Knowledge, practice and associated factors of nurses towards prevention of catheter-associated urinary tract infection in intensive care unit of public hospitals administered by Federal Government in Addis Ababa, Ethiopia: a cross-sectional institutional-based study

Catheter-associated Urinary Tract Infections (CAUTIs) is a urinary tract infections (UTIs) in a patient with a catheter present or within 48 h of catheter removal [1]. It affects any part of the urinary system, including the kidney, ureter, bladder, and urethra [2‐4]. CAUTIs are acquired when the insertion of a urinary catheter unnecessarily and the presence of a catheter for a long period in the bladder [5, 6]. More than 70% of UTIs are acquired due to the use of indwelling urinary catheters and unnecessary instrumentation [7].

CAUTIs are caused by organisms such as E.coli(21.4%), Enterococcus(14.9%), Pseudomonas Aeruginosa(10%), Klebsiella Pneumonia(7.75%) and Enterobacter (4.15%) [8, 9]. The risk factors associated with acquiring CAUTIs were; being female, prolonged duration of catheterization, immune-compromised patients, advanced age, and prolonged ICU stay [10].

CAUTIs can lead to different complications such as; prostatitis, epididymitis, bladder spasm, orchitis in males and cystitis, pyelonephritis, urosepsis, endocarditis, endophthalmitis, meningitis, and bloodstream infections [11]. It has been associated with increased morbidity, mortality, high financial cost, and prolonged length of stay in the hospital [11‐13]. According to the CDC guideline, catheterized patients have more than 80% of developing urinary tract infections when compared to non-catheterized patients, with a higher incidence in developing countries compared to developed countries [14, 15].

The knowledge and practice of nurses towards prevention of CAUTIs was poor in developing countries. For instance, in India (58.8%) [9], Philippines (70%) [16], Rwanda (64.52%) [15] and Egypt (83.94%) [17]. The guidelines for the prevention of CAUTIs have recommended proper catheter use, aseptic insertion, good maintenance, and cultural and behavioral change in the health care units are vital in avoiding catheter-associated UTIs [18, 19].

Shortening the duration of catheterization, avoiding unnecessary catheterization, preparing and implementing standard infections control protocols and using sterile precautions in the insertion and maintenance of indwelling urinary catheters can reduce catheter-related complications [12, 20].

Nurses are the primary healthcare providers responsible for inserting and maintaining urinary catheters, as well as the production of desired outcomes by which they follow the available guidelines, protocols, and standards during catheter insertion and catheter cares [21]. The evidence indicates that factors such as the availability of resources and presence of guidelines in the health facility have a positive impact on the knowledge and practice of nurses towards prevention of CAUTIs [22].

In the developing countries, the incidence of CAUTIs approximately ranged from 10 to 35 per 1000 patients [10]. Similarly, in African countries, including Ethiopia, CAUTIs are the most common healthcare-associated infections accounting for 80% of hospital-acquired infections [15]. Despite the high incidence of CAUTIs in Ethiopia, the data regarding knowledge, practice and associated factors of nurses towards prevention of CAUTIs are limited. Therefore, this study aimed to assess the knowledge, practice and associated factors of nurses towards prevention of CAUTIs in the Intensive Care Unit at public hospitals in Addis Ababa, Ethiopia.

Hospital-acquired infections (HAIs) constitute major public health problems worldwide; among which Catheter-Associated Urinary Tract Infections (CAUTIs) are the most common [23]. More than 70% of UTIs are reported because of indwelling catheters and unnecessary instrumentation [7, 13]. Nurses are the primary healthcare providers responsible for inserting and maintaining urinary catheters, as well as the production of desired outcomes by which they follow the available guidelines, protocols, and standards during catheter insertion and catheter cares [15, 21]. In recent years, many efforts have done to change the behaviors of nurses towards the prevention of CAUTIs and limit the unnecessary use of IUC [3]. Therefore, this study aimed to assess the knowledge, practice and associated factors towards prevention of CAUTIs among nurses working in the intensive care units at public hospitals in Addis Ababa, Ethiopia.

In this study finding, only 36.96% of nurses had good knowledge towards prevention of Catheter-associated UTIs. This finding is in line with the study conducted in India [9], Egypt [17] and Rwanda [15]. The possible reason might be due to the same study design used (cross-sectional) and study subjects (nurses). In contrast, this finding is relatively higher than the study conducted in Philippines at Iloilo city [16]. This might be due to the difference in the sample size, the previous study done in Philippines had a lower sample size (n = 30). But, the sample size in the current study was 204, which is higher than that of the previous study. However, this finding is lower than the findings of the studies conducted in Pakistan at public hospitals in Lahore [24] and Iran [25]. This discrepancy might be due to the differences in the health facility setup and availability of the guidelines.

The current study revealed that more than half (52.2%) of the study participants had good practice towards prevention of Catheter-associated UTIs. This finding is higher than the studies conducted in Pakistan [26], Philippines [16] and Egypt [17]. This discrepancy might be due to the educational status of the study participants, the difference in the study setting and the sample size. In the previous studies, Pakistan (73.4%), Philippines (66.7%) and Egypt (62.1%) were diploma nurses. But, in the current study, most nurses were a Bachelor of Science degree (79.5%), and the previous study had a lower sample size; Pakistan (184), Philippines (30), and Egypt (137). But, in the current study, the sample size was 204. However, this finding is lower than a study conducted in Rwanda [15]. This discrepancy might be due to the differences in the tool used to rate the outcome, availability of infection prevention protocols and guidelines and availability of supplies in their working units.

In the current study, nearly half (51.6%) of the study participants reported that guidelines/protocols were available in their working units. This finding is consistent with the study conducted in Pakistan at public hospitals in Lahore [24]. The possible reason for the consistency might be due to the same study setting since both studies were conducted in ICU, where critical patients were treated, and the study subjects (nurses). In this study finding, more than one-third (38.6%) of nurses had got on job training on how to prevent infections during catheterization. This finding is inconsistent with the findings of the studies conducted in Egypt [17] and Rwanda [15]. This discrepancy might be due to the difference in the institutional facility and resource limitation, in a country like Ethiopia with low socio-economic status, there is resource limitation in the health facility. However, more than half of the study participants reported that there were enough supplies (like a lubricant, solution for cleansing, sterile drapes), and hand washing facility in their working area. This study is consistent with the study conducted in Pakistan at public hospitals in Lahore [24]. The possible reason for the consistency might be due to the same study setting and study subjects (nurses).

According to the reports of this study, nurses’ level of knowledge is not statistically associated with nurses’ level of practice (P-value = 0.450). This finding agrees with the study conducted in Pakistan at Iloilo city [16] and Egypt [17]. The possible justification for this similarity might be due to similar study design used and poor nurses’ level of knowledge and practice in both studies. However, in the current study, there was a statistically significant association between professional work experience and nurses’ level of knowledge (at P-value = 0.031). This finding is in line with the study conducted in Pakistan [27]. The possible justification for the similarity might be due to the fact that work experience increases nurses’ level of knowledge towards prevention of CAUTIs. This implies that nurses can learn or gain knowledge from their experience if they stayed in the unit for a prolonged time. Thus, this study concluded that there is no impact of socio-demographic characteristics (except professional experience) and institutional factors on nurses’ knowledge and practice towards prevention of Catheter-associated UTIs.

The study had some limitations. Primarily, a cross-sectional study was used and it did not show a causal relationship between study variables. The study could not observe the actual nurses’ practices towards prevention of CAUTIs. Finally, the questionnaire was prone to social desirability bias; because everyone does not want to expose once inability to practice.

In this study, nurses’ knowledge and practice towards prevention of catheter-associated UTIs was relatively poor. Nurses’ professional work experience had a significant statistical association with the level of knowledge towards prevention of CAUTI. Therefore, we recommended increasing the knowledge of nursing staff through appropriate educational programs and training regarding the preventive measures of device-associated infections on how to avoid unnecessary urinary catheter use. We also recommended further studies with large sample sizes need to investigate factors affecting nurses’ knowledge and practice towards prevention of Catheter-associated UTIs.