CAUTIs remain one of the most common and preventable healthcare-associated infections. Evaluating adherence to CDC guidelines is essential for identifying gaps in clinical practice and for designing targeted interventions to reduce CAUTI incidence. This study provides region-specific evidence from a tertiary hospital, highlighting areas requiring urgent improvement.
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.
To the best of our knowledge, this is among the first systematic assessments of adherence to CDC catheterization guidelines conducted in a Middle Eastern tertiary referral hospital. Previous studies have mainly originated from the United States and China; therefore, our findings provide region-specific insights into clinical practice. The observed interdepartmental variability is particularly novel, as it identifies high-risk services (e.g., gynecology, emergency, plastic surgery) where focused interventions could have substantial impact.
The comparison of demographic variables between patients appropriately and inappropriately catheterized showed no significant difference which ensures proper randomization indicating that age, sex, and hospitalization duration were not associated with 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 [6]. Also Wei Jiang et al. reported 61% adherence in patients admitted to the Second Affiliated Hospital of Chongqing Medical University [5] which is also comparable to our 57.3%.
Our findings are consistent with recent studies that continue to report suboptimal adherence to CAUTI prevention guidelines in both high- and middle-income countries. For example, Lakoh et al. [8] observed high CAUTI incidence and related antibiotic resistance in Sierra Leone, emphasizing the persistent global challenge of inappropriate catheter use [8]. Similarly, the CDC [13] highlighted that delayed catheter removal remains a major modifiable risk factor [13]. Our overall adherence rate of 57.3% closely aligns with the rates reported in recent multicenter audits [4, 5], suggesting that despite advances in infection control, gaps in daily clinical practice persist. These findings underscore the universal need for regular audits, staff training, and institutional policy enforcement to enhance compliance with evidence-based catheterization practices.
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 [11, 12]. 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 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 [14] also Al-Sayaghi et al. have shown ward/unit to be an important factor of compliance of healthcare workers. [15]. 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.
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 [13]. 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.
Variation across wards which are described by detail in Table 2 and Fig. 3 may be influenced by factors such as patient case-mix, procedural frequency, or differences in staff experience. However, we did not directly measure workload, training levels, or staffing ratios, so these should be considered possible contributors rather than confirmed explanations. Future studies incorporating qualitative assessment of provider perspectives and institutional factors could clarify the underlying causes.
The low adherence in emergency department 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 [6].
Regarding our results both surgical and non-surgical specialties can have adherence challenges in this matter. Physicians should be encouraged to review catheter indications daily to prevent unnecessary continuation, 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. This study was limited by its short 2-month duration, which may reduce generalizability by missing seasonal or temporal variations in catheter use.
Another important limitation is the incomplete documentation of catheter removal dates which was caused by documentation missing. Without reliable removal data, we were unable to calculate catheter-days or evaluate adherence to timely removal recommendations. This omission limits our ability to quantify duration-related risk, which is central to estimating the true burden of CAUTIs. As prolonged catheterization increases infection risk by 3–7% per day [13], the lack of removal data represents a significant gap.
Although this study did not assess CAUTI rates by department due to incomplete microbiological documentation, future research should explore the relationship between adherence to guidelines and actual infection outcomes to better establish clinical relevance.
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. Because the study design was descriptive and several departments had small sample sizes, multivariate regression analysis to identify independent predictors of non-adherence was not performed. Future studies with larger, multi-center datasets could address this important aspect. Investigating the role of technological solutions, such as electronic reminders and decision-support systems, may also prove beneficial in promoting adherence.
link