WOCN FACT SHEET: Catheter-Associated Urinary Tract Infections: Fact Sheet
Diana Parker  
Laurie Callan  
Judith Harwood  
Donna Thompson  
Marilyn-Lu Webb  
Mary Wilde  
Margaret Willson  

Journal of Wound, Ostomy and Continence Nursing
March/April 2009 
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
* Malaise 3
* Offensive urine odor 3
* Change in color or character of urine, including cloudy urine or increased sediment 3,23
* Hematuria 23–25
* 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
Risk/Contributing Factors

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.



Graphic
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.



Graphic
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 52–54
* 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
References

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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.

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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.



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