- 1 Authors
- 2 Executive summary
- 3 Introduction
- 4 Definition
- 5 Epidemiology
- 6 Pathogenesis and risk factors
- 7 Diagnosis
- 8 Treatment
- 9 Algorithm
- 10 Abbreviations
- 11 References
Paul Anantharajah Tambyah (Division of Infectious Disease, Department of Medicine, National University Hospital, Singapore)
Edmund Chiong (Department of Urology, National University Hospital, Singapore)
Leyland Chuang (Division of Infectious Disease, Department of Medicine, Ng Teng Fong Hospital, Singapore)
Epidemiology and pathogenesis
1. CAUTIs are the commonest nosocomial infections. Definitions remain controversial, but the NHSN definitions have been widely accepted.
2. Higher rates of CAUTIs and antibiotic resistant organisms have been reported in parts of Asia. Hence, antimicrobial treatment choice should be guided by local antibiograms and culture results (LE: 4).
1. CAASB should not be routinely treated with antibiotics (LE: 1b). Routine surveillance cultures are not warranted and should not be done.
2. Reducing the duration of urethral catheterization remains key to the prevention of CAUTIs (LE: 2b), for which various reminder systems have been shown to be effective (LE: 1a).
3. Urinary catheter care bundles have also been shown to reduce CAUTI rates (LE: 2a).
CAUTI refers to UTIs associated with indwelling urinary catheters, which are defined as drainage tubes inserted into the urinary bladder through the urethra, left in place, and connected to a collection system.
The definition of CAUTI remains controversial, with all guidelines agreeing that symptoms alone are not reliable for the diagnosis of CAUTI. For surveillance purposes, the US CDC’s NHSN definitions have commonly been accepted and used in most published reports, despite these definitions being difficult to apply in practice. The NHSN definitions are described below in the diagnosis section.
Alternative urinary drainage methods are available, such as clean intermittent (“in-and-out”) urinary catheterization, external catheters that fit over or adhere to the genitalia (“condom” catheters), suprapubic catheters and nephrostomy tubes. Although UTIs associated with these methods may be considered device-associated, NHSN CAUTI definitions typically refer only to UTIs associated with indwelling urethral catheters. Hence, CAUTI will be taken to refer only to indwelling urethral catheters throughout this guideline.
UTIs remain the commonest nosocomial infections worldwide, and have been estimated to cause approximately 30% of HCAIs in the acute care setting in the United States. Of these, approximately 75% are associated with an indwelling urinary catheter.
The impact of CAUTI is likely to be even greater in Asia. A surveillance study was conducted over 6 years by the International Nosocomial Infection Control Consortium in 422 ICUs of 36 countries in Latin America, Asia, Africa, and Europe, of which 57% were in Asia. The study found developing countries to have a rate of 6.3 CAUTIs per 1,000 urinary catheter-days, compared to 3.3 per 1,000 catheter-days in comparable US ICUs. CAUTIs in developing countries were also associated with higher rates of antibiotic resistance on microbiological surveillance.
Pathogenesis and risk factors
The presence of a urethral catheter will bypass or inhibit natural host defenses, predisposing patients to CAUTIs. This is further exacerbated by the development of biofilm on the urinary catheters, which provides a favorable environment for bacterial proliferation & invasion. Bacteria may be introduced into the urinary tract via several routes, such as:
1. Inoculation at the time of catheter insertion, especially in patients who have had inadequate disinfection of the perineum prior to catheterization.
2. Via intraluminal ascent in the urinary catheter lumen after contamination of the closed urinary catheter system (such as via breaks in aseptic practice during the emptying of the urinary drainage bag, or temporary disconnection of catheters from urinary bags).
3. Via extraluminal route of ascent along the external surface of the urinary catheter into the urethra.
The most common uropathogen isolated from the catheterized urinary tract is Escherichia coli. Other common organisms isolated in patients who had short-term catheterisation include Pseudomonas, Klebsiella, Proteus, Enterococcius and Candida species. Proteus mirabilis bacteriuria is often associated with catheter obstruction, and polymicrobial bacteriuria is commonly found in patients with long-term catheters. Risk factors for CAUTI which have been identified in prospective observational studies include
• Duration of catheterization
• Female gender
• Anatomical or functional abnormalities of the urinary tract
• Insertion of the catheter outside the operating room
• Diabetes mellitus
• Poor catheter care or breaks in aseptic technique
Symptoms (physical examination)
Among patients without catheters with microbiology confirmed bacteriuria, the presence of symptoms attributable to an infection of the urinary tract has classically differentiated patients with asymptomatic bacteriuria from those with symptomatic UTI. These symptoms include fever, urgency, dysuria, hematuria, suprapubic pain and costovertebral angle tenderness.
However, this distinction may be difficult in some patients with chronic indwelling catheters, such as in patients with spinal cord injury, and patients who are unable to communicate due to illness, comorbidities or extremes of age In particular, symptoms referable to the urinary tract have been found to be uncommon in patients with CAUTI for whom the catheter alone may be a source of symptoms, and have poor predictive value for differentiating CAUTIs from CAASBs4.
Criteria and classification
The criteria and classifications of CAUTI and CAASB, as adapted from the US NHSN3, are as detailed below in Table 1. There are other more complex classification criteria which have been developed8 for research purposes, but the NHSN criteria are most practical in the setting of surveillance and clinical decision making. Criteria for the categories of presence of indwelling urinary catheter, symptoms and positive microbiology must all be met to qualify for the diagnosis of CAUTI. Culture of indwelling urinary catheter is not recommended.
The treatment, management and prevention of CAUTIs are as follows:
Medication / Drug Therapy
Significantly higher rates of antibiotic resistance have been found in Asia as compared to Europe and North America. In addition, clinical prescribing practices and availability of antibiotics differ between countries and healthcare facilities. Hence, no single set of recommendation for empiric antibiotics can be made for the treatment of CAUTIs in Asia. Recommendations with regards to selection of antibiotics are detailed in Table 2. There is considerable controversy regarding the duration of treatment, the need to treat bacteriuria once catheters are removed, and the role of periodic treatment in spinal cord injured patients. No general recommendation can be made for these situations.
Procedures and interventions
Asepsis of the urinary catheter system is vital for the prevention of CAUTI. Interventions towards this end have been recently been focused on the use of modified catheters, as well as aseptic insertion and maintenance of urinary catheters. Recommendations regarding the use of catheters are detailed in Table 3. 
Prophylaxis, prevention and monitoring
Principles for prevention of CAUTI may be broadly classified under the following categories:
• Avoiding unnecessary urinary catheterization and minimizing duration of catheterization via close surveillance and reminder systems.
• Preserving aseptic condition and closed drainage of urinary catheter system during insertion and maintenance.
• Implementation of urinary catheter care bundles and infection control programs.
Specific recommendations are detailed in Table 4.
CAASB: catheter-associated asymptomatic bacteriuria, CAUTI: catheter-associated urinary tract infection, CDC: Centers for Disease Control and Prevention, CFU: colony-forming unit, HAI/HCAI: healthcare-associated infections, ICU: intensive care unit, NHSN: National Healthcare Safety Network, US: United States, UTI: urinary tract infection, WBC: white blood cell
- Tenke P, Kovacs B, Bjerklund Johansen TE, Matsumoto T, Tambyah PA, Naber KG. European and Asian guidelines on management and prevention of catheter-associated urinary tract infections. Int J Antimicrob Agents. 2008; 31: S68–78.
- Lo E, Nicolle LE, Coffin SE, et al. Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014; 35: 464–79.
- Gould C V, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA. Guideline for prevention of catheter-associated urinary tract infections 2009. Infect Control Hosp Epidemiol. 2010; 31: 319–26.
- Tambyah PA, Maki DG. Catheter-associated urinary tract infection is rarely symptomatic: a prospective study of 1,497 catheterized patients. Arch Intern Med. 2000; 160: 678–82.
- Tambyah PA, Oon J. Catheter-associated urinary tract infection. Curr Opin Infect Dis. 2012; 25: 365–70.
- Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis. 2010; 50: 625–63.
- 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: S41–50.
- Johansen TEB, Botto H, Cek M, et al. Critical review of current definitions of urinary tract infections and proposal of an EAU/ESIU classification system. Int J Antimicrob Agents. 2011; 38S: 64–70.
- Saint S, Greene MT, Kowalski CP, Watson SR, Hofer TP, Krein SL. Preventing catheter-associated urinary tract infection in the United States: a national comparative study. JAMA Intern Med. 2013; 173: 874–9.
- Al-Qas Hanna F, Sambirska O, Iyer S, Szpunar S, Fakih MG. Clinician practice and the National Healthcare Safety Network definition for the diagnosis of catheter-associated urinary tract infection. Am J Infect Control. 2013; 41: 1173–7.
- Klevens RM, Edwards JR, Richards CL, et al. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep. 2007; 122: 160–6.
- Ling ML, Apisarnthanarak A, Madriaga G. The Burden of Healthcare-Associated Infections in Southeast Asia: A Systematic Literature Review and Meta-analysis. Clin Infect Dis. 2015;
- Rosenthal VD, Bijie H, Maki DG, et al. International Nosocomial Infection Control Consortium (INICC) report, data summary of 36 countries, for 2004-2009. Am J Infect Control. 2012; 40: 396–407.
- Centers for Disease Control and Prevention. Catheter-associated urinary tract infections [Internet]. [cited 2014 Nov 7]. Available from: http://www.cdc.gov/HAI/ca_uti/uti.html
- Yi SH, Baggs J, Gould C V, Scott RD, Jernigan JA. Medicare reimbursement attributable to catheter-associated urinary tract infection in the inpatient setting: a retrospective cohort analysis. Med Care. 2014; 52: 469–78.
- Hu B, Tao L, Rosenthal VD, et al. Device-associated infection rates, device use, length of stay, and mortality in intensive care units of 4 Chinese hospitals: International Nosocomial Control Consortium findings. Am J Infect Control. 2013; 41: 301–6.
- Castle N, Engberg JB, Wagner LM, Handler S. Resident and Facility Factors Associated With the Incidence of Urinary Tract Infections Identified in the Nursing Home Minimum Data Set. J Appl Gerontol. 2015;
- Maki DG, Tambyah PA. Engineering out the risk for infection with urinary catheters. Emerg Infect Dis. 2001; 7: 342–7.
- Nicolle LE. Urinary catheter-associated infections. Infect Dis Clin North Am. 2012; 26: 13–27.
- Warren JW. Catheter-associated urinary tract infections. Int J Antimicrob Agents. 2001; 17: 299–303.
- Foxman B. The epidemiology of urinary tract infection. Nat Rev Urol. 2010; 7: 653–60.
- Platt R, Polk BF, Murdock B, Rosner B. Risk factors for nosocomial urinary tract infection. Am J Epidemiol. 1986; 124: 977–85.
- Barbadoro P, Labricciosa FM, Recanatini C, et al. Catheter-associated urinary tract infection: Role of the setting of catheter insertion. Am J Infect Control. 2015;
- Conway LJ, Larson EL. Guidelines to prevent catheter-associated urinary tract infection: 1980 to 2010. Heart Lung. 2012; 41: 271–83.
- Beveridge LA, Davey PG, Phillips G, McMurdo MET. Optimal management of urinary tract infections in older people. Clin Interv Aging. 2011; 6: 173–80.
- Loeb M, Brazil K, Lohfeld L, et al. Effect of a multifaceted intervention on number of antimicrobial prescriptions for suspected urinary tract infections in residents of nursing homes: cluster randomised controlled trial. BMJ. 2005; 331: 669.
- Wagenlehner FME, Cek M, Naber KG, Kiyota H, Bjerklund-Johansen TE. Epidemiology, treatment and prevention of healthcare-associated urinary tract infections. World J Urol. 2012; 30: 59–67.
- Buhr GT, Genao L, White HK. Urinary tract infections in long-term care residents. Clin Geriatr Med. 2011; 27: 229–39.
- Morrissey I, Hackel M, Badal R, Bouchillon S, Hawser S, Biedenbach D. A review of ten years of the Study for Monitoring Antimicrobial Resistance Trends (SMART) from 2002 to 2011. Pharmaceuticals. 2013; 6: 1335–46.
- Harding GK, Nicolle LE, Ronald AR, et al. How long should catheter-acquired urinary tract infection in women be treated? A randomized controlled study. Ann Intern Med. 1991; 114: 713–9.
- Salomon J, Denys P, Merle C, et al. Prevention of urinary tract infection in spinal cord-injured patients: safety and efficacy of a weekly oral cyclic antibiotic (WOCA) programme with a 2 year follow-up--an observational prospective study. J Antimicrob Chemother. 2006; 57: 784–8.
- MacFadden DR, Ridgway JP, Robicsek A, Elligsen M, Daneman N. The predictive utility of prior positive urine cultures. Clin Infect Dis. 2014
- Darouiche RO, Al Mohajer M, Siddiq DM, Minard CG. Arch Phys Med Rehabil. 2014; 95: 290–6.
- Warren JW, Anthony WC, Hoopes JM, Muncie HL. JAMA. 1982; 248: 454–8.
- Schumm K, Lam TBL. Cochrane Database Syst Rev. 2008; CD004013.
- De Ridder DJMK, Everaert K, Fernández LG, et al. Eur Urol. 2005; 48: 991–5.
- Li L, Ye W, Ruan H, Yang B, Zhang S. Arch Phys Med Rehabil. 2013; 94: 782–7.
- Pickard R, Lam T, MacLennan G, et al. Lancet. 2012; 380: 1927–35.
- Makuta G, Chrysafis M, Lam T. Nurs Times. 109: 16, 18–9.
- Jahn P, Beutner K, Langer G. Cochrane database Syst Rev. 2012; 10: CD004997.
- Segev G, Bankirer T, Steinberg D, et al. J Vet Intern Med. 27: 39–46.
- Shapur NK, Duvdevani M, Friedman M, et al. J Endourol. 2012; 26: 26–31.
- Hunter KF, Bharmal A, Moore KN. Neurourol Urodyn. 2013; 32: 944–51.
- Healy EF, Walsh CA, Cotter AM, Walsh SR. Obstet Gynecol. 2012; 120: 678–87
- Raz R, Schiller D, Nicolle LE. J Urol. 2000; 164: 1254–8.
- Wald HL, Ma A, Bratzler DW, Kramer AM. Arch Surg. 2008; 143: 551–7.
- West DA, Cummings JM, Longo WE, Virgo KS, Johnson FE, Parra RO. Urology. 1999; 53: 292–7.
- Saint S, Wiese J, Amory JK, et al. Am J Med. 2000; 109: 476–80. .
- Meddings J, Rogers MAM, Macy M, Saint S. Clin Infect Dis. 2010; 51: 550–60.
- Apisarnthanarak A, Thongphubeth K, Sirinvaravong S, et al. Infect Control Hosp Epidemiol. 2007; 28: 791–8.
- Crouzet J, Bertrand X, Venier AG, Badoz M, Husson C, Talon D. J Hosp Infect. 2007; 67: 253–7.
- Robinson S, Allen L, Barnes MR, et al. Medsurg Nurs. 2007; 16: 157–61.
- Huang W-C, Wann S-R, Lin S-L, et al. Infect Control Hosp Epidemiol. 2004; 25: 974–8.
- Bruminhent J, Keegan M, Lakhani A, Roberts IM, Passalacqua J. Am J Infect Control. 2010; 38: 689–93.
- Elpern EH, Killeen K, Ketchem A, Wiley A, Patel G, Lateef O. Am J Crit Care. 2009; 18: 535–41.
- Fakih MG, Dueweke C, Meisner S, et al. Infect Control Hosp Epidemiol. 2008; 29: 815–9.
- Chen Y-Y, Chi M-M, Chen Y-C, Chan Y-J, Chou S-S, Wang F-D. Am J Crit Care. 2013; 22: 105–14.
- Cornia PB, Amory JK, Fraser S, Saint S, Lipsky BA. Am J Med. 2003; 114: 404–7.
- Nagle D, Curran T, Anez-Bustillo L, Poylin V. 2014; 57: 91–7.
- Topal J, Conklin S, Camp K, Morris V, Balcezak T, Herbert P. Am J Med Qual. 2005; 20: 121–6.
- Loeb M, Hunt D, O’Halloran K, Carusone SC, Dafoe N, Walter SD. J Gen Intern Med. 2008; 23: 816–20.
- Dumigan DG, Kohan CA, Reed CR, Jekel JF, Fikrig MK. Clin Perform Qual Health Care. 1998; 6: 172–8.
- Fakih MG, Heavens M, Ratcliffe CJ, Hendrich A. Am J Infect Control. 2013; 41: 950–4.
- Magers TL. Am J Nurs. 2013; 113: 34–42; quiz 44, 43.
- Parry MF, Grant B, Sestovic M. Am J Infect Control. 2013; 41: 1178–81.
- Mori C. Medsurg Nurs. 23: 15–21, 28. .
- Rothfeld AF, Stickley A. Am J Infect Control. 2010; 38: 568–71.
- Titsworth WL, Hester J, Correia T, et al. J Neurosurg. 2012; 116: 911–20.
- Andreessen L, Wilde MH, Herendeen P. J Nurs Care Qual. 2012; 27: 209–17.
- Kanj SS, Zahreddine N, Rosenthal VD, Alamuddin L, Kanafani Z, Molaeb B. Int J Infect Dis. 2013; 17: e686–90.
- Navoa-Ng JA, Berba R, Rosenthal VD, et al. J Infect Public Health. 2013; 6: 389–99.
- Rosenthal VD, Todi SK, Álvarez-Moreno C, et al. Infection. 2012; 40: 517–26.
- Marra AR, Sampaio Camargo TZ, Gonçalves P, et al. Am J Infect Control. 2011; 39: 817–22.
- Clarke K, Tong D, Pan Y, et al. Int J Qual Heal Care. 2013; 25: 43–9.
- Leblebicioglu H, Ersoz G, Rosenthal VD, et al. Am J Infect Control. 2013; 41: 885–91.
- Miller BL, Krein SL, Fowler KE, et al. Infect Control Hosp Epidemiol. 2013; 34: 631–3.
- Fakih MG, George C, Edson BS, Goeschel CA, Saint S. Infect Control Hosp Epidemiol. 2013; 34: 1048–54.
- Saint S, Olmsted RN, Fakih MG, et al. Jt Comm J Qual Patient Saf. 2009; 35: 449–55.
- Jain M, Dogra V, Mishra B, Thakur A, Loomba PS. Indian J Crit Care Med. 2015; 19: 76–81.
- Hu F-W, Chang C-M, Tsai C-H, Chen C-H. J Clin Nurs. 2015;
- Lusardi G, Lipp A, Shaw C. Cochrane Database Syst Rev. 2013; 7: CD005428
- Marschall J, Carpenter CR, Fowler S, Trautner BW. BMJ. 2013; 346: f3147.
- Niël-Weise BS, van den Broek PJ, da Silva EMK, Silva LA. Cochrane Database Syst Rev. 2012; 8: CD004201.