4 .35
ASA=5 5 0.4 5 0.2 .35
Disseminated Cancer 25 1.7 31 1.3 .88
Chronic Steroid Use 38 2.7 84 3.4 .12
a
Other races include: Asian, Native American, American Indian, Native Alaskan, Native Hawaiian, Other Pacific Islander,
and not identified.

Table 2. Comparison of CAUTI Incidence in Pre- and Postintervention Groups

Pre-intervention % Post-intervention % P value
N = 1404 N = 2469
UTI 36 2.6% 38 1.5% .028

Table 3. Comparison of Complications Between Patients in Pre- and Postintervention Groups

Pre-intervention N % Post-intervention % P value
= 1404 N = 2469
Urinary Tract Infection 36 2.6% 38 1.5% .028
Superficial Incisional SSI 31 2.2% 67 2.7% .251
Deep Incisional SSI 24 1.7% 16 0.6% .002
Organ/Space SSI 15 1.1% 24 1.0% .282
Wound Disruption 8 0.6% 14 0.6% .858
Combined SSI/Wound Disruption 78 5.6% 121 4.9% .399
Pulmonary Embolism 2 0.1% 5 0.2% .387
Acute Renal Failure 4 0.3% 14 0.6% .182
Cardiac Arrest Requiring CPR 10 0.7% 8 0.3% .280
Myocardial Infarction 2 0.1% 9 0.4% .128
Bleeding Requiring Transfusion 84 6.0% 140 5.7% .05
DVT Requiring Therapy 7 0.5% 11 0.4% .747
Sepsis 27 1.9% 44 1.8% .364
Abbreviations: SSI, surgical site infection; DVT, deep vein thrombosis; CPR, cardiopulmonary resuscitation

200 CONNECTICUT MEDICINE, APRIL 2016

Figure 4. Postintervention NSQIP Data Showing Reduction in our UTI Rates. Discussion
The solid black line is the reference line. Each vertical line transecting it depicts
a 95% confidence interval for CAUTI rates. The small dot on each vertical line CAUTIs pose a significant
depicts the odds ratio estimate for each institution. burden to the health care system.
They are associated with unnec-
essary postoperative morbidity,
increased hospitalization, and an
increase in 30-day mortality.15 In
addition, they have a high cumu-
lative financial impact, due to their
high frequency of occurrence, de-
spite being relatively inexpensive
compared to other hospital ac-
quired infections. Furthermore,
treatment of CAUTI can compli-
cate postoperative recovery as un-
necessary antimicrobial therapy
can result in antiobiotic-related
adverse events, most notably,
Clostridium difficile infections.
Such complications can signifi-
The rates of other complications, including surgi- cantly lengthen hospital stay and are associated with
cal site infections, pulmonary embolism, acute renal real morbidity and mortality. In addition, multidrug
failure, cardiac arrest, myocardial infarction, blood resistance (MDR) is a common problem among uri-
transfusion, deep vein thrombosis, and sepsis were nary pathogens, and can be a source of gram-negative
similar between our pre- and postintervention groups bacteremia.16
(Table 3). Because early removal of IUC reduces infection
The 1.1% reduction in CAUTI after protocol im- rates, CAUTI prevention strategies are most effective
plementation resulted in an estimated $81,840 to when tailored towards avoiding prolonged catheter-
$320,540 annual savings based on the cost associated ization.15,17,18 Surgical intensive care units and patient
with a hospital diagnosis of CAUTI. This estimate care areas (surgical wards, step-down units) have no-
when spread over 6200 surgical procedures per annum toriously high-catheter utilization.19 Our interventions
in general, vascular, colorectal, and bariatric surgery, were aimed at both minimizing the duration of cath-
increases the value by $13.20 – $51.70 per operation eterization and improving documentation of catheter
(Table 4). usage. This was achieved initially through staff educa-
Conclusion tion and then through modification of the electronic
health record (EHR) to reflect best practices in cath-
Our intervention of adopting a guideline for peri- eter usage. The latter involved creating “hard stops” in
operative catheter use addressing insertion, mainte- electronic order sets, mandatory selection from drop-
nance, and removal of IUC, in accordance with surgi- down menus for insertion indications and daily alerts
cal care improvement project core measures, reduced for users reminding providers that a urinary catheter
the risk of postoperative CAUTI from 2.6% to 1.5% as is in place. These alerts have been demonstrated to en-
analyzed through the ACS NSQIP database. This risk courage and reinforce best practices.20
reduction saved our hospital an estimated $81,840 to
$320,540 annually ($87,714 – $343,546 when adjusted The educational components were reviewed annu-
for inflation for 2015). ally. Established benchmarks demonstrate that 89%
of nurses include routine hand hygiene before catheter
insertion, 3% did not use
Table 4. Value of Intervention
sterile gloves and only 81%
A. Absolute risk reduction for UTI 1.10% used a sterile barrier during
B. Vascular, colorectal, bariatric and general surgery cases/year 6200 placement, as recommend-
C. Cost of postoperative UTI $1,200 – $4,700 ed by the manufacturer.21
Regular reinforcement of
D. Annual value of intervention (E x B) $81,840 – $320,540
best practices can eliminate
E. Value per case (A x C) $13.20-$51.70 these deficiencies. Equally

VOLUME 80, NO. 4 201
challenging is the reluctance of bedside staff to remove
urinary catheters. The change at our hospital empow-
ered staff, especially nurses, to routinely discuss man-
agement of IUCs and remove them at the appropriate
postoperative day.
Prevention strategies similar to ours have been
employed by other institutions with variable success.
Purvis et al 22 showed a reduction in their CAUTI
rate from 4.7 per 1000 catheter days to 2.4 per 1000
catheter days after using a protocol to minimize cath-
eter days. Chen and colleagues23 utilized a protocol
for catheter management in an ICU setting, result-
ing in a 48% reduction in CAUTI rates as well as a
22% reduction in catheter utilization. Implementation
of such protocols is relatively inexpensive and is often
offset by the ultimate cost savings through preven-
tion in hospital-acquired infections. They do however
require significant cooperation from staff to ensure
transparency, promote internal accountability and re-
iterate best practices periodically.
Despite strict vigilance and adherence to preventive
strategies, some patients with an indwelling urinary
catheter will develop CAUTI. Multiple host risk fac-
tors can contribute to this, including age > 55, female
gender, American Society of Anesthesiologists (ASA)
classification > 1, patients with active sites of infec-
tion, and patients with a major preexisting condition
such as diabetes, malnutrition, or renal insufficien-
cy.1,18 Additional risk factors specific to postoperative
patients include longer operative time, operative tech-
nique, (laparoscopic vs open), and whether surgery
is elective or emergent.24 Laparoscopic and electively
performed procedures have lower rates of CAUTI
compared to their open and emergent counterparts.24
This is attributed to inherent advantages of the lapa-
roscopic approach which leads to decreased pain,
greater mobility, and consequently shorter catheter-
ization time.25 Use of modified equipment (antibiotic-
impregnated catheters, silver-coated urinary catheters,
etc.) and alternate methods of catheterization (exter-
nal or suprapubic catheterization) can help mitigate
risk and further reduce rates, but routine use is not yet
recommended.26,27 Further, asymptomatic bacteriuria
should not be treated with antibiotics, and resolves
subsequently after catheter removal. Timely catheter
removal is the core component of our intervention.
Our study has a few limitations to consider. The
study design did not include measuring total catheter
days on surgical wards. This variable is usually reported
as catheter days/1000 hospital days and consequently
CAUTI are reported as CAUTI/1000 catheter days.
Showing a decrease in both variables would have add-
ed further validity to our results. Secondly, our data
202
on financial savings is not generalizable to all US hos-
pitals. The estimated hospital cost savings of $81,840
to $320,540 was extrapolated through hospital billing
data for local treatment for a hospital-acquired UTI.
Cost savings will vary among hospitals with differ-
ent levels of acuity of care as well as different settings
(ICU, step down) within the same institution.
Organizational behaviors and institutional cul-
ture are a challenge to change. Patient safety-minded
platforms such as the ACS NSQIP can be utilized to
catalyze changes in these behaviors, but are not es-
sential. We utilized the ACS NSQIP data to jump-
start a multifaceted approach for the adoption of best-
practices. Further research will hopefully bring forth
newer methods and novel technologies to help reduce
the burden of CAUTI on the health care system even
further.
REFERENCES
1. Chenoweth CE, Saint S. Urinary tract infections. Infect Dis
Clin North Am. 2011;25(1):103–15.
2. Haley RW, Culver DH, White JW, et al. The nationwide
nosocomial infection rate. A new need for vital statistics. Am
J Epidemiol. 1985;121(2):159–67.
3. Wald HL, Ma A, Bratzler DW, et al. Indwelling urinary
catheter use in the postoperative period: analysis of the na-
tional surgical infection prevention project data. Arch Surg.
2008;143(6):551–7.
4. Yokoe DS, Mermel LA, Anderson DJ, et al. A compendium
of strategies to prevent healthcare-associated infections in
acute care hospitals. Infect Control Hosp Epidemiol. 2008;29
Suppl 1:S12–21.
5. Elpern EH, Killeen K, Ketchem A, et al. Reducing use of
indwelling urinary catheters and associated urinary tract
infections. Am J Crit Care. 2009;18(6):535–41.
6. Porter ME. A strategy for health care reform--toward a
value-based system. N Engl J Med. 2009;361(2):109–12.
7. Porter ME. What is value in health care? N Engl J Med.
2010;363(26):2477–81.
8. Wald HL, Kramer AM. Nonpayment for harms resulting
from medical care: catheter-associated urinary tract infections.
JAMA. 2007;298(23):2782–4.
9. Bologna RA, Tu LM, Polansky M, et al. Hydrogel/silver
ion-coated urinary catheter reduces nosocomial urinary tract
infection rates in intensive care unit patients: a multicenter
study. Urology. 1999;54(6):982–7.
10. Saint S. Clinical and economic consequences of noso-
comial catheter-related bacteriuria. Am J Infect Control.
2000;28(1):68–75.
11. Tambyah PA, Knasinski V, Maki DG. The direct costs
of nosocomial catheter-associated urinary tract infection
in the era of managed care. Infect Control Hosp Epidemiol.
2002;23(1):27–31.
12. Umscheid CA, Mitchell MD, Doshi JA, et al. Estimating
the proportion of healthcare-associated infections that are
reasonably preventable and the related mortality and costs.
Infect Control Hosp Epidemiol. 2011;32(2):101–14.
CONNECTICUT MEDICINE, APRIL 2016
13. Program ACoSNSQI. ACS NSQIP 2015 [cited 2012].
Available from: http://www.acsnsqip.org/main/pro-
gramspecs/program_data_collection.jsp.
14. Set SCIPCM. Surgical Care Improvement Project Core
Measure Set 2015. Available from: http://www.jointcommis-
sion.org/assets/1/6/Surgical%20Care%20Improvement%20
Project.pdf.
15. Saint S, Kowalski CP, Kaufman SR, et al. Preventing hospital-
acquired urinary tract infection in the United States: a national
study. Clin Infect Dis. 2008;46(2):243–50.
16. Platt R, Polk BF, Murdock B, et al. Risk factors for nosocomial
urinary tract infection. Am J Epidemiol. 1986;124(6):977–85.
17. Huang WC, Wann SR, Lin SL, et al. Catheter-associated
urinary tract infections in intensive care units can be reduced
by prompting physicians to remove unnecessary catheters.
Infect Control Hosp Epidemiol. 2004;25(11):974–8.
18. Saint S, Lipsky B, Goold S. Indwelling urinary catheters: a
one point restraint? Ann Intern Med. 2002;137(2):125–7.
19. http://www.cdc.gov/nhsn/PDFs/dataStat/2010NHSN
Report.pdf. Accessed November 25, 2015.
20. Welden LM. Electronic health record: driving evidence-based
catheter-associated urinary tract infections (CAUTI) care
practices. Online J Issues Nurs. 2013,18(3):6.
21. Fink R, Gilmartin H, Richard A, et al. Indwelling urinary
catheter management and catheter-associated urinary
tract infection prevention practices in nurses improving
care for healthsystem elders hospitals. Am J Infect Control.
2012;40(8):715–20.
VOLUME 80, NO. 4
22. Chen YY, Chi MM, Chen YC, et al. Using a criteria-
based reminder to reduce use of indwelling urinary cath-
eters and decrease urinary tract infections. Am J Crit Care.
2013;22(2):105–14.
23. Purvis S, Gion T, Kennedy G, et al. Catheter-associated
urinary tract infection: a successful prevention effort employ-
ing a multipronged initiative at an academic medical center.
J Nurs Care Qual. 2014;29(2):141–8.
24. Zielinski MD, Thomsen KM, Polites SF, et al. Is the Centers
for Medicare and Medicaid Service’s lack of reimbursement
for postoperative urinary tract infections in elderly emergency
surgery patients justified? Surgery. 2014;156(4):1009–15.
25. Navez B, Navez J. Laparoscopy in the acute abdomen. Best
Pract Res Clin Gastroenterol. 2014;28(1):3–17.
26. Karchmer TB, Giannetta ET, Muto CA, et al. A randomized
crossover study of silver-coated urinary catheters in hospital-
ized patients. Arch Intern Med. 2000;160(21):3294–8.
27. Lo E, Nicolle L, Classen D, et al. Strategies to prevent
catheter-associated urinary tract infections in acute care
hospitals. Infect Control Hosp Epidemiol. 2008;29(S1):S41–50.
203
Copyright of Connecticut Medicine is the property of Connecticut State Medical Society and
its content may not be copied or emailed to multiple sites or posted to a listserv without the
copyright holder's express written permission. However, users may print, download, or email
articles for individual use.