Catheter-associated Urinary Tract Infection (CAUTI)

Background

• CAUTI refers to a urinary tract infection (UTI) while a urinary or suprapubic catheter is in place, shortly after its removal, or in the setting of intermittent catheterization.
• CAUTI is a common cause of healthcare-associated infection and a leading cause of nosocomial bacteremia. As many as 20% of hospital-acquired bacteremias are of urinary source.
• As many as 70% of cases may be preventable by limiting unnecessary catheterization and shortening catheterization duration.
• The duration of catheterization is the single most important, and potentially modifiable, risk factor for infection.
• Catheters are associated with increased hospital length of stay and morbidity. There are an estimated 13,000 deaths attributable to CAUTI annually in the United States.

Evaluation

• Symptoms are not always present with catheter-associate bacteriuria.
  • Fever may be the sole presenting symptom.
  • Other systemic symptoms may include malaise, altered mental status, or systemic inflammatory response syndrome.
  • Genitourinary symptoms are often absent, but when present may include suprapubic or flank pain or tenderness.
• Diagnosis of a symptomatic CAUTI is based on both:
  • the presence of signs or symptoms compatible with a urinary traction infection (not attributable to other causes) such as:
    • fever, rigors, lethargy, flank pain, pelvic discomfort, costovertebral angle tenderness, or hematuria
    • classic UTI symptoms such as dysuria, urgency, frequency, suprapubic tenderness, flank tenderness, nausea, or fever in patients whose catheter has been recently removed
    • other systemic symptoms including altered mental status or systemic inflammatory response syndrome
    • increased spasticity or autonomic dysreflexia in patients with a spinal cord injury or other disorders associated with neurogenic bladder
  • the presence of ≥ 10⁵ colony-forming units (CFU)/mL of ≤ 2 bacterial species
• When considering treatment for CAUTI, it is important to distinguish symptomatic CAUTI from catheter-associated asymptomatic bacteriuria (CA-ASB).

Management

• Antibiotic therapy is not recommended for most patients with CA-ASB or asymptomatic funguria.
• Treatment for asymptomatic bacteriuria is indicated in pregnant women and patients undergoing urological procedures with potential for mucosal bleeding (Strong recommendation). (See Asymptomatic Bacteriuria for additional information)
• Antimicrobial therapy is recommended for patients with a symptomatic CAUTI (Strong recommendation).
  • Empiric therapy should be selected based on local uropathogen susceptibility patterns.
  • Treatment of symptomatic CAUTI similar to that of complicated UTI (Strong recommendation). (See Complicated Urinary Tract Infection (UTI) for additional information)
  • The catheter should be removed or replaced before starting antimicrobial therapy when feasible (Strong recommendation).
  • Obtain a urine culture before antimicrobial therapy to guide appropriate coverage based on isolated organisms (Strong recommendation).
• Duration of treatment:
  • 7 days for patients with quick resolution of symptoms (Strong recommendation).
  • 10-14 days for patients with delayed response, regardless of whether patient remains catheterized (Strong recommendation).
  • Consider 5-day course of levofloxacin in patients who are not severely ill (Weak recommendation).
  • Consider 3-day treatment course in women ≤ 65 years old without upper urinary tract symptoms after removal of indwelling catheter (Weak recommendation).
• If patient does not respond clinically with defervescence within 72 hours, extended treatment and urologic examination may be required.
• Key preventive measures include:
  • adherence to the appropriate indications for catheter insertion
  • aseptic insertion technique by trained individuals
  • maintenance of closed and unobstructed drainage system
  • removal of catheter as soon as feasible
• Systemic antimicrobial prophylaxis is not routinely recommended while a catheter is in place or at the time of its removal (Strong recommendation).