← AAUS Clinical GuidelinesUrinary Tract Infections

Catheter associated UTIs

Authors

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)

Executive summary

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).

Treatment

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).

Introduction

This guideline is an update of recently published guidelines from Asia[1] and beyond[2][3] on the management and prevention of CAUTIs.

Definition

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[3].

The definition of CAUTI remains controversial, with all guidelines agreeing that symptoms alone are not reliable for the diagnosis of CAUTI[1][2][3][4][5][6][7][8]. For surveillance purposes, the US CDC’s NHSN definitions have commonly been accepted and used in most published reports[9], despite these definitions being difficult to apply in practice[10]. 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.

Epidemiology

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[11]. Of these, approximately 75% are associated with an indwelling urinary catheter.

The impact of CAUTI is likely to be even greater in Asia[12]. 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[13]. CAUTIs in developing countries were also associated with higher rates of antibiotic resistance on microbiological surveillance.

The sheer frequency of urinary catheter usage in most healthcare settings highlights the impact and significance of CAUTI in the healthcare system globally and in Asia[3][12][14][15][16][17][18]

Pathogenesis and risk factors

The presence of a urethral catheter will bypass or inhibit natural host defenses, predisposing patients to CAUTIs[19]. This is further exacerbated by the development of biofilm on the urinary catheters, which provides a favorable environment for bacterial proliferation & invasion[1][20]. 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[21]. Risk factors for CAUTI which have been identified in prospective observational studies include[19][22][23][24]

Diagnosis

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[25][26][27].

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[2][22][26][28][29] 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.

Table 1. Criteria and classifiscation of CAUTI and CAASB

indwelling urinary catheter criteria

Symptoms criteria

Microbiological criteria

CAUTI

In place for >2days, and the catheter was in place on the date of development of CAUTI

At least 1 of the following:

  • Fever >38℃

  • Suprapubic pain or tenderness

  • Flank pain of costovertebral angle tenderness

Positive urine culture of ≥105 CFU/ml, with no more than 2 species of microorganisms.

OR

Positive urine culuture of ≥103 and <105 CFU/ml, with no more than 2 species of microorganisms, AND one of the following:

  • Positive urine dipstick for leukocyte esterase and/or nitrite

  • Pyuria (≥10 WBC/mm3 of unspun urine or >5 WBC/high power field of spun urine

  • Microorganism seen on Gram's stain of unspun urine

In place for >2 days, but removed on the day of, or the day before the development of CAUTI

At least 1 of the following:

  • Urgency, frequency or dysuria with no other cause

  • Fever >38℃

  • Suprapubic pain or tenderness

  • Flank pain or costovertebral angle tenderness

Positive urine culture of ≥105 CFU/ml, with no more than 2 species of microorganisms.

OR

Positive urine culuture of ≥103 and <105 CFU/ml, with no more than 2 species of microorganisms, AND one of the following:

  • Positive urine dipstick for leukocyte esterase and/or nitrite

  • Pyuria (≥10 WBC/mm3 of unspun urine or >5 WBC/high power field of spun urine

  • Microorganism seen on Gram's stain of unspun urine

CAASB

In place for >2 days, and either in place on the date of assessment, OR removed on the day of or the day before assessment

No symptoms of UTI, including:

  • Urgency, frequency or dysuria

  • Fever

  • Suprapubic pain or tenderness

  • Flank pain or costovertebral angle tenderness

Positive urine culture of ≥105 CFU/ml

*Routine urine cultures in asymptomatic catheterized patients are not recommended.

Treatment

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[30]. 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[31], and the role of periodic treatment in spinal cord injured patients[32]. No general recommendation can be made for these situations.[33][34][35]

Table 2. Principles to guide selection of antibiotics

Recommendation

LE/GR

1. Monitoring of local antibiotic resistance patterns in uropathogens.

4/C

2. Urine cultures, preferably before initiation of antibiotic therapy, to guide choice of definitive antibiotic therapy.

4/C

3. Empiric antimicrobial therapy could be guided by recent prior urine culture results, where possible.[33]

2b/C

4. Early de-escalation of antibiotic therapy, as guided by urine culture results, to the narrowest spectrum antibiotic available.

4/C

5. Shorter 5 say course of antibiotics with catheter exchange may be considered in the treatment of CAUTI in patients with spinal cord injury.[34]

1b/B

6. CAASB should not be routinely treated with antibiotics.[2][35]

1b/B

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.[36][37][38][39][40][41][42][43][44][45][46]

Table 3. Recommendations on the use of urinary catheters

Recommendation

LE/GR

1. Evidence for antibiotic or antiseptic impregnated or coated urinary catheters are as follows:[19][36][37][38][39]

  • Use of hydrophilic-coated catheters was associated with a lower incidence of CAUTIs.[37][38]

  • Antibiotic-impregnated catheters lowered rates of asymptomatic bacteriuria in the short term (less than 1 week), but this effect was not significant at longer durations.[19][36][39][40][41]

  • Silver alloy catheters significantly reduced incidence of asymptomatic bacteriuria, and may be considered. However, clinical impact on reduction of symptomatic CAUTI has not been determined, and increased costs of these catheters must be considered. Conversely, silver oxide catheters have not been found to decrease incidence of bacteriuria.[36][39][40][41]

  • Consider changing long-term indwelling urinary catheters prior to initiating antimicrobial therapy.[46]

1b/C

2. Alternative methods of bladder drainage with external and suprapubic catheters may be considered, but evidence of efficacy in preventing CAUTI remains limited.[[44][45]

1b/C

Consider changing long-term indwelling urinary catheters prior to initiating antimicrobial therapy.[46]

1b/B

Prophylaxis, prevention and monitoring

Principles for prevention of CAUTI may be broadly classified under the following categories:

Specific recommendations are detailed in Table 4.[47][48][49][50][51][52][53][54][55][56][57][58][59][60][61][62][63][64][65][66][67][68][69][70][71][72][73][74][75][76][77][78][79][80][81][82][83][84]

Table 4. Recommendations for the prevention of CAUTIs

Recommendation

LE/GR

1. Early removal of indwelling urinary catheters reduces the risks of subsequent CAUTI[47] and other complications.[48]

2b/B

2. Health care workers are often unaware about the presence of an indwelling catheter in patients.[49] This should be addressed, so as to minimize inappropriate use of indwelling catheters and reduce duration of catheterization.

3/B

3. Nurse generated or electronic-based remider and stop-order systems for the removal of urinary catheters reduce utilization of indwelling catheters and rates of CAUTIs[50-68]

1a/B

4. Urinary catheter care bundles and infection control programs reduce rates of CAUTI.[2][9][69-79] These bundles and programs may include the following components:

  • Educational and training interventions on catheter indications,[80][81] insertion techniques, care and management.

  • Avoidance of indwelling catheter use, and the use of alternatives to indwelling urinary catheters where appropriate.

  • Aseptic catheter insertion technique by trained personnel, with all necessary supplies needed being made conveniently available.

Records and indications for catheter insertion should be maintained.

  • Attention to hand hygiene practices.

  • Surveillance and performance feedback systems.

2a/B

5. Secure and maintain integrity of closed urinary catheter systems, and prevent flow obstruction.[2]

3/B

6. No recommendation can be made for the routine use of antibiotic prophylaxis for the prevention of CAUTI:

  • The use of antibiotic prophylaxis during short-term urinary catheterization of up to 14 days in adult patients was reviewed in several randomized controlled trials. Meta-analysis showed only limitied evidence in reduction of rates of bacteriuria, pyuria and febrile morbidity in surgical patients post-operatively, and reduction of symptomatic UTIs with antibiotic prophylaxis at the time of catheter removal.[32][82][83]

  • Meta-analysis on the use of antibiotic prophylaxis in patients requiring long-term intermittent or indwelling urinary catheterization showed inconsistent and limited evidence of efficacy.[84]

  • The decision to use antibiotic prophylaxis must consider local microbial prevalence and antibiotic resistance patterns, as well as risk-benefit ratio and cost considerations of the antibiotic. In Asia, it is unlikely that prophylaxis will be effective in view of high rates of antimicrobial resistance, and it might have the unintended consequence of selecting for even more resistant pathogens.

1a/D

Algorithm

Figure 1. Algorithm for diagnosis, classification and management of CAUTI and CAASB

Abbreviations

CAASB: catheter-associated asymptomatic bacteriuria, CAUTI: catheter-associated urinary tract infection, CDC: Centers for Disease Control and Prevention, CFU: colony-forming unit, HAI/HCAI: healthcareassociated infections, ICU: intensive care unit, NHSN: National Healthcare Safety Network, US: United States, UTI: urinary tract infection, WBC: white blood cell

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