Urinary Catheter associated Urinary Tract Infection

Aka: Urinary Catheter associated Urinary Tract Infection, Urinary Catheter associated UTI, UTI associated with Urinary Catheter, Urinary Tract Infection due to Urinary Catheter, Prevention of Urinary Catheter associated UTI, Urinary Catheter Associated Asymptomatic Bacteriuria, Catheter-Associated Urinary Tract Infection, CAUTI, Purple Urine Bag Syndrome

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II. Epidemiology

  1. Incidence: 93,300 cases/year in United States
    1. Accounts for 30% of nosocomial infections (most common Health Care-Associated Infection)
  2. Indwelling Urinary Catheters are used in up to 15-25% of hospitalizations
  3. Incidence: 10-25% with indwelling catheters will develop Urinary Tract Infections (CAUTI)

III. Causes: Organisms

  1. Enterobacteriaceae (Proteus, Providencia, Klebsiella, Morganella)
  2. Pseudomonas aeruginosa
  3. Enterococcus

IV. Symptoms: Urinary Catheter associated UTI

  1. Typical UTI symptoms may be present (e.g. Dysuria, urgency, frequency, Hematuria, Suprapubic Pain)
  2. Urinary Tract Infections may present with Flank Pain, fever or Sepsis
  3. Patient condition change from baseline (decreased functional status)
  4. New Incontinence in patients who are typically dry between intermittent Self Catheterization
  5. Atypical symptoms may be present in those with neurogenic Bladder or Spinal Cord Injury
    1. Patients may be aware of specific but atypical symptoms they experience with UTI

V. Signs: Urinary Catheter associated UTI

  1. See also Urinary Tract Infection
  2. Pyelonephritis signs
    1. Fever over 38.3C (100.9F) for over 24 hours
    2. Mental status change
    3. Hypotension
  3. Increased urine cloudiness
  4. Increased frequency of Urinary Catheter blockage
  5. Increased detrusor Muscle spasms
  6. Purple Urine Bag Syndrome (PUBS)
    1. Rare variant of UTI in catheterized patients with alkaline urine
    2. Depends on phosphatase and sulfatase producing Gram Negative Bacterial strains
    3. Differential diagnosis includes Hemolysis and Rhabdomyolysis

VI. Exam

  1. Evaluate if catheter hub is positioned far enough from the Urethral meatus?
  2. Observe urine in catheter tubing
  3. Observe and palpate the Urethra for erosions or Urethral abscess
  4. Evaluate the Scrotum for Epididymitis or Orchitis
  5. Examine for suprapubic tenderness or Costovertebral Angle Tenderness (CVA Tenderness)
  6. Rectal Exam for Prostate size (avoid in Acute Bacterial Prostatitis)

VII. Labs: Symptomatic UTI

  1. Urinalysis
    1. Urine is fully colonized after one month of indwelling catheter
    2. Urine WBCs alone is neither sensitive nor specific for CAUTI
    3. Negative LE, Nitrite and Bacteria and <10 WBC/hpf effectively excludes CAUTI
      1. Stovall (2013) J Am Coll Surg 217(1): 162-6 [PubMed]
  2. Urine Culture
    1. Replace the catheter and obtain sample from new catheter
    2. Positive Urine Culture with >=10^3 colony forming units (CFU)/ml of at least 1 Bacterial species
  3. Blood Culture
    1. Indicated for suspected bacteremia

VIII. Imaging

  1. Bedside Ultrasound
    1. Catheter position
    2. Catheter obstruction (high residual Urine Volumes)
  2. CT Abdomen
    1. Nephrolithiasis
    2. Complicated Pyelonephritis
      1. Immunocompromised or transplant patient
      2. Refractory or recurrent course

IX. Diagnosis: Catheter Associated UTI

  1. Three criteria should be present for CAUTI diagnosis (IDSA)
  2. Indwelling catheter
    1. Catheter in place for 2 or more days
    2. Catheter still in place within 24 hours of onset of symptoms OR
      1. Catheter removed within 48 hours of symptom onset OR
      2. Intermittent self-catheterization
  3. Patient with change in condition (at least one of the following)
    1. Acute Hematuria
    2. Costovertebral Angle Tenderness or Flank Pain
    3. Classic UTI symptoms (Dysuria, urgency, frequency) within 48 hours of catheter removal
    4. Spinal Cord Injury patients with increased spasticity, Autonomic Dysreflexia or sense of unease
    5. New onset fever, rigors, Altered Mental Status, lethargy, malaise
    6. Pelvic discomfort
  4. Positive Urine Culture
    1. Positive Urine Culture with >=10^3 colony forming units (CFU)/ml of at least 1 Bacterial species
  5. References
    1. Hooton (2010) Clin Infect Dis 50(5): 625-63 [PubMed]

X. Management: Asymptomatic Bacteriuria (colonization)

  1. Colonization occurs in all Urinary Catheter patients
    1. Long-term catheterization: 3-6 weeks
    2. Clean intermittent catheterization: 2-3 months
  2. Prophylactic Antibiotics are not indicated
  3. Consider limiting Antibiotics to symptomatic UTI only
  4. Periodic screening Urine Culture not indicated

XI. Management: Symptomatic UTI

  1. Indications for Antibiotic management
    1. Symptomatic UTI (esp. fever, pain) or
    2. Persistent bacteriuria >48 hours after Urinary Catheter removal
  2. Catheter replacement
    1. Replace catheters in place for more than 2 weeks
      1. Urinalysis and Urine Culture should be obtained from the new catheter
      2. Otherwise, catheter replacement may offer no benefit
        1. Study of catheters in place >7 days (did not identify maximum duration before change)
        2. Babich (2018) J Am Geriatr Soc 66(9):1779-84 [PubMed]
    2. Consult urology before removing the catheter in cases of obstruction (risk of urinoma, peritonitis)
      1. Neurogenic Bladder
      2. Bladder outlet obstruction (e.g. obstructive BPH)
      3. Genitourinary surgery or Trauma
      4. Urologist placed catheter
  3. Approach
    1. Obtain Urine Culture before Antibiotics are initiated
    2. Duration of Antibiotic therapy
      1. Rapid response to therapy: 7 days
      2. Delayed response to therapy: 10 to 14 days
  4. Short-term catheterization (single Bacteria)
    1. Trimethoprim Sulfamethoxazole (Septra or Bactrim)
    2. Ciprofloxacin 500 mg orally twice daily
    3. Levofloxacin 750 mg orally daily
    4. Nitrofurantoin (Macrobid)
      1. Do not use in suspected Pyelonephritis (fever, Flank Pain)
  5. Long-term catheterization (polymicrobial infection)
    1. Noncritical illness
      1. Trimethoprim Sulfamethoxazole (Septra or Bactrim) - if local resistance rates <20%
      2. Ciprofloxacin 500 mg orally twice daily
      3. Levofloxacin 750 mg orally daily
      4. Cefuroxime or other second generation Antibiotic
      5. Intravesical Gentamicin
        1. Consider in resistant cases or high risk of Antibiotics, e.g. recurrent C. difficile
    2. Critical Illness (systemic symptoms, high risk for multi-drug resistance)
      1. Preferred agents
        1. Carbapenem (e.g. Imipenem, Meropenem, Doripenem)
          1. Ertapenem 1 g IV every 24 hours
        2. Piperacillin-Tazobactam (Zosyn)
        3. Cefepime 2 grams IV every 12 hours
      2. Alternative agents
        1. Ampicillin AND Gentamicin
        2. Ciprofloxacin 400 mg IV every 12 hours
        3. Levofloxacin 750 mg IV every 24 hours
        4. Ceftazidime (Fortaz) 2 grams IV every 8 hours
          1. Consider with avibactam if high risk for drug resistance

XII. Management: Urology Consultation indications

  1. CAUTI in post-operative or Trauma-related catheters
  2. Urinary tract abscess (e.g. peri-Urethral abscess, prosthetic abscess, Pyelonephritis with abscess)

XIII. Prevention: Urinary Catheter associated UTI

  1. Catheterize only when absolutely necessary
    1. Do not catheterize for care convenience
    2. Acute Urinary Retention or Bladder outlet obstruction
    3. Accurate Urine Output monitoring in critically ill patients
    4. Prolonged immobilization
    5. End of life care
  2. Remove catheters when no longer needed (consider EHR reminders or stop orders)
    1. Catheter associated UTI is rare in first 72 hours, but 15% at 3-6 days and 68% at >8 days
    2. Al-Hazmi (2015) Res Rep Urol 7:41-7 [PubMed]
  3. Insert catheter using sterile technique
  4. Anchor catheter to prevent Urethral traction
    1. Men
      1. Penis over low Abdomen
      2. Tape catheter over Abdomen
    2. Women
      1. Tape catheter to anteromedial thigh
  5. Maintain closed, sterile, unobstructed drainage system
    1. Collection system should be below the level of Bladder
  6. Routinely clean the meatus (but avoid antiseptic application aside from at time of insertion)
  7. Caretakers wash hands before and after catheter care
  8. Indications for catheter change (avoid routine change)
    1. Monitor time to obstruction
      1. Change just before anticipated catheter obstruction
    2. Change catheter if no flow in 4 to 8 hours
    3. Consider change with symptomatic UTI
  9. Indications for Urinalysis and Urine Culture
    1. Symptoms of Urinary Tract Infection prompt evaluation
    2. Routine screening is not indicated
    3. Cloudy of foul smelling urine is not indications
  10. Avoid ineffective or harmful measures
    1. Avoid routine Bladder Irrigation
    2. Avoid prophylactic systemic Antibiotics
  11. Intravesical Antibiotics
    1. See Intravesical Gentamicin

XIV. References

  1. (2019) Sanford Guide Antimicrobial, accessed on IOS, 9/25/2019
  2. Jhun and Diaz in Herbert (2015) EM:Rap 15(10): 7-9
  3. Walsh (1998) Campbell's Urology, Saunders, p. 159-62
  4. Cagle (2022) Am Fam Physician 105(3): 262-70 [PubMed]
  5. Cravens (2000) Am Fam Physician 61(2): 369-76 [PubMed]
  6. Gould (2010) Infect Control Hosp Epidemiol 31(4): 319-26 [PubMed]
  7. Hsu (2014) Am Fam Physician 90(6): 377-82 [PubMed]
  8. Sharp (2014) Am Fam Physician 90(8): 542-7 [PubMed]

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