Prevention of

Catheter-Associated
Urinary Tract Infections

Learning objectives
1. Describe the relevance of urinary
tract infections in health care
institutions.
2. Identify risk factors for urinary tract
infections.
3. Describe measures for prevention.

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Time involved
50 minutes

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Introduction
Up to 40% of all HAIs
Most involve urinary
catheterisation
Risk of bacteriuria
5% per day during the first week to almost
100% at 4 weeks of catheterisation

1 to 4% of patients with bacteriuria

will develop infection
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Urinary tract sites commonly

associated with infection

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Urine
Urine is an ultrafiltrate of blood, is
normally sterile
Small numbers of perineal/ vaginal/bowel
microorganisms in the distal urethra
Constantly washed out by micturition

Bacteriuria = bacteria in the urine

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Collection of urine
Specimen contamination reduced by
Cleaning external urethral area before
collection
Collecting mid-stream urines
Urethral bacteria washed out in the first part of
the stream

Processing specimen promptly, or

refrigerating, to prevent overgrowth of
contaminants

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Laboratory diagnosis
Urine must be processed promptly
Contaminants can multiply at room
temperature and give falsely high colony
counts

If delay expected, transport the

specimen in an ice box or add boric acid
(1% W/V or 1 g/10 ml of urine)

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Microbiology
Usually endogenous microorganisms
E. coli and Proteus commonest in
community infections
Catheter-associated UTI (CAUTI)
E. coli commonest
Increasingly caused by resistant species
Klebsiella, Pseudomonas, Enterococcus and
multiply drug resistant ESBL, VRE

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Bacteria Causing UTIs (%)

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10 10

Microbiological support
The diagnosis of UTI depends on the
microbiological support available
In patients with indwelling catheters,
infections frequently polymicrobial
Presence of multiple bacteria does not
necessarily indicate contamination

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11 11

Quantitative bacteriology
Small numbers of bacteria are
insignificant
True infections have large numbers in
bladder urine
Microbiology labs count the number of
bacteria in a urine specimen as colonyforming units (cfu)
Significant bacteriuria gives a >95%
likelihood of true UTI
100,000 cfu/mL urine in 2 carefully-collected
mid-stream urines (MSUs)
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Urethral bacteria contaminate

specimens, small numbers

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Significant bacteriuria
When large numbers of bacteria
(>105/mL) in specimens of bladder urine
& evidence of true UTI
Smaller (insignificant) numbers may be due
to contamination of the urine specimen
during collection - urine has to pass through
urethra
Contamination can come from
perineum/genitalia
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True UTI with significant bacteriuria

bacteria
in bladder
urine multiply to high numbers
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before collection

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Quantitative microbiology
distinguishes between true UTI &
contamination or overgrowth

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Clinical diagnosis
In non-catheterised patients:
Fever, supra-pubic tenderness, frequency,
dysuria
Pyuria
Positive nitrite reaction and a positive
leukocyte esterase reaction

In catheterised patients
Fever and leukocytosis or leucopenia
additional diagnostic criteria

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Definition and Surveillance

Surveillance of CAUTI in selected
patients
e.g. intensive care or surgical

Definition may be obtained:

USA CDC/NHSN
Centers for Disease Control and Prevention/
National Healthcare Safety Network

HELICS
Hospital in Europe for Link Infection Control
through Surveillance
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Pathogenesis of a CatheterAssociated UTI

Normally urethral flora flushed out
With catheterisation, flushing
mechanism circumvented
Flora can pass up through catheter or
from drainage bag
Hands of personnel may contaminate
the system during insertion or
management
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Four main sites through which

bacteria may reach the bladder
in a catheterised patient

from Damani N N, Keyes JK. Infection Control Manual, 2004

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Principles to Prevent UTI - 1

Care bundle approach
Evidence-based interventions
When implemented together result in
reduction in CAUTIs

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Principles to Prevent UTI - 2

Staff training
Training on procedures for insertion and
maintenance of urinary catheters based on
local written protocols

Catheter size
Smallest diameter catheter that allows free
flow of urine

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Principles to Prevent UTI - 3

Antimicrobial coated catheters
Reduce asymptomatic bacteriuria
For placement less than 1 week
No evidence they decrease symptomatic
infections
Should not be used routinely
Should be considered in selected high risk
patients
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Principles to Prevent UTI - 4

Catheter insertion and care
Sterile equipment and aseptic technique
Sterile lubricant or local anaesthetic gel
Meatal cleansing with soap and water
Antimicrobial ointment harmful
Should be avoided

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Principles to Prevent UTI - 5

Drainage tubing and bag
Secure to the patient
Catheter drainage bag below the bladder
Bag and tap not in contact with the floor
Clamp drainage during movements
Not disconnect the drainage bag
Bag emptied when full
Hand hygiene
Alcohol impregnated swabs
No disinfectant added to bag
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Principles to Prevent UTI - 6

Specimen collection
Samples from the port
Aseptic technique
Disinfection of port with
alcohol
Sterile needle, syringe,
container
Never a sample from the
bag.
No routine testing
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Principles to Prevent UTI - 7

Antimicrobial agents
Routine administration not
recommended
Single dose prophylactic may be used in
selected patients
No routine use while the catheter in situ
Treatment may not be successful

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Principles to Prevent UTI - 8

Condom catheters
May be used for short-term
drainage
Frequent changes
Removed if irritation or skin
breakdown
Condom for 24 hour
continuous use should be
avoided

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Key points
Avoid urinary catheterisation
not for incontinence
consider intermittent catheterisation

Remove catheters as soon as possible

Aseptic technique and sterile equipment
Dont change catheters routinely
Closed drainage system
No irrigation or instillation
Empty drainage bag

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References

1. APIC Elimination Guide: Guide to the Elimination of

Catheter- Associated Urinary Tract Infections (CAUTIs); Developing and applying facility-based
prevention interventions in acute and long-term care
settings, 2008.
http://www.apic.org/Content/NavigationMenu/Practic
eGuidance/APIC EliminationGuides/CAUTI_Guide.pdf
2. HICPAC. Guidelines for prevention of Catheterassociated Urinary Tract infections 2009. Atlanta,
GA: CDC, 2009.
http://www.cdc.gov/hicpac/cauti/002_cauti_toc.html
3. European and Asian guidelines on management and
prevention of catheter-associated urinary tract
infections. Intern J Antimicrobial Agents 2008: 31S;
S68-S78.
http://www.escmid.org/fileadmin/src/media/PDFs/4ES
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CMID_Library/2Medical_Guidelines/other_guidelines/

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References
4. SHEA /IDSA Practice Recommendation: Strategies to
Prevent Catheter-Associated Urinary Tract Infections in
Acute Care Hospitals. Infect Control Hospital Epidemiol
2008; 29 (Supplement 1): S 41-S50.
http://www.jstor.org/stable/10.1086/591066
5. High Impact Intervention No 6. Urinary Catheter Care
Bundle. London, Department of Health, 2007.
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digit
alassets/@dh/@en/documents/digitalasset/dh_078125.
pdf
6. UK Dept. of Health epic2: Guidelines for preventing
infections associated with the use of short-term
urethral catheters. J Hospital Infect 2007; 65S: S28-S33.
http://www.vidyya.com/2pdfs/0124 infection.pdf
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References
7. Infectious Diseases Society of America Guidelines.
Diagnosis, Prevention, and Treatment of CatheterAssociated Urinary Tract Infection in Adults: 2009
International Clinical Practice
8. Guidelines from the Infectious Diseases Society of
America. Clin Infect Dis 2010; 50:625663.
http://www.idsociety.org/content.aspx?id=4430#uti

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