Hospital acquired infection,CAUTI

1. Catheter associated urinary tract infection
(CAUTI)
Dr. Deepa Devhare

2. Outline
Definition
Epidemiology
Pathogenesis
Diagnosis
Treatment
Prevention
CAUTI surveillance

3. Epidemiology
Catheter associated bacteriuria risk:
• Per catheter day : 3-10%
• At the end of one week: 25%
• At the end of one month: 100%
India: CAUTI rate 1.63-2.1 per 1000 catheter days

4. Definition
Catheter associated Urinary tract
infection (CAUTI)
• significant bacteriuria in a
catheterized or recently catheterized
patient within 48 hrs
• with symptoms or sign referable to
the urinary tract.
Catheter associated
asymptomatic bacteriuria
(CA-ASB):
• significant bacteriuria in a
catheterized or recently
catheterized patient
• without symptoms or sign
referable to the urinary tract.

5. Risk factors
Device related Patient related Care giver related
Type of catheterization
Indwelling
short term <30 days
Long term >30 days
Intermittent
Condom
Suprapubic
 Females
 Fatal underlying
illness
 Older age
 DM
 Elevated sr. creat
 Poor hygiene
 Urethral
colonization
 Incomplete
emptying of bladder
 Fecal incontinence
 Failure of adherence to
aseptic technique
 Emergency catheter
insertion
Organism related
 Biofilm
 Struvite stone: Proteus
species
Type of cathere material
• Latex: high risk of CAUTI
(urethritis, stricture and
obstruction)
• Slilicon

6. Indwelling urinary catheter
•Inserted in bladder through
urethra
•left in place
•Connected to a collection system
•Foleys catheter

7. Pathogenesis

8. Why indwelling catheters at more risk of UTI??
Patient movement/catheter manipulation
Pressure differentials
Incomplete emptying of bladder
Urine pools around balloon and serves as
nidus for infection
Risk of CAUTI directly proportional to duration
Lateral urethral pressure
Decreased mucosal blood flow
Mucosal disruption
Impaired mucin secretion

9. Pathogens
Short term catheter (<30 Days) : Monomicrobial
• Enterobacteriacae: E.coli, Klebsiella, Serratia, citrobacter, enterobacter
• Non fermenters: Pseudomonas, acinetobacter
• GPC: CONS, Enterococcus
• Fungi: Candida
Long term catheter (>30days) : Polymicrobial
Additionally Proteus, Providentia, Morganella

10. • Catheter obstruction and
bladder stone formation
• Local genitourinary
infections
• Fistula formation
• Urinary incontinence
• Bladder cancer
Complications

11. Catheter criteria
Symptom criteria
Significant bacteruria
Diagnosis of CA-UTI &CA-ASB

12.  Catheter present >48hrs or
 Catheter was present but removed within
previous 48hrs
Symptomatic Asymptomatic
Significant bacteriuria=
10^3 CFU/ml
Catheterized: Significant bacteriuria= 10^5
Non catheterized
In females = 10^5 CFU/ml of same species in two
specimens
males =10^5 CFU/ml in one specimens
CAUTI
CA-ASB

13. Signs and symptoms
• New onset or worsening of fever, incontinence, malaise or lethargy
• Altered mental status
• Flank pain
• Costovertebral angle tenderness
• Rigors
• Pelvic discomfort
• Patients with spinal cord injury: increased spasticity, autonomic
dysreflexia, sense of un ease
• After catheter removal: dysuria, frequency, urgency

14. Sample collection
In catheterized patients
• Short term catheter <30days: from
sample port or from catheter
directly by syringe and needle
• Long term catheter >30 days: from
freshly inserted catheter

15. Candiduria
• Reported in 3-32% of cases
• Clinical significance doubtful
• Source
contamination during collection
Bladder colonization
Upper UTI (Hematogenous spread / ascending infection
from bladder)

16. Treatment only in case of
Symptomatic cystitis/pyelonephritis & patients at risk of disseminated disease
Neutropenic or immunocompromised pts
Pts undergoing urological manipulation
If associated with bladder wall invasion or obstruction
Critically ill patients with high risk of invasive candidiasis
Low birth weight infants
Candiduria cont…

17. Treatment
CA-UTI
• Empirical based on antibiotic policy
• Definitive: Based on culture and
susceptibility results
• Duration:
• Mild to moderate: 5-7days
• Severe: 5-14 days
• Removal of Catheter: when
biofilm formation suspected
CA-ASB
• Bacteriuria persists for >48 hrs
after catheter removal
• Pregnancy
• Prior to traumatic urological
surgery

18. Insertion bundle
Appropriate indication for catheter insertion
Sterile items used
Non touch technique for insertion
Continuous closed drainage system
Catheter of appropriate size
Secure catheters properly(plaster-tube-plaster technique)
Prevention

19. Maintenance bundle
Meatal care with hand hygiene and gloves: soap and water. Anti septics and
ointments not recommended
Catheter secured all the time
Drainage bag must be always above floor and below the bladder level
Closed drainage all the time
Collection of urine from bag-hand hygiene and change of gloves between
patients, separate jug, use alcohol swabs for outlet: 8hrly or ¾ th filled
whichever is early, emptied completely
Daily assessment for readiness of catheter removal: signs of UTI, recurrent
obstruction, fecal incontinence

21. Catheter related parameters
• Catheter size: smallest size which allows free flow of urine and prevents
potential trauma to urethra and sphincter
• Men: 12-16 Fr( French scale)
• Women: 12-14 Fr
• Newborn: 5-6 Fr
• Children: 5-10 Fr
• Catheter type:
• Short term: Latex
• Medium term: Teflon
• Long term: silicon
Larger diameter:
• blocks urethral glands
• pressure on urethral mucosa
• leading to ischemic necrosis

22. No touch technique
• Treated as
minor surgical
procedure
• All sterile items, sterile
field should be used
• Operator does
not have contact
with the shaft of
the catheter

23. Collection system
• Closed system
• Bag below the level of bladder to prevent reflux of
urine
• Should not touch the floor to prevent contamination
• Catheter secured to leg by plastic tape-catheter-
plastic technique to prevent movement and urethral
meatal ulceration
• Leg bags a/w more infection

24. Care bundle approach
• Each component of bundle should be followed by caregiver
• Compliance to care bundle calculation
• All or none approach: failure to compliance to any of the component
leads to non compliance to whole care bundle
Calculated as follows:
Number of patients on device where the all components of care
bundle are followed x100
Total no of patients on device

25. AMSP concerns
Odorous and cloudy urine: not an indication for antimicrobial treatment
Pyuria: always associated with CAUTI
• Absence of pyuria suggests diagnosis other than CAUTI
• Pyuria also seen in CA-ASB, so cannot used to differentiate between
CAUTI and CA-ASB
CA-ASB is not an indication for antimicrobial treatment
Controversial practices : Antimicrobial coated catheters and prophylactic
systemic antimicrobial therapy

26. What is HAI surveillance??
• HAI surveillance is a system that monitors the HAI’s in hospital
• Continuous, systematic collection, analysis and interpretation of
data on specific health related event
• Primary aim of reducing the HAI’s risk within hospital

27. Common terminologies
 DOE(Date of event): the date when the first symptom appears or first
diagnostic test becomes positive whichever is earlier
 POA(Present on admission): if the DOE is on either side of the first two
calendar days(not read as 24hrs) of admission to the hospital

28. Infection window period

30. UTI surveillance
• Carried out from the day of catheterization till the next day of
catheter removal
• Candida, yeast, mold, diamorphic fungi, parasites excluded from
surveillance
• Only indwelling catheters included for surveillance

31. NHSN criteria for urinary tract infection events
ABUTI (Asymptomatic
bacteremic UTI)
SUTI (Symptomatic urinary
tract infections)
>1year < 1year
Any age

32. SUTI 1a (CA-SUTI)
>1 year of age
SUTI 1b (Non
CA-SUTI)
>1 year of
age
SUTI 2
<1 year of age
ABUTI
Catheter Catheter >2 consecutive days /removed
within previous 48 hrs
without
catheter
With or without catheter With or without
catheter
Symptom Only one of the following
Fever >380c, suprapubic tenderness,
costovertebral angle pain or
tenderness, urinary urgency, frequency,
dysuria
Same as
SUTI 1a
Fever >380 C,
Hypothermia (<36 0C ,
apnea, bradycardia,
lethargy, vomiting,
suprapubic tenderness
No signs or symptoms
Urine culture • 1 or 2 organisms isoalted with
atleast one of them >105 CFU/ml
• >2 organisms considered
contaminant
• <105 not significant even if clinically
significant
Same as
SUTI 1a
Same as SUTI 1a Same as SUTI 1a
Blood isolate
Culture /non
culture
method
NA NA NA 1 matching organism
of urine culture

33. N on
Catheter
associated
events
Non catheter
associated
events

34. Practice questions
1. A 2month old baby is admitted in paediatric ICU. A suprapubic
catheter is inserted on day 1. Patient develops symptoms on day 4.
Urine culture grows E.coli >10^5 CFU/ml collected on day 4. Is the
surveillance diagnosis CAUTI??
No – suprapubic catheters not considered for surveillance.

35. Hospital
day
Criteria
1 Admit Foleys
inserted
2 Foleys
3 Foleys
4 Foleys,
Fever+
5 Foleys,E.c
oli >10^5
CFU/ml
6
7
Catheter associated SUTI
Date of
Event
Infection
Window
Period
A patient was catheterized
on day 1 of
hospitalization and
the catheter was in place till
day 5. PT
developed fever(101oF) on
day 4. Urine specimen
collected on day 5 grew
E.coli >10^5 CFU/ml.
Hence the surveillance
diagnosis is

36. Hospital
day
Criteria
1 Admit
2
3 Foleys inserted
4 Foleys, Fever+,
E.coli >10^5
CFU/ml
5
6
7
Non Catheter associated SUTI
Date
of
Event
Infection
Window
Period
A hospitalized patient
was catheterized on day 3.
He developed fever 39oC
on day 4. Urine specimen
collected on day 4
grew E.coli >10^5 CFU/ml.
The surveillance diagnosis
is:

37. Hospital
day
Criteria
1 Admit Foleys
inserted
2 Foleys
3 Foleys
4 Foleys, E.coli
>10^5
CFU/ml
5 Blood
culture: E.coli
6
7
ABUTI
Date of
Event
Infection
Window
Period
A hospitalized patient
was catheterized on day 1.
Urine specimen collected
on day 4 grew E.coli >10^5
CFU/ml. Blood grew
E.coli. Patient had no
symptoms of UTI. The
surveillance diagnosis is:

38. 2. A patient was catheterized on day 1 of hospitalization. PT
developed fever(101oF) on day 4. Urine specimen collected on day
4 grew Candida species. Is the surveillance diagnosis CAUTI??
No: Candida is excluded from CAUTI surveillance