II. Epidemiology

  1. Incidence: 93,300 cases/year in United States (most common Health Care-Associated Infection)
  2. Indwelling Urinary Catheters are used in up to 15-25% of hospitalizations

III. Pathophysiology: Causative Organisms

IV. Symptoms: Urinary Catheter associated UTI

  1. Typical UTI symptoms may be present (e.g. Dysuria, urgency, frequency, Hematuria, Suprapubic Pain)
  2. Patient condition change from baseline (decreased functional status)
  3. New Incontinence in patients who are typically dry between intermittent Self Catheterization
  4. 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 WBCs alone is neither sensitive nor specific for CAUTI
    2. 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
  3. Blood Culture (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. Indwelling catheter
    1. Catheter in place for 2 or more days
    2. Catheter still in place within 24 hours of onset of symptoms OR
    3. Intermittent self-catheterization
  2. Patient with change in condition AND
  3. Positive Urine Culture

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. 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 or other Quinolone
    3. Nitrofurantoin (Macrobid)
  5. Long-term catheterization (polymicrobial infection)
    1. Noncritical illness
      1. Trimethoprim Sulfamethoxazole (Septra or Bactrim)
      2. Ciprofloxacin or Levofloxacin
      3. Cefuroxime or other second generation antibiotic
    2. Critical Illness
      1. Preferred agents
        1. Ampicillin AND Gentamicin
        2. Piperacillin-Tazobactam (Zosyn)
        3. Ticarcillin-Clavulanic Acid (Timentin)
        4. Carbapenem (Imipenem, Meropenem, Doripenem)
      2. Alternative agents
        1. Ciprofloxacin 400 mg IV every 12 hours
        2. Levofloxacin 750 mg IV every 24 hours
        3. Ceftazidime (Fortaz) 2 grams IV every 8 hours
        4. Cefepime 2 grams IV every 12 hours

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. Remove catheters when no longer needed (consider EHR reminders or stop orders)
  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
  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

XIV. References

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

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