Catheter-Associated

Urinary Tract
Infection
Guidelines from the CDC define a CAUTI as a UTI after placement of an
indwelling urinary catheter for more than 2 days (Centers for Disease Control
and Prevention: Urinary Tract Infection, 2015). To be diagnosed with a CAUTI,
patients must have one symptom of a UTI (suprapubic tenderness, CVA
tenderness, urinary frequency/urgency/dysuria, or fever >100.4°F) and a urine
culture with a single organism more than 100,000 CFU/mL.
Catheter-associated bacteriuria is widely recognized as the most common
hospital-acquired infection. The development of bacteriuria in the presence
of an indwelling catheter is inevitable and occurs at an incidence of
approximately 10% per day of catheterization. Sterile and clean
intermittent catheterization has been associated with rates of bacteriuria
ranging from 1% to 3% per catheterization (Warren, 1997). The most
important risk factors associated with increased likelihood of developing
catheter-associated bacteriuria are duration of catheterization, female
gender, absence of systemic antimicrobial agents, and catheter-care
violations (Stamm, 1991). Most patients with catheter-associated bacteriuria
are asymptomatic. In patients with short-term catheter placement, only 10% to
30% of bacteriuric episodes produce typical symptoms of acute infection (Haley
et al., 1981; Hartstein et al., 1981). Similarly, although patients with long-term
catheters are bacteriuric, the incidence of febrile episodes occurs at a rate of only
1 per 100 days of catheterization (Warren, 1991).
Each CAUTI is estimated to cost between $589 and $758 (Anderson et al.,
2007; Tambyah et al., 2002). In patients requiring intensive care, the cost is
roughly $2000 per nosocomial UTI (Chen et al., 2009). The nosocomial costs for
E. coli infections with relatively susceptible strains are considerably lower than
for those caused by resistant gram-negative bacteria, which often require
expensive parenteral antimicrobial therapy (Tambyah et al., 2002).
In 2008 the Center for Medicare and Medicaid Services (CMS) announced
that it will no longer reimburse hospitals for the extra costs resulting from
CAUTIs. Judicious use of indwelling Foley catheters in perioperative patients
helps to prevent CAUTI. Current recommendations for perioperative use of an
indwelling urinary catheter include intraoperative urine output monitoring,
prolonged surgeries, and urologic surgeries (Gould, 2009). Limiting the duration
of indwelling catheters in these patients is critical. Large nationwide hospital
initiatives have helped to reduce the CAUTI rates. The Mayo Clinic reported a
70% decrease in their CAUTI rate over 1 year. They described their protocol as
the bundled 6-C CAUTI approach: consider (appropriate placement and daily
need for indwelling catheter), connect, clean (catheter care), closed (maintain
closed system), call (irrigation when necessary) and culture (only for indication)
(Sampathkumar et al., 2016).

Pathogenesis
Bacteria enter the urinary tract of a catheterized patient by several routes.
Bacteria can be introduced at the time of initial catheter placement by either
mechanical inoculation of urethral bacteria or contamination from poor
technique. Subsequently, the bacteria most commonly gain access via a
periurethral or intraluminal route (Stamm, 1991). In women, periurethral
entry is the most prevalent. Daifuku and Stamm (1984) found that among 18
women who developed catheter-associated bacteriuria, 12 had antecedent
urethral colonization with the infecting strain. Bacteria may also enter the
drainage bag and follow the intraluminal route to the bladder. This route is
particularly common in patients who are clustered among other patients with
indwelling catheters (Maizels and Schaeffer, 1980; Tambyah et al., 1999).
The urinary catheter system provides a unique environment that allows
for two distinct populations of bacteria: those that grow within the urine
and those that grow on the catheter surface. A bacterial biofilm represents a
microbial environment of microorganisms embedded in an extracellular matrix
of bacterial products and host components that often lead to catheter encrustation
(Bonadio et al., 2001; Stamm, 1991). The bacterial biofilm prevents antibiotic
contact with the bacteria and can result in CAUTI and antibiotic resistance
(Chenoweth and Saint, 2016). Certain bacteria, particularly of the Pseudomonas
and Proteus species, are adept at biofilm growth, which may explain their higher
incidence in this clinical setting (Mobley and Warren, 1987). The uropathogens
isolated from the catheterized urinary tract often differ from those found in
uncatheterized ambulatory patients. E. coli is still the most common organism
isolated, but Pseudomonas, Proteus, and Enterococcus spp. are prevalent
(Warren, 1991). In patients with long-term catheterization (more than 30 days),
the bacteriuria is usually polymicrobial, and the presence of four or five
pathogens is not uncommon (Warren et al., 1982). Although certain species may
persist for long periods, the bacterial populations in these patients tend to be
dynamic.

Clinical Presentation
Most patients are asymptomatic. Suprapubic discomfort and development of
fever, chills, or flank pain may indicate a symptomatic UTI.

Laboratory Diagnosis
Significant bacteriuria in patients with catheters is present when greater
than 100 CFU/mL is present, because even this low level progresses to
greater than 105 CFU/mL in almost all patients (Maizels and Schaeffer, 1980;
Stark and Maki, 1984). Pyuria is not a discriminate indicator of infection in this
population.

Management
Careful aseptic insertion of the catheter and maintenance of a closed
dependent drainage system are essential to minimize development of
bacteriuria. The catheter-meatal junction should be cleaned daily with water,
but antimicrobial agents should be avoided because they lead to colonization
with resistant pathogens, such as Pseudomonas.
Incorporation of silver oxide (Schaeffer et al., 1988) or silver alloy (Saint et
al., 1998) into the catheter and hydrogen peroxide into the drainage bag has been
reported to decrease the incidence of bacteriuria in some studies (Schaeffer et al.,
1988), but not in other populations (Stamm, 1991). The major benefit of silver
alloy is that it decreases the likelihood of bacteriuria in hospitalized adults
catheterized for the short term (Brosnahan et al., 2004; Newton et al., 2002;
Saint et al., 2000).
If an asymptomatic catheterized patient has had an indwelling catheter for 3 or
more days and will have the catheter removed, a dipstick test can be used to rule
out bacteriuria (Tissot et al., 2001). Concurrent administration of systemic
antimicrobial agents transiently decreases the incidence of bacteriuria
associated with short-term catheterization, but after 3 to 4 days the
incidence of bacteriuria is similar to the rate in catheterized patients not
taking systemic antimicrobials agents, and the prevalence of resistant
bacteria and side effects is substantial. Therefore this practice is not
recommended. The concept of instilling nonvirulent bacteria into the bladder to
completely block colonization and infection by pathogens has been tested in
patients with SCI (Hull et al., 2000). Patients successfully colonized with the
nonvirulent strain had reduced symptomatic UTI and a subjective improvement
in quality of life.
Patients with indwelling catheters should be treated only if they become
symptomatic (e.g., febrile). Urine cultures should be performed before
initiating antimicrobial therapy. The antimicrobial agent should be
discontinued within 48 hours of resolution of the infection. Because the
catheter has been indwelling, encrustation may shelter bacteria from the
antimicrobial agent; therefore the catheter should be changed.

Key Points: Catheter-Associated Bacteriuria

• Careful aseptic insertion of the catheter and maintenance of a closed,