Catheter Associated Urinary Tract Infections ( CAUTI ) in adults ( ≥ 16 years of age ) - Guideline for the management of in secondary care
|Last review: 07/09/2017|
|Next review: 01/09/2020|
|Approved By: Improving Antimicrobial Prescribing Group|
|Copyright© Leeds Teaching Hospitals NHS Trust 2017|
This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
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Guideline for management of Catheter Associated Urinary Tract Infections (CAUTI) in Adults (≥ 16 years of age)
Catheter Associated Urinary Tract Infections ( CAUTI ) in adults ( ≥ 16 years of age )
Non anti-microbial management
See also - Duration of treatment
Recommendation: CAUTI is normally diagnosed clinically.
Catheter Associated Urinary Tract Infections (CAUTIs) symptoms include fever >38ºC, suprapubic tenderness, or otherwise unexplained systemic symptoms such as altered mental status.
If there are symptoms of upper UTI in patients with a urinary catheter please see the upper UTI guideline. Upper UTI symptoms include fever, costovertebral angle tenderness, back pain or where the severity of infection is not in keeping with a lower urinary tract infection e.g. hypotension or evidence of a Systemic Inflammatory Response Syndrome (SIRS). 1
Patients who are no longer catheterised but had indwelling urinary catheters within the past 48 hours are also considered to have catheter-associated UTI if they have these symptoms. These patients may also have dysuria and/or urinary frequency in addition to the symptoms listed above.1
Recommendation: If CAUTI is associated with severe sepsis, please manage according to the upper UTI guideline.
Recommendation: If CAUTI is associated with systemic inflammatory response syndrome (SIRS) please consider if the patient should be managed according to the upper UTI guideline.
Evidence review/justification for recommendations5/6
Interpretation of microbiology results
The interpretation of microbiology investigations for UTIs is heavily dependent upon the pre-test probability i.e. the probability of infection based on the clinical examination and history. For example, where there is a high probability of infection based on the clinical history negative microbiology results do not exclude a diagnosis of urinary tract infection. . A guide to when to use urine dipstick and MSU/CSU testing in the diagnosis of lower UTI is provided in Figure 1, see below.
Urine dipstick testing [Evidence level B]
Urine dipstick testing should NOT be used on urine samples collected from indwelling catheters because bacteria colonising the catheter and the inflammation caused by the catheter will give falsely positive nitrite and leucocyte esterase results respectively. [Evidence level B]
Laboratory urinary analysis (including culture) [Evidence level B]
The interpretation of urine samples is heavily dependent upon the clinical details and the method of urine collection. For example, in the absence of urinary symptoms any growth of bacteria is likely to represent urinary catheter colonisation only. CA-bacteruria is not a disease and requires no treatment.
Urinary catheters inevitably become colonised with bacteria so the growth of bacteria from urine collected via an indwelling catheter cannot be used alone as evidence of a urinary tract infection.
In the microbiology laboratory urine samples may undergo the following tests:
White cell count
Red cell count
Bacterial count and culture
Antibacterial susceptibility testing
Routine susceptibility testing of urines is standardised i.e. it is not different depending upon if a patient has upper or lower tract infection. Therefore not all antibiotics reported on urine culture results are suitable for the treatment of upper UTI. For example, Nitrofurantoin is suitable for the treatment of lower UTI but not upper UTI. The susceptibility testing completed and reported may be modified if clinical details provided by the requester indicate upper tract infection.
Collecting urine sample(s) for Microbiology
Blood cultures [Evidence level B]
Where patients have sepsis blood cultures should be taken.
Non microbiological investigation
Urine appearance: Production of turbid urine is reported to have a sensitivity of 90% and a specificity of 66% for the presence of symptomatic bacteriuria. This means if a patient has clear urine it is unlikely they have a UTI, but does not exclude it. It also means many patients with turbid urine do not have a UTI. Turbid urine should not in itself be used to diagnose a UTI. 5/6[Evidence level B]
Figure 1: A summary of the process to be followed when considering if a patient has a lower urinary tract infection.
Recommendation: In patients with catheter associated UTI (CAUTI) if the urinary catheter is no longer indicated, remove the catheter at the earliest possible opportunity [Evidence level D].
Recommendation: In patients with catheter associated UTI (CAUTI) consider catheter exchange when the urinary tract is considered to be sterile (>48 hours after treatment initiated) and the patient is still on antibiotics [Evidence level D].
Note: Urinary catheters do not need to be changed routinely in patients without clinical evidence of a urinary tract infection. This applies to patients with and without catheter associated bacteriuria.
|Empirical Antimicrobial Treatment|
Recommendation: Catheterised patients with asymptomatic bacteriuria should not receive antibiotic treatment1 [Evidence level B].
Recommendation: Patients with an indwelling catheter and symptomatic urinary tract infection should ideally have their catheter changed in addition to appropriate antibiotic treatment for infection [Evidence level C].
Before commencing an empirical regimen please check the results server to see if previous results are available to allow immediate initiation of directed antimicrobial therapy e.g. GP CSU sample.
These empirical regimes are suitable for most patients with suspected lower urinary tract infection. In some patients where the consequences of a lower urinary tract infection may be significant e.g. urological patients, alternative agents may be considered empirically e.g. Gentamicin IV. Consideration should be given to the risk benefit of alternative regimens e.g. renal impairment and ototoxicity.
|Directed Antimicrobial Treatment (when microbiology results are known)|
When a bacterial pathogen is identified in a urine sample antibiotic susceptibility testing will be available to guide antibiotic therapy. The susceptibility results may have to be requested by phoning microbiology on extension 23962. Susceptibility results are not routinely released on CSU samples as it is not possible for microbiologists, without clinical information, to differentiate CAUTI from CA-bacteruria.
|Duration of Treatment|
Table 4. Treatment duration for CAUTI. [Evidence level B-D]
|Switch to oral agent(s)|
Oral switch regimens should be based on the results of susceptibility testing results - Table 3.
If no susceptibility results available see Table 1: Empirical antimicrobial regimens for the treatment of CAUTI.
To investigate treatment failure consider
Catheter Associated Urinary Tract Infections
|Target patient group:||Adults >16 years|
|Target professional group(s):||Secondary Care Doctors
- Hooton TM, Bradley SF, Cardenas DD, Colgan R, Geerlings SE, Rice JC, Saint S, Schaeffer AJ, Tambayh PA, Tenke P, Nicolle LE. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis. 2010 Mar 1;50(5):625-63.
- Haley RW, Hooton TM, Culver DH, Stanley RC, Emori TG, Hardison CD, Quade D, Shachtman RH, Schaberg DR, Shah BV, Schatz GD. Nosocomial infections in U.S. hospitals, 1975-1976: estimated frequency by selected characteristics of patients. Am J Med. 1981;70(4):947.
- Kunin CM, Chin QF, Chambers S. Morbidity and mortality associated with indwelling urinary catheters in elderly patients in a nursing home—confounding due to the presence of associated diseases. J Am Geriatr Soc 1987; 35:1001–1006.
- Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA. Guideline for prevention of catheter-associated urinary tract infections 2009. Healthcare Infection Control Practices Advisory CommitteeSOInfect Control Hosp Epidemiol. 2010;31(4):319.
- SIGN Management of suspected bacterial urinary tract infection in adults A national clinical guideline July 2006.
- Nicolle LE, Bradley S, Colgan R, Rice JC, Schaeffer A, Hooton TM. Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. 2005 Mar 1;40(5):643-54.
- NICE: Multidrug resistant urinary tract infections: fosfomycin trometamol https://www.nice.org.uk/advice/esuom17/chapter/key-points-from-the-evidence
- PHE: Management of infection guidance for primary care for consultation and local adaptation
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. Leeds consensus. (where no national guidance exists or there is wide disagreement with a level C recommendation or where national guidance documents contradict each other)
Improving Antimicrobial Prescribing Group
LHP version 1.0
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