Catheter-associated UTI

Evalyn A. Roxas, MD, FPCP, FPSMID

Basic Competency Training Course For Infection Control Nurses
Speaker Sonny Belmonte Auditorium 7th Floor East Avenue Medical Center Quezon City Auditorium
February 15, 2017
MODULE IV: Prevention and Control of Common Healthcare
Associated Infections (HAIs): The Bundle Approach

Catheter-associated UTI (CAUTI)

Objectives:
1.To define what is catheter associated UTI
2.To introduce the epidemiology of catheter associated
UTI
3.To mention the treatment of catheter associated UTI
4.To discuss and give examples of preventive and
control measures for CAUTI

2
 Diagnosis, Prevention, and Treatment of
Catheter-Associated Urinary Tract Infection in
Adults:









2009 International Clinical Practice Guidelines from
the Infectious Diseases Society of America





4
Definition
Catheter-Associated (CA) Infection
- a person who is currently catheterized
- has been catheterized within the previous 48 hours

Urinary Tract Infection (UTI)

- significant bacteriuria
- symptoms and signs attributable to UTI

Asymptomatic Bacteriuria (ASB)

- significant bacteriuria
- without signs and symptoms attributable to
UTI
Epidemiology
CA-bacteriuria is the most common health-care
associated infection worldwide.
Tambyah PA. Catheter Associated urinary tract infections: diagnosis and prophylazixs.
Int J Antimicrob Agents 2004; 24(Suppl 1):S44-S48

The incidence of bacteriuria associated with

indwelling catheters is 3% - 8% per day.
Garibaldi RA, Burke JP, Dickman ML, et al. Factors predisposing tobacteriuria during indwelling urethral catheterization.
N Engl J Med1974; 291:215–219.

The duration of catheterization is the most

important risk factor for the development of
CA-bacteriuria.
Saint S, Lipsky BA. Preventing catheter-related bacteriuria: shouldwe? Can we? How?
Arch Intern Med 1999; 159:800–808.
Microbiology
• Bacteriuria in patients with short-term
catheters is usually caused by a single
organism.
Tambyah PA. Catheter Associated urinary tract infections: diagnosis and prophylazixs.
Int J Antimicrob Agents 2004; 24(Suppl 1):S44-S48

• E. coli is the most frequent species isolated.

Nicolle LE. Catheter-related urinary tract infection. Drugs Aging 2005; 22:627–639.

• Other Enterobacteriaceae (Klebsiella,

Serratia, Citrobacter, Enterobacter),
Pseudomonas, Gram positive cocci, CONS,
Enteroccocus
Nicolle LE. Catheter-related urinary tract infection. Drugs Aging 2005; 22:627–639.
Microbiology
• UTIs in patients with long-term
catheterization is usually polymicrobial…
species such as P. mirabilis, Morganella
morganii, P. stuartii are common.
Nicolle LE. Catheter-related urinary tract infection. Drugs Aging 2005; 22:627–639.

• New episodes of infection often occur

periodically in the presence of existing
infection.
Warren JW, Tenney JH, Hoopes JM, et al. A prospective microbiologicstudy of bacteriuria
in patients with chronic indwelling urethral catheters. J Infect Dis 1982; 146:719–723.
Pathogenesis

Approximately 2/3 (79% for gm+ cocci,

54% gm- bacilli) of the uropathogens that
cause CA-bacteriuria in patients with
indwelling catheters are extraluminally
acquired.

Tambyah PA, Halvorson KT, Maki DG. A prospective study of pathogenesis

of catheter-associated urinary tract infections.
Mayo Clin Proc 1999; 74:131–136.
Pathogenesis

Once attached to the catheter surface,

bacteria change phenotypically and produce
exoplysaccharides that entrap and protect
replicating bacteria, forming microcolonies,
and eventually mature biofilms.
Jacobsen SM, Stickler DJ, Mobley HL, et al. Complicated catheterassociated urinary tract infections
due to Escherichia coli and Proteus mirabilis. Clin Microbiol Rev 2008; 21:26–59.
Table 1. Risk factors for catheter-associated urinary tract infection,
based on prospective studies and use of multivariable statistical modelling

Factor Relative Risk

Prolonged Catheterization >6 days 5.1 - 6.8
Female Gender 2.5 - 3.7
Catheter insertion done outside the operating room 2.9 - 5.3
Urology Service 2.0 - 4.0
Other active site of infection 2.2 - 2.4
Diabetes 2.3 – 2.4
Malnutrition 2.4
Azotemia (creatinine > 2.0mg/dl) 2.1 – 2.6
Ureteral Stent 2.5
Monitoring of Urine Output 2.0
Drainage tube below bladder but above collection 1.9
bag
Antibiotic usage 0.1 – 0.4
11
Adapted from Maki, D.G. and P.A. Tambyah, Engineering out the risk for infection with urinary catheters.
Emerg Infect Dis, 2001 Mar-Apr. 7(2): p. 342-347.
Complications of Short-Term Catheterization

• Less than 25% of hospitalized patients with CA-

bacteriuria develop UTI symptoms.
Hartstein AI, Garber SB, Ward TT, et al. Nosocomial urinary tractinfection: a prospective evaluation of 108 catheterized patients.
Infect Control 1981; 2:380–386.

• Approximately 15% of cases of nosocomial

bacteremia are attributable to the GUT.
Bryan CS, Reynolds KL. Hospital-acquired bacteremic urinary tractinfection: epidemiology and outcome.
J Urol 1984; 132:494–498.

• Bacteriuria is the most common source of

gram-negative bacteremia among hospitalized
patients.
Kreger BE, Craven DE, Carling PC, et al. Gram-negative bacteremia.III. Reassessment of etiology, epidemiology
and ecology in 612 patients. Am J Med 1980; 68:332–343.
Complications of Short-Term Catheterization

• The effect of CA-bacteriuria on mortality

remains controversial.
Platt R, Polk BF, Murdock B, et al. Mortality associated with nosocomialurinary-tract infection.
N Engl J Med 1982; 307:637–642.

• Patients who develop CA-bacteriuria have

their hospital stays extended by 2-4 days.
Givens CD, Wenzel RP. Catheter-associated urinary tract infections in surgical patients:
J Urol 1980; 124:646–648.
Green MS, Rubinstein E, Amit P. Estimating the effects of nosocomial infections
on the length of hospitalization.J Infect Dis 1982; 145: 667–672.

• CA-ASB comprises a large reservoir of

antimicrobial-resistant organisms.
Maki DG, Tambyah PA. Engineering out the risk for infection with urinary catheters.
Emerg Infect Dis 2001; 7:342–347.
Complications of Long-Term Catheterization
(>30 days)

▪ Lower and upper CA-UTI

▪ Bacteremia
▪ Frequent febrile episodes
▪ Renal and bladder stone formation
▪ Catheter obstruction
▪ Local GU infections
▪ Fistula formation incontinence
▪ Bladder cancer

Warren JW. Catheter-associated urinary tract infections.

Infect Dis Clin North Am 1997; 11:609–622.
15
When is catheter-associated UTI (CA-UTI) suspected or diagnosed?
1.1 UTI in patients with indwelling urethral or suprapubic catheter or
in those undergoing intermittent catheterization is termed as CA-UTI.

CA-UTI is diagnosed when:

(1) signs or symptoms compatible with UTI are present with no other
identified source of infection
(2) ≥ 103 colony forming units (CFU)/ml of ≥ 1 bacterial species are
present in a single catheter urine specimen or in a midstream voided urine
specimen
(3) in a patient with an indwelling urethral, suprapubic or condom
catheter or has been removed within the previous 48 hours.

Strong recommendation, Low quality of evidence

1.2 There is no sufficient evidence to define the quantitative cut-off

for CA-UTI among men with condom catheters.

Weak recommendation, Low quality of evidence

16
 Diagnosis, Prevention, and Treatment of
Catheter-Associated Urinary Tract Infection in
Adults:









2009 International Clinical Practice Guidelines from
the Infectious Diseases Society of America





Diagnosis

(1) CA-UTI is defined by presence of

symptoms or signs compatible with UTI with
no other identified source along with
>= 1000 cfu/mL of >= 1 bacterial species (A-
III).*
Lipsky BA, Ireton RC, Fihn SD, et al. Diagnosis of bacteriuria in men: specimen collection and culture interpretation.
J Infect Dis 1987; 155: 847–854.
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.

* Has a 97% sensitivity and 97% specificity

Should patients with indwelling urethral, indwelling suprapubic or
intermittent catheterization be screened and treated for
asymptomatic bacteriuria?

2.1 Screening and treatment of catheter-associated

asymptomatic bacteriuria (CA-ASB) are NOT routinely
recommended.
Strong recommendation, Moderate quality of evidence

2.2 Screening and treatment of CA-ASB are recommended only

for pregnant patients and those who will undergo urologic
procedures.
Strong recommendation, Moderate quality of evidence

2.3 Data is insufficient to make any recommendations regarding

screening and treatment of CA-ASB among post-solid organ
transplant and neutropenic patients.
19
In patients with suspected CA-UTI, what diagnostic tests should be
done to assist the physician in managing the infection effectively?

3.1 Similar with the general recommendations in complicated

UTI, it is necessary to obtain urine gram stain and cultures
BEFORE starting empiric antibiotic coverage for CA-UTI.
Strong recommendation, Moderate quality of evidence

3.2 In catheterized patients, pyuria alone is NOT diagnostic

of CA-UTI and should not be interpreted as an absolute
indication for initiating empiric antibiotics.
Strong recommendation, Moderate quality of evidence

3.3 The presence or absence of odorous or cloudy urine

alone in catheterized patients is also not an indication for
antibiotic treatment.
20
Strong recommendation, Low quality of evidence
How should urine for culture and sensitivity studies be collected from
patients with suspected CA-UTI?

4.1 For patients in whom catheterization is still indicated, the urine specimen
should be obtained from the freshly placed catheter prior to the initiation of
antimicrobial therapy. Urine sample should be aspirated from the catheter
port, or if not present, by puncturing at the distal end of the catheter with
sterile needle and syringe after disinfecting the area WITHOUT disconnecting
the junction of the catheter and drainage tube.
Strong recommendation, Low quality of evidence

4.2 For individuals whose catheters can be or have been recently removed
and requires no further catheterization, a mid-stream, clean catch urine
should be obtained. Urine samples for culture should not be obtained
from collection bags.
Strong recommendation, Low quality of evidence

4.3 Urine specimens for culture should be processed as soon as

possible, preferably within one hour of obtaining the specimen. If this
is not possible, the urine specimen should be refrigerated.
Refrigerated specimens should be processed within 24 hours.
Strong recommendation, Low quality of evidence
21
Table 4. Antibiotics Options for the Treatment of CA-UTI

Recommended Dose and

Antibiotic Comments
Duration
Amikacin (First line) 15 mg/kg q24h Be cautious in giving aminoglycosides in patients with
renal insufficiency
Ertapenem 1g IV q24h1 For patients with no risk for Pseudomonas or
Enterococcus
Anti-Pseudomonal carbapenems For patients with risk for Pseudomonas infection
For ESBL-producing Enterobacteriaceae
Doripenem2 500 mg q8h
Imipenem-cilastin3 500 mg q6h
Meropenem4 1 g q8h
Vancomycin 1g IV q 12 For suspected staphylococcal infections5

Colistin (Colistimethate sodium) For multidrug-resistant Enterobacteriaceae, Klebsiella

pneumonia carbapenemase-producing (KPC) bacteria,
Colomycin6 31,250–62,500 IU/kg per Multi-drug resistant (MDR) Pseudomonas sp. or MDR
day, divided in 2-4 equal Acinetobacter sp.
doses(240-480 mg/kg/day)

Coly-Mycin Double the dose of

colomycin (400-800 mg/kg/
day)
Tigecycline 100 mg IV loading dose then For vancomycin-resistant Enterococci
50 mg IV q12 For ESBL-producing Enterobacteriaceae (except
Pseudomonas sp.

22
Table 4. Antibiotics Options for the Treatment of CA-UTI

Antibiotic Recommended Dose and Duration Comments

Tigecycline 100 mg IV loading dose then 50 mg For vancomycin-resistant
IV q12 Enterococci
For ESBL-producing
Enterobacteriaceae (except
Pseudomonas sp.
Ampicillin 1-2 g IV q6-8h For susceptible enterococcal
infections
Cefepime 1-2 g IV q8-12h For Pseudomonas or Acinetobacter
sp. infections
Ceftazidime 1-2 g IV q8h+
Piperacillin- 4.5 g IV q24
Tazobactam
Levofloxacin 750 mg q24h For mild infections with no history
of previous third generation
cephalosporin or fluoroquinolone
use
Fluconazole For fungal infections (see Section
on Urinary Candidiasis and Candida
Amphotericin Urinary Tract Infections for dosing
B± regimens)
5-flucytosine 23
What is the approach to the presence of the
indwelling urinary catheter once the diagnosis of
CA-UTI is made?

• Whenever possible, the indwelling catheter should be

removed to help eradicate the bacteriuria.
Strong recommendation, High quality of evidence

• For patients in whom indwelling bladder

catheterization is necessary, long-term indwelling
catheters should be replaced with new catheters before
initiating antimicrobial therapy for symptomatic UTI.
Strong recommendation, High quality of evidence

24
 Diagnosis, Prevention, and Treatment of
Catheter-Associated Urinary Tract Infection in
Adults:









2009 International Clinical Practice Guidelines from
the Infectious Diseases Society of America





Prevention 

(Limiting Unnecessary Catheterization)

• Indwelling catheters should be placed only

when they are indicated (A-III).
Saint S, Lipsky BA. Preventing catheter-related bacteriuria: should we? Can we? How? Arch Intern Med 1999; 159:800–808.

• Indwelling urinary catheters should not be

used for the management of urinary
incontinence (A-III). *
Munasinghe RL, Yazdani H, Siddique M, et al. Appropriateness of use of indwelling urinary catheters in patients admitted to
themedical service.
Infect Control Hosp Epidemiol 2001; 22:647–649.
Gardam MA, Amihod B, Orenstein P, et al. Overutilization of indwelling urinary catheters
and the development of nosocomial urinary tract infections. Clin Perform Qual Health Care 1998; 6:99–102.
Prevention (Limiting Unnecessary Catheterization)
Acceptable Indications for Indwelling Catheter Use

▪ Accurate urine • During prolonged surgical

output monitoring procedures with general or
required spinal anesthesia; selected
▪ Frequent or urgent urological and gynecologic
monitoring needed, procedures in the
such as in critically perioperative period
ill patients
• Temporary relief or long-
▪ Patient unable to term drainage if medical
collect urine therapy is NOT effective
▪ Clinically and surgical correction is
significant urinary not indicated
retention
Prevention 

(Limiting Unnecessary Catheterization)

• Institutions should develop a list of

appropriate indications for inserting
indwelling urinary catheters, educate staff
about such indications, and periodically
assess adherence to the institution-specific
guidelines (A-III).
Gokula RM, Smith MA, Hickner J. Emergency room staff education and use of a urinary catheter indication sheet
improves appropriate use of foley catheters. Am J Infect Control 2007; 35:589–593.
Prevention (Limiting Unnecessary Catheterization)

NOTE:
The Panel did not find evidence that the routine
use of catheters in patients with pressure ulcers
improved wound healing when compared with
other measures to prevent urinary incontinence.
Therefore this was not recommended as an
appropriate indication for routine urinary catheter
placement. .

(As opposed to the guidelines released below)

Centers for Disease Control and Prevention. Healthcare Infection
Control Practices Advisory Committee (HICPAC) Web page. http://
www.cdc.gov/hicpac/index.html. Accessed 21 January 2010.
Prevention 

(Indwelling Catheter Insertion Technique)

Indwelling urethral catheters should be

inserted using aseptic technique and sterile
equipment (B-III).
Tambyah PA, Halvorson KT, Maki DG. A prospective study of pathogenesis of catheter-associated
urinary tract infections. Mayo Clin Proc 1999; 74:131–136.

Catheter insertion outside the operating room

is associated with increased risk of early CA-
bacteriuria.
Shapiro M, Simchen E, Izraeli S, et al. A multivariate analysis of risk factors for acquiring bacteriuria
in patients with indwelling urinary catheters for longer than 24 hours. Infect Control 1984; 5:525–532.
It is recommended that appropriate strategies for the
prevention of CAUTI be included and implemented in
an institution-specific, multimodal, quality
improvement bundle.

Periodic assessment of compliance with these bundles,

once instituted, is likewise recommended.

Strong recommendation, Moderate quality of evidence

31
Is condom catheter a reasonable alternative
to indwelling catheterization in the prevention of
CAUTI?

Condom catheterization is an alternative to

indwelling catheter for male patients in whom a
urinary catheter is necessary provided post-void
residual urine is minimal and the patient
has no cognitive impairment.

Strong recommendation, High quality of evidence

32
Is intermittent catheterization a reasonable alternative
indwelling catheterization to prevent CAUTI?

Intermittent catheterization can also be considered an

alternative to short term (Strong recommendation,
Moderate quality of evidence,) or long-term (Weak
recommendation, Moderate quality of evidence) indwelling
urinary catheterization with trained and dedicated
healthcare staff.

Intermittent catheterization however requires more

manpower hours as well as the full cooperation of
patients for frequent repeated catheterization.

33
Is suprapubic catheterization an alternative to
urethral catheterization?

Suprapubic catheterization may be an

alternative to urethral catheterization when
there are excellent support mechanisms from
the surgical and caregiver staff.

Weak recommendation, Low quality of evidence

34
Prevention 

(Alternatives to Indwelling Urethral
Catheterization)

Clean (nonsterile) rather than sterile

technique may be considered in outpatient
(A-III) and institutional (B-I) settings with no
difference in risk of CA-bacteriuria or CA-
UTI.
Moore KN, Burt J, Voaklander DC. Intermittent catheterization in the rehabilitation setting:
a comparison of clean and sterile technique. Clin Rehabil 2006; 20:461–468.
Prevention 

(Alternatives to Indwelling Urethral
Catheterization)

Multiple-use catheters may be considered

instead of sterile single-use catheters in
outpatient (B-III) and institutional (C-I)
settings with no difference in risk of CA-
bacteriuria or CA-UTI.
Moore KN, Kelm M, Sinclair O, et al. Bacteriuria in intermittent catheterization users:
the effect of sterile versus clean reused catheters. Rehabil Nurs 1993; 18:306–309.
Prevention 

(Closed Catheter System)

A closed catheter drainage system, should be

used to reduce CA-bacteriuria (A-II) and CA-UTI
(A-III) in patients with short-term indwelling
urethral or suprapubic catheters and to reduce
CA-bacteriuria (A-III) and CA-UTI (A-III) in
patients with long-term indwelling urethral or
suprapubic catheters.
Thornton GF, Andriole VT. Bacteriuria during indwelling catheter drainage. II.
Effect of a closed sterile drainage system. JAMA 1970; 214:339–342.
Wolff G, Gradel E, Buchman B. Indwelling catheter and risk of urinary infection:
a clinical investigation with a new closed-drainage system. Urol Res 1976; 4:15–18.
Prevention

(Closed Catheter System)

Use of a preconnected system may be

considered to reduce CA-bacteriuria.
Platt R, Polk BF, Murdock B, et al. Reduction of mortality associated with nosocomial urinary tract infection.
Lancet 1983; 1:893–897
.

Use of a complex closed drainage system or

application of tape at the junction after
catheter insertion is NOT recommended to
reduce CA-bacteriuria or CA-UTI.
Huth TS, Burke JP, Larsen RA, et al. Clinical trial of junction seals for the prevention of urinary catheter-associated bacteriuria.
Arch Intern Med 1992; 152:807–812.
Prevention 

(Antimicrobial-Coated Catheters)

In patients with short-term indwelling urethral

catheterization, antimicrobial (silver alloy or
antibiotic)-coated urinary catheters may be
considered to reduce or delay the onset of CA-
bacteriuria.

Drekonja DM, Kuskowski MA, Wilt TJ, et al. Antimicrobial urinary catheters: a systematic review.
Expert Rev Med Devices 2008; 5:495–506.
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; 144:116–126.
Saint S, Elmore JG, Sullivan SD, et al. The efficacy of silver alloycoated urinary catheters
in preventing urinary tract infection: a metaanalysis. Am J Med 1998; 105:236–241.
Prevention 

(Prophylaxis with Systemic Antimicrobials)

Systemic antimicrobial prophylaxis should NOT be

routinely used in patients with short-term (A-III) or
long-term (A-II) catheterization, to reduce CA-
bacteriuria or CA-UTI because of concern about
selection of antimicrobial resistance.

Niel-Weise BS, van den Broek PJ. Antibiotic policies for short-term catheter bladder drainage in adults.

Cochrane Database Syst Rev 2005: CD005428.

Jaffe R, Altaras M, Fejgin M, et al. Prophylactic single-dose co-trimoxazole for prevention of urinary tract infection

after abdominal hysterectomy. Chemotherapy 1985; 31:476–479.

van der Wall E, Verkooyen RP, Mintjes-de Groot J, et al. Prophylactic ciprofloxacin

for catheter-associated urinary-tract infection. Lancet 1992; 339:946–951.

 Prevention 

(Prophylaxis with Methenamine Salts)

(31) Methenamine salts may be considered for

the reduction of CA-bacteriuria and CA-UTI in
patients after a gynecological surgical
procedure who are catheterized for no more
than 1 week (C-I).
Lee BB, Simpson JM, Craig JC, et al. Methenamine hippurate for preventing urinary tract infections.
Cochrane Database Syst Rev 2007: CD003265.

* It is reasonable to assume that a similar effect would be seen after other

types of surgical procedures.
Prevention 

(Prophylaxis with Cranberry Products)

Cranberry products should NOT be used

routinely to reduce CA-bacteriuria or CA-UTI
in patients with neurogenic bladders
managed with intermittent or indwelling
catheterization (A-II).
Jepson RG, Craig JC. Cranberries for preventing urinary tract infections.
Cochrane Database Syst Rev 2008:CD001321.
Prevention 

(Enhanced Meatal Care)

Daily meatal cleansing with povidone-iodine

solution, silver sulfadiazine, polyantibiotic
ointment or cream, or green soap and water is
NOT recommended for routine use in men or
women with indwelling urethral catheters to
reduce CA-bacteriuria (A-I).
Burke JP, Garibaldi RA, Britt MR, et al. Prevention of catheter-associated urinary tract infections:
efficacy of daily meatal care regimens.Am J Med 1981; 70:655–658.
Burke JP, Jacobson JA, Garibaldi RA, et al. J Urol 1983; 129:331–334.
Marples RR, Kligman AM. Antimicrob Agents Chemother 1974; 5:323–329..
Prevention (Catheter Irrigation)

Catheter irrigation with antimicrobials may be

considered in selected patients who undergo
surgical procedures and short-term
catheterization to reduce CA-bacteriuria (C-I).

van den Broek PJ, Daha TJ, Mouton RP. Bladder irrigation with povidone-iodine in prevention of urinary-tract infections
associated with intermittent urethral catheterisation. Lancet 1985; 1:563–565.
Ball AJ, Carr TW, Gillespie WA, et al. Bladder irrigation with chlorhexidine for the prevention of urinary infection
after transurethral operations: a prospective controlled study. J Urol 1987; 138:491–494.
Prevention 

(Catheter Irrigation)

Catheter irrigation with normal saline should

NOT be used routinely to reduce CA-
bacteriuria, CA-UTI or obstruction in patients
with long-term indwelling catheterization (B-
II).
Muncie HL Jr, Hoopes JM, Damron DJ, et al. Once-daily irrigation of long-term urethral catheters with normal saline:
lack of benefit. Arch Intern Med 1989; 149:441–443.
Elliott TS, Reid L, Rao GG, et al. Bladder irrigation or irritation?
Br J Urol 1989; 64:391–394.
Prevention 

(Antimicrobials in the Drainage Bag)

Routine addition of antimicrobials or

antiseptics to the drainage bag of
catheterized patients should NOT be used to
reduce CA-bacteriuria (A-I) or CA-UTI (A-I).
Sweet DE, Goodpasture HC, Holl K, et al. Evaluation of H2O2 prophylaxis of bacteriuria in patients
with long-term indwelling Foley catheters: a randomized, controlled study. Infect Control 1985; 6:263–266.
Gillespie WA, Simpson RA, Jones JE, et al. Does the addition of disinfectant to urine drainage bags
prevent infection in catheterised patients? Lancet 1983; 1:1037–1039.
Reiche T, Lisby G, Jorgensen S, et al. A prospective, controlled, randomized study of the effect of a slow-release
silver device on the frequency of urinary tract infection in newly catheterized patients. BJU Int 2000; 85:54–59.
Prevention 

(Routine Catheter Change)

Data are insufficient to make a

recommendation as to whether routine
catheter change (eg, every 2-4 weeks) in
patients with functional long-term indwelling
urethral or suprapubic catheters reduces the
risk of CA-ASB or CA-UTI, even in patients who
experience repeated early catheter blockage
from encrustation.

Kunin CM, Chin QF, Chambers S. Indwelling urinary catheters in the elderly: relation of “catheter life”
to formation of encrustations in patients with and without blocked catheters. Am J Med 1987; 82: 405–411.
 Prevention

(Prophylactic Antimicrobials at Time of
Catheter Removal or Replacement)
Prophylactic antimicrobials, given systemically or by
bladder irrigation, should NOT be administered routinely to
patients at the time of catheter placement to reduce CA-UTI
(A-I) or at the time of catheter-removal (B-I) or replacement
(A-III) to reduce CA-bacteriuria.
Romanelli G, Giustina A, Cravarezza P, et al. A single dose of aztreonam in the prevention of urinary tract infections

9:573–575.
How can unnecessary long-term catheterization
be avoided?

Consider using alternative strategies for timely

removal and prevention of unnecessary
long-term catheterization such as instituting
automatic stop orders, nurse-based or
electronic physician reminder systems or chart
reminders.

Weak recommendation, Moderate quality of evidence

49
Summary
Table: Strategies for reducing the risk of CA-UTI

Strategy Strength of Level of

Recommendation Evidence

Use indwelling catheters only when Strong Low

necessary
Use aseptic technique including appropriate Strong Low to Moderate
hand hygiene and sterile gloves

Allow only trained health personnel to insert Weak Low

foley catheters

Properly secure catheters after insertion to Weak Low

prevent movement and urethral traction

Maintain a closed sterile drainage system. Strong Moderate

Maintain good hygiene at the catheter- Strong Moderate
urethral interface.
Maintain unobstructed urine flow Strong Moderate
Remove catheters when no longer needed. Strong High
Do not change indwelling catheters or Weak Low
drainage bags at fixed intervals. 51
What should NOT be done for patients with urinary catheters?

Strategy Strength of Level of

Recommendation Evidence

1. Use of antibiotic–coated catheters Strong High

2. Routine use of systemic prophylactic Strong Moderate

antibiotics at the time of insertion,
during and upon removal of indwelling urinary
catheters
3. Catheter or bladder irrigation with Strong High
antimicrobial agents
4. Routine addition of antibiotics or Strong High
antiseptics to drainage bags and antireflux
vents and valves
5. Daily meatal care Strong High

6. Changing of catheters and drainage bags at Weak Low

arbitrarily fixed intervals
52
MODULE IV: Prevention and Control of Common Healthcare
Associated Infections (HAIs): The Bundle Approach

Catheter-associated UTI (CAUTI)

Objectives:
1.To define what is catheter associated UTI
2.To introduce the epidemiology of catheter associated
UTI
3.To mention the treatment of catheter associated UTI
4.To discuss and give examples of preventive and
control measures for CAUTI

53
THANK YOU