|WOCN FACT SHEET: Catheter-Associated Urinary Tract Infections: Fact Sheet
|Journal of Wound, Ostomy and Continence Nursing
Volume 36 Number 2
Pages 156 - 159
Prevalence and Incidence
Catheter-associated urinary tract infections (CAUTI) are one of the most frequent infections today:
* The daily risk of developing CAUTI is 3% to 7% in the acute care setting.1
* CAUTI comprise 40% of all institutionally acquired infections.2
* There is an 8% prevalence of CAUTI in the home care setting.3
* There is limited evidence regarding the incidence of CAUTI in long-term suprapubic catheter users compared to urethral catheter users.4
The Centers for Medicare & Medicaid Services (CMS) identified hospital-acquired CAUTI as 1 of 8 conditions for which hospitals will not receive additional reimbursement.5,6 Long-term care facilities also follow the CMS regulatory guidance. In the long-term-care federal regulation (F-315 Tag), the use of urinary catheters must be medically justified and care rendered to reduce the risk of infection for all residents with or without a catheter.7 The CMS regulations emphasize the complications/risks of CAUTI, which include the following conditions 6,8:
* cystitis, periurethral abscess, prostatitis, epididymitis, and acute or chronic pyelonephritis 9,10
* gram negative bacteremia 11
* urosepsis, which can be fatal in 40% to 60%2,9,12–15
Bacteriuria: Bacteria in the urine 16
* Long-term catheter users (catheter for >= 30 days) have high concentrations of bacteria in the urine that tend to be polymicrobial.17,18
* Asymptomatic bacteriuria
is defined as at least 1 microorganism found in 2 consecutively collected urine specimens with >= 100,000/colony-forming units/mL and no lower urinary tract symptoms.19
* People with catheters acquire bacteriuria at different rates. Incidence of conversion from sterile urine to bacteriuria occurs at the rate of 3% to 10% per day.20
* Asymptomatic bacteriuria will be present in virtually every long-term catheter user once the catheter has been in place > 30 days.10,21
* Asymptomatic bacteriuria should not be treated in long-term catheter users. Bacteriuria may be treated in selected cases of short-term catheter users such as patients who are immunocompromised, pregnant, or scheduled for urological surgery.18
Bacteremia: Blood stream infection
* Approximately 3% of all patients with a catheter will develop bacteremia, which is a serious and possibly life-threatening complication.22
* CAUTI is the second most common cause of nosocomial bloodstream infection.4
Diagnosis of CAUTI
The diagnosis of CAUTI is based on finding bacteriuria along with an elevated white blood cell count on a urinalysis examination. Additionally, in some cases, an elevated serum white blood cell and 2 or more of the following signs/symptoms may be present 3:
* Pain or burning in the region of the bladder, urethra, or flank 23
* Fever (greater than 100.4ºF or 38ºC) or chills 3,23
* Change in color or character of urine, including cloudy urine or increased sediment 3,23
* Bladder spasms/leakage 12
* Catheter obstruction 12
* Increased weakness or spasticity, especially, in those with neurological disease or injury 12
* Change in mental status, particularly in older adults, such as confusion, lethargy, agitation, delirium, or subtle changes in behavior 2,9,12,26
* Bacteremia (especially after trauma to the urinary mucosa)3,24,25
Certain individuals are more prone to developing CAUTI. Some catheter management techniques can also contribute to increased risks for developing CAUTI. A summary of the risks and factors contributing to CAUTI is presented in Table 1.
|Table 1. Risk and Contributing Factors for Developing Catheter-Associated Urinary Tract Infections
Treatment of Symptomatic CAUTI
* Identify the microorganism causing infection and differentiate that species from other bacteria found in the existing catheter.31
* Initial treatment may be empirical, but the choice of therapy with oral or parenteral antimicrobial drugs should be based on results of culture and sensitivity testing.12
* Urosepsis is the most serious complication of indwelling catheter use and requires aggressive antibiotic therapy and supportive care and may require hospitalization.12
Prevention of CAUTI
A key component of any plan for the prevention of bacteriuria or symptomatic urinary tract infection (UTI) involves prompt removal of the catheter, whenever possible, and use of an alternative method of bladder drainage (eg, spontaneous voiding, clean intermittent catheterization, or external condom). If catheter removal is not an option, other effective UTI prevention strategies can be implemented such as those indicated in Table 2.
|Table 2. Strategies to Prevent Urinary Tract Infections
Unproven Strategies to Prevent UTI
Research indicates none of the following practices are useful in preventing urinary tract infection with indwelling catheter use:
* Instilling antibiotics or other additives to the drainage bag 47–49
* Antiseptic compounds applied to the meatus 12,46
* Specific agents used for meatal cleansing 12,35,36
* Systemic antibiotics for prophylaxis 2,12,19,26,50,51
* Cranberry juice may be helpful in preventing recurring UTI in noncatheterized persons, but there is insufficient evidence to support this practice to prevent CAUTI.
* The juice does not affect the acidity of the urine but interacts with the mucosal walls of the urethra to prevent microbial replication and adherence.52–55
1. 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(suppl 1):s41-s50. [Context Link]
2. National Center for Health Statistics, Centers for Disease Control and Prevention, US Department of Health and Human Services, September 2004. Urinary tract infections in adults. Series 13, No. 157. Hyattsville, MD. [Context Link]
3. Getliffe K, Newton R. Catheter-associated urinary tract infections in primary and community health care. Age Aging. 2006;35:447–481. [Context Link]
4. Maki D, Tambyah P. CDC-engineering out the risk of infection with urinary catheters. 2001. http://www.cdc.gov/ncidod/eid/vol7no2/maki.htm . Accessed October 31, 2005. [Context Link]
5. Beaver M. CMS reimbursement changes put spotlight on prevention of catheter-related infections. Infection Control Magazine. 2008; www.infectioncontroltoday.com/articles/402/cms-regulations-catheter-infections.html . Published May 18, 2008. Accessed October 20, 2008. [Context Link]
6. Centers for Medicare & Medicaid Services (CMS). 2008. Hospital acquired conditions (present on admission indicator) overview. www.cms.hhs.gov/HospitalAcqCond/06_Hospital-Acquired_Conditions.asp. Accessed October 13, 2008. [Context Link]
7. CMS Guidance for revised F-tag 315. http://www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/SCletter05-23.pdf . Accessed November 9, 2008. [Context Link]
8. Centers for Medicare & Medicaid Services (CMS). www.cms.hhs.gov/GuidanceforLawsAndRegulations/12_NHs.asp#TopOfPage. Accessed October 13, 2008. [Context Link]
9. Kunin C. Urinary Tract Infections: Detection, Prevention, and Management, 5th ed. Baltimore, MD: Williams & Wilkins; 1997. [Context Link]
10. Smith J. Indwelling catheter management: from habit-based to evidence-based practice. Ostomy Wound Manage. 2003;49:34–45. [Context Link]
11. Rahn DD. Urinary tract infections: contemporary management. Urol Nurs. 2008;28:334–341. [Context Link]
12. Cravens DD, Zweig S. Urinary catheter management. Am Fam Physician. 2000;61:369–376. [Context Link]
13. Kunin CM, Douthitt S, Dancing J, Anderson J, Moeschberger M. The association between the use of urinary catheters and morbidity and mortality among elderly patients in nursing homes. Am J Epidemiol. 1992;135:291–301. [Context Link]
14. Rosser CJ, Bare RL, Meredith JW. Urinary tract infections in the critically ill patient with a urinary catheter. Am J Surg. 1999;177:287–290. [Context Link]
15. Warren JW, Damron D, Tenney JH, Hoopes JM, Deforge B, Muncie HLJ. Fever, bacteremia, and death as complications of bacteriuria in women with long-term urethral catheters. J Infect Dis. 1987;155:1151–1158. [Context Link]
16. Trautner B, Hull R, Darouiche R. Prevention of catheter-associated urinary tract infection. Curr Opin Infect Dis. 2005;18:37–40. [Context Link]
17. Ouslander JG, Greengold B, Chen S. Complications of chronic indwelling urinary catheters among male nursing home patients: a prospective study. J Urol. 1987;138:1191–1195. [Context Link]
18. Warren JW, Tenney JH, Hoopes JM, Muncie HL, Anthony WC. A prospective microbiologic study of bacteriuria in patients with chronic indwelling urethral catheters. J Infect Dis. 1982;146:719–723. [Context Link]
19. Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005;40:643–654. [Context Link]
20. Stensballe J, Treve M, Looms D, et al. Infection risk with nitrofurazone impregnated urinary catheters in trauma patients. Ann Intern Med. 2007;147:285–293. [Context Link]
21. Maki DG, Tambyah PA. Engineering out the risk for infection with urinary catheters. Emerg Infect Dis. 2001;7:342–347. [Context Link]
22. Saint S, Lipsky B, Goold S. Indwelling catheters: a one point restraint? Ann Intern Med. 2002;137:125–127. [Context Link]
23. Reinhart E. Infection control in home care. Emerg Infect Dis. 2001;7:208–211. http://www.cdc.gov/ncidod/eid/vol7no2/rhinehart.htm . Accessed January 21, 2009. [Context Link]
24. Herrmann V, Palma P, Geo MS, Lima RS. Urinary tract infections: pathogenesis and related conditions. Int Urogynecol J Pelvic Floor Dysfunct. 2002;13:210–213. [Context Link]
25. Seiler WO, Stahelin HB. Practical management of catheter-associated UTIs. Geriatrics. 1988;43:43–50. [Context Link]
26. Wong E, Hooton T. Guidelines for the Prevention of Catheter-Associated Urinary Tract Infections. Guidelines for the Prevention and Control of Nosocomial Infections. Atlanta, GA: US Centers for Disease Control and Prevention; 1982. [Context Link]
27. Getliffe KA, Dolman M. Promoting Continence: A Clinical and Research Resource. London: Bailliere Tindall; 2003.
28. Cox CE, Lacy SS, Hinman F. The urethra and its relationship to urinary tract infection. II. The urethral flora of the female with recurrent urinary tract infection. J Urol. 1968;99:632–638.
29. Norden CW, Kass EH. Bacteriuria of pregnancy: a critical appraisal. Annu Rev Med.1968;19:431–470.
30. Wald H, Epstein A, Kramer A. Extended use of indwelling urinary catheters in post operative hip fracture patients. Med Care. 2005;43:1009–1017.
31. Raz RD, Schiller D, Nicolle LE. Chronic indwelling catheter replacement before antimicrobial therapy for symptomatic urinary tract infection. J Urol. 2000;164:1254–1258. [Context Link]
32. Wilde MH, Carrigan MJ. A chart audit of factors related to urine flow and urinary tract infection. J Adv Nurs. 2003;43:254–262.
33. Newman DK. Managing indwelling urethral catheters. Ostomy Wound Manage. 1998;44:26–28, 30, 32.
34. Lapides J. Role of hydrostatic pressure and distention in urinary tract infection. In: Kass EH, ed. Progress in Pyelonephritis, 2nd International Symposium on Pyelonephritis. Philadelphia, PA: FA Davis; 1964:578–580.
35. Burke JP, Jacobson JA, Garibaldi RA, Conti MT, Alling DW. Evaluation of daily meatal care with poly-antibiotic ointment in prevention of urinary catheter-associated bacteriuria. J Urol. 1983;129:331–334. [Context Link]
36. Cleland V, Cox F, Berggren H, MacInnis MR. Prevention of bacteriuria in female patients with indwelling catheters. Nurs Res. 71;20:309–318. [Context Link]
37. Webster J, Hood RH, Burridge CA, Doidge ML, Phillips KM, George N. Water or antiseptic for periurethral cleaning before urinary catheterization: a randomized controlled trial. Am J Infect Control. 2001;29:389–394.
38. Glahn BE, Braendstrup O, Olesen HP. Influence of drainage conditions on mucosal bladder damage by indwelling catheters. II. Histological study. Scand J Urol Nephrol. 1988; 22:93–99.
39. Gray M, Newman D, Einhorn C, Czarapata B. Expert Review: Best Practices in Managing the Indwelling Catheter. Burlington, VT: Saxe Healthcare Communications; 2006.
40. Johnson JR, Kuskowski MA, Wilt TJ. Systematic review: antimicrobial urinary catheters to prevent catheter-associated urinary tract infection in hospitalized patients. Ann Intern Med. 2006;144:116–127.
41. Wilde MH, Brasch J. A pilot study of self-monitoring of urine flow in people with long-term urinary catheters. Res Nurs Health. 2008;31:490–500.
42. Gray M, Krissovich M. Does fluid intake influence the risk of urinary incontinence, urinary tract infection, and bladder cancer? J Wound Ostomy Continence Nurs. 2003;30:128–129.
43. Karchmer TB, Giannetta ET, Muto CA, Strain BA, Farr BM. A randomized crossover study of silver-coated urinary catheters in hospitalized patients. Arch Intern Med. 2000;160:3294–3298.
44. Saint S, Elmore JG, Sullivan SD, Emerson SS, Koepsell TD. The efficacy of silver alloy-coated urinary catheters in preventing urinary tract infection: a meta-analysis. Am J Med. 1998;105: 236–241.
45. Drekonja DM, Kuskowski MA, Wilt TJ, Johnson JR. Antimicrobial urinary catheters: a systematic review. Expert Rev Med Devices. 2008;5:495–506.
46. Cottenden A, Bliss D, Buckley B, et al. Management using continence products. In: Abrams P, Cardozo L, Khoury L, Wein A, eds. 4th International Consultation on Continence. Paris: International Continence Society, Plybridge Distribution; 2008. [Context Link]
47. Stickler DJ, Chawla JC. The role of antiseptics in the management of patients with long-term indwelling bladder catheters. J Hosp Infect. 1987;10:219–228. [Context Link]
48. Washington EA. Instillation of 3% hydrogen peroxide or distilled vinegar in urethral catheter drainage bag to decrease catheter-associated bacteriuria. Biol Res Nurs. 2001;3:78–87. [Context Link]
49. Yum S, Amkraut A, Dunn T, Chin I, Killian D, Willis E. A disinfectant delivery system for control of micro-organisms in urine collection bags. J Hosp Infect. 1988;11:176–182. [Context Link]
50. Kunin C. Nosocomial urinary tract infections and the indwelling catheter: what is new and what is true? Chest. 2001;120:10–12. [Context Link]
51. Nicolle LE; Long-term-care-committee. Urinary tract infections in long-term-care facilities. Infect Control Hosp Epidemiol. 2001;22:167–175. [Context Link]
52. Griffiths P. The role of cranberry juice in the treatment of urinary tract infections. Br J Community Nurs. 2003;8:557–561. [Context Link]
53. Jepson RG, Craig JC. Cranberries for preventing urinary tract infections. Cochrane Database Syst Rev. 2008;(1):CD001321. [Context Link]
54. Schmidt DR, Sobota AE. An examination of the anti-adherence activity of cranberry juice on urinary and non-urinary bacteria isolates. Int Microbiol. 1988;55:173–181. [Context Link]
55. Sobota AE. Inhibition of bacterial adherence by cranberry juice: potential use for the treatment of urinary tract infections. [Context Link]
Additional Bibliography Sources
1. Doughty DB. Urinary & Fecal Incontinence: Current Management Concepts. St Louis, MO: Mosby; 2006.
2. Emr K, Ryan R. Best practice for indwelling catheter in the home setting. Home Healthc Nurse. 2004;22:820–828; quiz, 829–830.
3. Garibaldi RA, Burke JP, Beitt MR, Miller WA, Smith CB. Meatal colonization and catheter associated bacteriuria. N Engl J Med. 1980;303:316–318.
4. Girao MJ, Baracat EC, Lima GR. Urinary tract infection: immunological aspects. Int Urogynecol J Pelvic Floor Dysfunct. 2002;13:195–197.
5. Kuznar W. Urosepsis occurs less often with suprapubic catheters. Urol Times. 2003;31:13.
6. Pitt M. Fluid intake and urinary tract infection. Nurs Times. 1989;85:36–38.
7. Schaeflfer AJ, Schaeffer EM. Infections and inflammations. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, eds. Campbell-Walsh Urology. 9th ed. Philadelphia, PA: Elsevier-Saunders;2007:221–303.
8. Wilson ML, Gaido L. Laboratory diagnosis of urinary tract infections in adult patients. Clin Infect Dis. 2004;38: 1150–1158.