Catheter-Associated Urinary Tract Infection (CAUTI):

Prevention Diagnosis and Management

CAUTIs contribute an estimated $340-450 million per year in excess health care costs. 20-25% of hospitalized patients have a
short−term indwelling urinary catheter placed during their stay. Many are placed without appropriate indications. The
American College of Critical Care Medicine (ACCCM) and the Infectious Diseases Society of America (IDSA) note that
catheter associated bacteriuria is typically colonization, is rarely symptomatic and is an infrequent cause of fever or secondary
bloodstream infection (BSI).

Scope of Guideline o
Intermittent straight catheterization (ISC) in
post-op patients and in patients with spinal
 This guideline should be used to assist the MD/LIP and cord injury or neurogenic bladder.
RN with appropriate o See Mosby’s Nursing Skills Urinary
o Indications for indwelling urinary catheter use Catheter Straight and Indwelling (Foley)
o Use of an indwelling urinary catheter Catheter Insertion and Specimen
o Recommendations for replacing an indwelling Collection: Female / Male
catheter o Bedside commode or urinal.
o Catheter insertion and maintenance o Incontinence pads and barrier creams.
o Indication for urine collection and testing.  Use portable, bedside ultrasound bladder scanners
 This guideline applies to patients with indwelling to assess urine volume and/or verify urinary
urethral catheters; it does not apply to patients who retention/incomplete emptying prior to intermittent
intermittently self-catheterize or patients with catheterization or placing an indwelling catheter.
suprapubic catheters, nephrostomy tubes nor urinary o See OSUWMC Nursing Indwelling Urinary
diversion devices. Catheter Removal Protocol
 This guideline should be used in conjunction with the o See Mosby’s Nursing Skills: Bladder Scan
Urinary Tract Infection in Adult Patients: Diagnosis and
Management Clinical Practice Guideline Catheter Maintenance and Key Prevention Strategies

Complications of Indwelling Urinary Catheters  Document daily perineal hygiene and catheter care
 Maintain a sterile continuously closed-drainage
 Urinary tract infection (urethritis, cystitis) system
 Urethral and bladder trauma resulting in urethral  Leave catheters in place for as short a time as
strictures/erosion, hematuria, and inflammation possible.
 Patientdiscomfort/pain  For post-operative patients, remove the catheter
 Prolonged immobilization, restriction of activities and within 24 hours or document an appropriate
increased risk of falls indication for continued use.
 Increased length of stay o See Appendix B for catheter insertion and
 Inadvertent increase in antimicrobial use with maintenance.
unnecessaryantibiotics for catheter-associated  Assess and document the need for continued
asymptomatic bacteria (CA-AB). catheter use DAILY by both MD/LIP and RN.
 If an appropriate indication for a catheter is no longer
Risk Factors met, remove per OSUW MC Nursing Indwelling
 Prolonged use Urinary Catheter Removal Protocol or notify MD/LIP
for order to remove.
 Female gender
 Poor perineal hygiene
When to Replace Indwelling Catheters
 Impaired immunity
 Improper insertion technique Recommendations are to replace an indwelling catheter
with a MD/LIP order for the following indications:
Appropriate Urinary Catheter Use o Symptomatic infection
o Obstruction
 Insert catheters only for appropriate indications. o Break or leak in the closed system
o See Appendix A for appropriate and o Prior to specimen collection for analysis
inappropriate indications for catheters. if indwelling for ≥ 3 calendar days or
 Avoid use of urinary catheters in patients for date of placement is unknown
management of incontinence. o Patients transferred from outside facilities
 Consider alternatives to indwelling catheters: or nursing homes with signs or
symptoms of a UTI or sepsis before
o External (condom) catheters in sampling urine.
cooperative males without urinary
 Do not replace catheters routinely to prevent a
retention or bladder outlet obstruction
CAUTI.
 Do not replace catheters routinely in patients
transferred from outside facilities or nursing homes
unless an indication above is met.
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Catheter Irrigation Indications for Urine Specimen

(Urinalysis and/or Culture)
Irrigate catheter only when necessary
 Inappropriate catheter irrigation can lead to an  Signs and symptoms of CAUTI:
increased risk of a CAUTI and patient morbidity. o Suprapubic pain or tenderness
 Catheters should only be irrigated if there is o Costovertebral angle pain or
concern for catheter occlusion, such as, in the tenderness
presence of a blood clot or sediment. o New onset of fever >100.4°F (38°C)
o Note: Low urinary output is NOT an without an alternative cause of fever.
indication for irrigation.  Nonspecific signs and symptoms compatible with a
CAUTI without an alternative cause.
Performing catheter irrigation o Clinical sepsis AND no evident source of
 A 60 ml Toomey Syringe should be connected infection is evident.
directly to the indwelling catheter by o New onset altered mental status in the
disconnecting the catheter bag. elderly patient without an alternative
 Sixty (60) ml of sterile water should be instilled cause.
then aspirated. This process may need to be o Increased spasticity or autonomic
dysreflexia in patients with spinal cord
repeated in the setting of multiple blood clots, but
injury.
no more than 120 ml should be instilled, if there
is no return of fluid on aspiration.
INAPPROPRIATE Indications for Urine Culture
 The side/sampling port should not be used for
routine irrigation in the setting of catheter  Malodorous or foul smelling urine.
occlusion.  Sediment in urine, dark urine, cloudy urine, or
change in urine color.
Urine Specimen Considerations  Leukocytosis without signs of suprapubic or CVA
tenderness
 The decision to order a urinalysis and/or urine
 Test of cure; prior UTI diagnosis.
culture should be based on a clinical evaluation of
 Upon discontinuation of the urinary catheter.
the patient.
 A urinalysis with reflex to culture is  If patient is receiving end of life/DNR-CC, urine
recommended as part of an evaluation only if all culture testing is not recommended per goals of
other more plausible sites of infection have been care.
ruled out in the general population.  If the patient has ESRD, bacteriuria is inevitable.
o Urinary Tract Infection in Adult Patients:
Diagnosis and Management Clinical Specimen Collection
Practice Guideline (See box A).
o Given most signs and symptoms of a UTI in  Unless removal is contraindicated per protocol or
catheterized patients are nonspecific, catheter was placed by urology, catheters MUST be
CAUTI is often a diagnosis of exclusion. changed prior to obtaining a urine specimen for
evaluation if catheter is in place for ≥ 3 calendar
o Always consider other sources for fever first,
except if immune compromised, pregnant, days or date of placement is unknown
having undergone urologic procedures, or  Disinfect sample port prior to sampling.
renal transplant recipient. In these  Aspirate from needleless sample port ONLY.
situations, order a UA AND a urine culture  Use sterile syringe / cannula adapter.
as UA may not be reliable.  Quality of specimen determines accuracy of result.
o For recommended guidance for Urinalysis
and culture refer to the Urinary Tract Interpretation of Urinalysis and Urine Culture Results
Infection in Adult Patients: Diagnosis and
Management Clinical Practice Guideline (See  Positive urine cultures in a symptomatic patient can
box B). guide selection of antimicrobials.
 Screening and/or treatment for asymptomatic  For recommended treatment when indicated refer to
bacteriuria is not recommended in patients with the Urinary Tract Infection in Adult Patients:
indwelling catheters, except in early pregnancy Diagnosis and Management Clinical Practice
and prior to urologic procedures in which visible Guideline
mucosal bleeding is anticipated.
 All orders for urinalysis and/or urine culture must
have an appropriate indication.

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Definitions Diseases: 2013 Recommendations by the

Infectious Diseases Society of America (IDSA) and
The National Health Safety Network (NHSN) surveillance the American Society for Microbiology (ASM) (a).
definition calls a CAUTI if there is: Clin Infect Dis, 57(4):e22-e121.
 A UTI where an indwelling urinary catheter was in  Coman T, et al. (2014). Diagnostic Accuracy of
place for > 2 calendar days on date of event, with Urinary Dipstick to Exclude Catheter-Associated
day of device placement as day 1, AND an Urinary Tract Infection in ICU Patients: A
indwelling urinary catheter was in place on date of Reappraisal. Infection, 42(4):661-8.
event or day before.  Drekonja DM, et al. (2013). Preoperative Urine
 If an indwelling urinary catheter was in place for > 2 Cultures at a Veterans Affairs Medical Center.
calendar days and then removed, date of event for JAMA Intern Med, 173(1):71-72.
the UTI must be the day of discontinuation or the  Golob JF, et al. (2008). Fever and Leukocytosis in
next day for the UTI to be catheter-associated. Critically Ill Trauma Patients: It’s not the Urine.
 Catheter-associated Asymptomatic bacteriuria (CA- Surg Infect (Larchmt), 9(1):49-56.
AB) is the presence of bacteriuria in a patient without  Gould CV, et al. (2010). Guideline for Prevention of
signs/symptoms consistent with a UTI. Catheter-Associated Urinary Tract Infections. Infect
o Patients with indwelling catheters acquire Control Hosp Epidemiol, (4):319-26.
bacteriuria at a rate of 2-7% per day.  Hartley S, et al. (2013). Inappropriate Testing for
o Virtually all catheterized patients will have Urinary Tract Infection in Hospitalized Patients: An
bacteriuria by 30 days. Opportunity for Improvement. Infect Control Hosp
Epidemiol, 34(11):1204-7.
Quality Measures
 Hartley S, et al. (2015). Overtreatment of
Note: Quality measures are measured and stratified by Asymptomatic Bacteriuria: Identifying Targets for
hospital, unit, and location-type (e.g. ED, ICU, Med/Surg). Improvement. Infect Control Hosp Epidemiol,
36(4):470-3
Process Measures  Hollingsworth JM, et al. (2013). Determining the
Noninfectious Complications of Indwelling Urethral
 Is review of daily necessity documented by both
Catheters: A Systematic Review and Meta-
RN and MD/LIP?
Analysis. Ann Intern Med, 159(6):401-10.
 Hooton TM, et al. (2010). Diagnosis, Prevention,
Outcome Measures
and Treatment of Catheter-Associated Urinary
 NHSN CAUTI rate: number of CAUTIs per 1,000 Tract Infection in Adults: 2009 International Clinical
catheter-days. Practice Guidelines from the Infectious Diseases
 Standardized Infection Ratio (SIR): observed Society of America. Clinical Infectious Diseases,
number of CAUTIs / expected number of CAUTIs 50:625–663
 Rate of Bloodstream Infections (BSI)  Huang SS, et al. (2013). Targeted Versus
attributable to a CAUTI: number of BSIs Universal Decolonization to Prevent ICU Infection.
attributable to CAUTI per 1,000 catheter-days. N Engl J Med, 368:2255-226.
o BSI attributable to CAUTI: defined as  Humphries RM, et al. (2016). Point-Counterpoint:
blood culture organism matches urine Reflex Cultures Reduce Laboratory Workload and
specimen in a patient with a CAUTI. Improve Antimicrobial Stewardship in Patients
 Device utilization ratio: number of catheter-days Suspect of Having Urinary Tract Infection. Journal
/ number patient-days. If the device utilization of Clinical Microbiology, 54 (2): 2545-258.
ratio on a unit is 2-3 times what it should be for a  J Nurs Care Qual. 2017 Jul/Sep;32(3):202-206
similar unit, less urinary catheterization overall is PMID: 27611579
recommended.  Kubilay Z, et al. (2013). What we don’t know may
hurt us: urinary drainage system tubing coils and
Patient Education Materials CA-UTIs-A prospective quality study. Am J Infect
 Preventing Infections during Urinary Catheter Use Control, 41: 1278-80.
 Foley Catheter Care (Male)  Leis JA, et al. (2013). Downstream impact of urine
cultures ordered without indication at two acute
 Foley Catheter Care (Female)
care teaching hospitals. Infect Control Hosp
Epidemiol, 34(10):1113-4.
References  Lo E, et al. (2014). Strategies to prevent catheter-
 APIC Implementation Guideline: Guide to associated urinary tract infections in acute care
Preventing Catheter-Associated UrinaryTract hospitals: 2014 update. Infect Control Hosp
Infections. 2014. Association for Professionals in Epidemiol, 35(5): 464-479.
Infection Control and Epidemiology, Washington,  Magill SS, et al. (2014). Multistate point-prevalence
DC. survey of health care-associated infections. N Engl
J Med, 370:1198-208.
 Baron EJ, et al. (2013). A guide to Utilization of the
Microbiology Laboratory for Diagnosis of Infectious

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University Technology Commercialization Office
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 Meddings J, et al. (2015). The Ann Arbor Criteria  Trautner BW, Grigoryan L. (2014). Approach to a
for Appropriate Urinary Catheter Use in positive urine culture in a patient without urinary
Hospitalized Medical Patients: Results Obtained by symptoms. Infect Dis Clin North Am, 28(1):15-31.
Using the RAND/UCLA Appropriateness Method.  Umscheid CA, et al. (2011). Estimating the
Ann Intern Med, 162(9 Suppl):S1-34. proportion of healthcare-associated infections that
 Newton EH, et al. (2015) Undermeasuring are reasonably preventable and the related
Overuse--An Examination of National Clinical mortality and costs. Infect Control Hospital
Performance Measures. JAMA Intern Med, Epidemiology, 32(2):101-14.
175(10):1709-11.
 Nicolle LE, et al. (2005). Infectious Diseases Policies/ Guidelines
Society of America Guidelines for the Diagnosis  OSUW MC Nursing Indwelling Urinary Catheter
and Treatment of Asymptomatic Bacteriuria in Removal Protocol and Bladder Scan Guideline
Adults. Clin Infect Dis, 40:643–54.
 Urinary Tract Infection in Adult Patients: Diagnosis
 O’Grady NP, et al. (2008). Guidelines for evaluation and Management Clinical Practice Guideline
of new fever in critically ill adult patients:
2008 update from the American College of Critical Resources
Care Medicine and the Infectious Diseases Society
of America. Crit Care Med, 36 (4): 1330-1349.  Mosby’s Nursing Skills: Bladder Scan
 Silver SA, et al. (2009). Positive urine cultures: A  Mosby’s Nursing Skills Urinary Catheter Straight
major cause of inappropriate antimicrobial use in and Indwelling (Foley) Catheter Insertion and
hospitals. Can J Infect Dis Med Microbiol, 20(4): Specimen Collection: Female / Male
107–111.
 Saint, S et al (2016). A program to Prevent CAUTI Guideline Authors
in Acute Care. NEJM 2016;374:2111-9.  Jamie St. Clair, MS, RN, ACNS-BC, CCRN
 Tambyah PA, Maki DG. (2000). Catheter-assoc.  Megan Hoying, RN, BSN
urinary tract infection is rarely symptomatic: a
 Amy Knupp, PhD, RN, APRN-CNS, CPPS
prospective study of 1,497 catheterized patients.
 Eric Abel, Pharm D
Arch Intern Med, 160(5):678-82.
 Lynne Brophy, MSN, RN-BC, CNS, AOCN
 Tambyah PA, Maki DG. (2000). The relationship
between pyuria and infection in patients with  Michele Grove, MBOE, BSN, RN, MBOE
indwelling urinary catheters: a prospective study of  Zachary Gordon, MD
761 patients. Arch Intern Med, 160(5):673-7.  Julie Mangino, MD
 The prevention and management of urinary tract
infections among people with spinal cord injuries. Guideline Approved
National Institute on Disability and Rehabilitation
Research Consensus Statement. January 27-29, August 30, 2017 Fourth Edition.
1992. J Am Paraplegia Soc 1992; 15(3):194-204.
 Toolkit for Reducing Catheter-Associated Urinary Disclaimer: Clinical practice guidelines and algorithms at
Tract Infections in Hospital Units: Implementation The Ohio State University Wexner Medical Center
Guide. October 2015. Agency for Healthcare (OSUWMC) are standards that are intended to provide
Research and Quality, Rockville, MD. general guidance to clinicians. Patient choice and
 Trautner BW, et al. (2013). Development and clinician judgment must remain central to the selection of
validation of an algorithm to recalibrate mental diagnostic tests and therapy. OSUWMC’s guidelines and
models and reduce diagnostic errors associated algorithms are reviewed periodically for consistency with
with catheter-associated bacteriuria. BMC Med new evidence; however, new developments may not be
Inform Decis Mak, 13: 48. represented.
 Trautner BW, et al. (2015). Effectiveness of an
Antimicrobial Stewardship Approach for Urinary
Catheter-AssociatedAsymptomaticBacteriuria.
JAMA Intern Med, 175(7):1120-7.

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Appendix A. Indications for Indwelling Urethral Catheter

Appropriateness Indications

 Bladder outlet obstruction or treatment for bladder hemorrhage: BPH exacerbation; urethral
stricture/trauma; gross hematuria with clots.
 Acute urinary retention due to spinal cord injury (i.e. acute neurogenic bladder).
 Chemical paralysis or moderate sedation (current RASS ≤ -2).
 Chronic urinary retention (> 30 days) unable to be managed with intermittent catheterization.
 Assist healing of stage III-IV sacral/perineal wounds when urinary incontinence cannot be managed with
other urinary management strategies.¹
 Urinary incontinence when adequate skin care is not possible despite other urinary management
strategies¹ and available resources, such as lift teams and mechanical lift devices.
o Turning causes hemodynamic or respiratory instability.²
o Excess weight (> 300 lbs.) from severe edema or obesity.
 Hourly measurement of urine volume required to provide treatment.
 Management of hemodynamic instability requiring hourly titration of fluids, vasopressors, inotropes, or
life-supportive therapy.
 Daily (not hourly) measurement of urine volume required to guide treatment and cannot be assessed by
other volume³ and urine collection strategies.⁴
o Acute IV or oral diuretic management.
Appropriate o IV fluid management in respiratory or heart failure.
 Strict prolonged immobilization required due to unstable spine or pelvic/hip fractures.
 Improve comfort for end-of-life care, if needed. Avoid removal of Foley and evaluation of urine
samples.
 Required for healing following recent urologic or gynecologic surgery e.g. prostatectomy, urethroplasty,
bladder reconstruction/repair.
 Peri-procedural use⁵- catheter to be removed within 24hrs. after surgery.

¹ Other urinary management strategies: barrier creams, absorbent pads, prompted toileting, non- indwelling catheters.

² Hemodynamic instability is defined as requiring pharmacologic or mechanical support to maintain a normal blood
pressure or adequate cardiac output.

³ Other volume assessment strategies: physical examination, daily weighing.

⁴ Other urine collection strategies: urinal, bedside commode, bedpan, external catheter, intermittent catheterization.

⁵ Catheters placed for this indication should either be removed within 24 hrs. postoperatively, or an appropriate
indication for continued use must be documented.
 Urinary incontinence when adequate skin care can be provided with other urinary management strategies
and available resources including patients with:
o Intact skin.
o Incontinence-associated dermatitis.
o Stages I-II sacral/perineal wounds.
o Closed deep-tissue injury.
 Routine use in ICU without an appropriate indication.
 Monitoring of urine output that can be obtained by means other than an indwelling catheter.
 Prolonged postoperative use (> 24 hours after surgery) without documented exception for use by LIP.
 Morbid obesity or immobility (including “bed rest” without strict immobility requirement) when the patient
Inappropriate can voluntarily void.
 To reduce risk of falls by minimizing the need to get up to urinate.
 Confusion or dementia.
 Patient and/or family request.
 Nursing convenience.
 Urine specimen collection.
 Preventing UTI in patient with fecal incontinence or diarrhea.
 Management of frequent, painful urination in patients with UTI.
 Post-void residual urine volume assessment.
 Routinely for patients receiving epidural anesthesia.

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Appendix B. Catheter Insertion and Maintenance

Process Step Comments

 Determine if indwelling catheter is appropriate per approved indications (see Appendix A).
o If indication is acute urinary retention, then use ultrasound bladder scanner to verify retention prior to
catheterization.
 Obtain assistance as needed (e.g. 2-person insertion) to facilitate appropriate visualization/insertion technique.
 Perform hand hygiene.
 Perform peri-care with Castile soap wipe provided in the catheter insertion kit.
o If soap wipes are unavailable, use soap and water or Aloe Vesta Cleaning Foam, if available.
 Re-perform hand hygiene.
 Maintain strict aseptic technique throughout the actual indwelling catheter insertion procedure.
o Use sterile gloves and equipment and establish/maintain sterile field.
o It is no longer recommended to pre-inflate the balloon to test it.
Insertion  Insert catheter to appropriate length and check urine flow before balloon inflation to prevent urethral trauma.
o In males, insert fully to the “y” connection.
o In females, advance ~1 inch or 2.5 cm beyond point of urine flow.
 Inflate catheter balloon correctly.
o Inflate to labeled 5 ml or 10 ml per manufacturer’s instructions.
 Perform hand hygiene upon completion of procedure.

®)
Secure catheter using the provided stabilization device (e.g. StatLock , (label with date/time) or leg-strap to
prevent movement or urethral traction.
 Position drainage bag below the bladder; should not rest on the floor.
 Check system for closed connections and ensure no obstructions, kinks, or dependent loops in tubing.
 Label bag with date/time of insertion, with provided label in kit and document in EMR.

 Assess need for continued catheter use daily; document indication for ongoing need in IHIS by both RN and
MD/LIP, daily.
 Maintain appropriate securement at all times.
 Maintain unobstructed urine flow.
o Ensure the drainage bag is below the level of the bladder at all times (not on the floor, even when
emptying).
o Check tubing frequently to ensure proper drainage—no kinks or dependent loops in tubing (may use
green sheet clips to assist).
 Maintain a sterile continuously closed-drainage system.
o Empty drainage bag at least once each shift, whenever ⅔ full, and before any transfer off the unit
(e.g. going to radiology) using a container designated for that patient only.
o Avoid contact or contamination of drainage spout with the collection container.
o If breaks in the closed system are noted (e.g., disconnection, cracked tubing), replace the catheter
and collecting system.
o Follow standard precautions and perform proper hand hygiene before and after handling the drainage
device.
 Perform urethral catheter and perineal care with 2% Chlorhexidine gluconate (CHG) wipes at least once daily
Maintenance and after a bowel movement or an incontinent episode, unless the patient has a CHG allergy.
o With bath per OSUW MC bathing protocol.
 Use one CHG wipe to clean the perineum and extend along catheter at minimum 6 inches from the patient.
 With incontinence episode:
o First cleanse stool with water and washcloth or pre-moistened disposable cloth (non-CHG).
 Do not use soap.
 Use one CHG wipe to clean the perineum and extend along catheter at minimum 6 inches from the patient.
 Only clean the external genitalia and avoid vigorous cleaning at the urethral meatus.
 Avoid irrigation.
 If concern for catheter obstruction, contact Urology.
o For low urine output, perform bladder scan prior to irrigation.
o If it is determined that the catheter is obstructed and the catheter must remain, replace the catheter
and drainage system.
o Do not remove any seals between the catheter and drainage tubing or disconnect the closed system.
 Remove catheter promptly when no longer indicated; it is not necessary to clamp the catheter prior to
removal.
 Patients doing self-catheterization at home should use disposable, single use urinary catheters.
 See Mosby’s Nursing Skills Urinary Catheter Straight and Indwelling (Foley) Catheter Insertion and
Specimen Collection: Female / Male

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