George Allen
PhD, CIC, CNOR
No
Disclosures

Identify mandates, clinical & regulatory for
monitoring and preventing CAUTI

Review the surveillance definitions and
criteria for CAUTI

Discuss strategies institutions can utilize to
reduce the risk for the development of CAUTI
 Discomfort to the patient
 Limit mobility
 Prolonged hospital stay
 Increased cost and mortality
 Each year 1.7- 2 million Americans (5-10% of
hospitalized patients) acquire at least one
infection while hospitalized
 90-100 thousand die of those infections
 One third of these are believed preventable
 Conservatively HAI cost $33 billion each year

Urinary tract – most common site of healthcare
associated infections; most are associated with
urinary catheterization
 15 - 25% of inpatients are catheterized

80% of hospital associated UTIs caused by a
urinary catheter

CAUTI cost $500 – $1000 - $2,800 if bacteremia

Most CAUTIs are asymptomatic bacteriuria, 1-5%
lead to secondary bacteremia

5% of all deaths from HAI are urinary catheter
associated.
 CAUTI are the most common HAI accounting
for about 30%
 Each year more than 13,000 deaths are
associated with UTI Klevens RM, Edwards JR, et al. Estimating health
care-associated infections and deaths in U. S hospitals, 2002. Public Health Reports 2007:
122:160-166.
 The good news is that many CAUTIs may be
prevented with recommended infection
control measures.

Up to 380,000 infections and 9000 deaths
related to CAUTI per year could be prevented
http://www.cdc.gov/ncidod/dhqp/hai.html
Umscheid et al. Infec Control & Hospital Epidemiology 2011; Scott, 2009

Proper management and use of catheters could
prevent infections

Study in Lansing, MI: Less than half of urinary
catheters in teaching hospital were indicated.
Am J Infect Control. 2004 Jun;32(4):196-9. Inappropriate use of urinary catheters in elderly
patients at a midwestern community teaching hospital.Gokula RR, Hickner JA, Smith MA.

Urinary catheters are uncomfortable, limit mobility

Virtually all healthcare associated urinary
tract infection are caused by
instrumentation of the urinary tract

CAUTI can lead to complications

Cystitis

Pyelonephritis

Gram-negative bacteremia

Prostatitis

Epididymitis

Orchitis in males

Endocarditis

Vertebral osteomyelitis

Septic arthritis

Endophthalmitis

Meningitis

The Joint Commission NSPG 07.06.01

CMS Value Based Purchasing

CMS Inpatient Quality Reporting Program

Goals
 To eliminate and sustain reductions in CAUTI

Mandatory Reporting through NHSN

Denial of CMS dollar reimbursement

CAUTI must be included in monthly NHSN

NY Partnership for Patients
Core Measures
▪ To reduce unnecessary catheter utilization
▪ To eliminate preventable catheter-associated urinary tract
infections
 As of Oct. 2008 CMS will no longer reimburse
hospitals for eight “reasonably preventable”
conditions.
 Included are CAUTI and hospital acquired
pressure ulcers.
 Reimbursement to the hospital for care of
these patients will be decreased.
Report by the following facility/institution:

Acute Care Hospitals: Adult and Pediatric ICUs
▪ January 2011

Long Term Care Hospitals: All inpatient location
▪ October 2012

Inpatient Rehabilitation Facilities: All inpatient
locations
▪ October 2012

Report CAUTI indentified by surveillance

Indicate NO CAUTI detected for specific location

Report total device days for specific location

Report total patient days in specific location

NPSG.07.06.01 Implement evidence based
practices to prevent CAUTI (2012 = Planning year;
by January 2013 = full implementation)
http://www.jointcommission.org/assets/1/6/NPSGs
_CAUTI-VAP_HAP_20101119.pdf
EPI 2 Insert indwelling urinary catheters
according to established-evidence based
guidelines that address the following:
Limiting use & duration to situation necessary for patient care
Using aseptic techniques for site preparation, equipment & supplies
EPI 3 Manage indwelling urinary catheters
according to established evidence-based guidelines
that address the following:
Securing catheters for unobstructed urine flow & drainage
Maintaining the sterility of the urine collection system
Replacing the urine collection system when required
Collecting urine samples
EPI 4 Measure & monitor catheter associated
urinary tract infection prevention processes &
outcomes in high-volume areas by doing the
following:
Selecting measures using evidence based guidelines or best practices
Monitoring compliance with evidence-based guidelines or best practices
Evaluating the effectiveness of prevention efforts
GUIDELINE FOR PREVENTION OF CATHETERASSOCIATED URINARY TRACT INFECTIONS 2009
Carolyn V. Gould, MD, MSCR 1; Craig A. Umscheid, MD, MSCE 2; Rajender K.
Agarwal, MD, MPH 2; Gretchen Kuntz, MSW, MSLIS 2; David A. Pegues, MD 3
and the Healthcare Infection Control Practices Advisory Committee (HICPAC) 4
Category IA
A strong recommendation supported by high to moderate
quality evidence suggesting net clinical benefits or harms
Category IB
A strong recommendation supported by low quality evidence
suggesting net clinical benefits or harms or an accepted practice
(e.g., aseptic technique) supported by low to very low quality
evidence
Category IC
A strong recommendation required by state or federal regulation.
Category II
A weak recommendation supported by any quality evidence
suggesting a trade off between clinical benefits and harms
No recommendation/
unresolved issue
Unresolved issue for which there is low to very low quality evidence
with uncertain trade offs between benefits and harms

1A.1. Use urinary catheters in operative patients
only as necessary, rather than routinely.
(Category IB)

1A.2. Avoid use of urinary catheters in patients
and nursing home residents for management of
incontinence. (Category IB)


1A.2.a. Further research is needed on periodic
(e.g., nighttime) use of external catheters in
incontinent patients or residents and the use of
catheters to prevent skin breakdown. (No
recommendation/unresolved issue)
1A.3. Further research is needed on the benefit
of using a urethral stent as an alternative to an
indwelling catheter in selected patients with
bladder outlet obstruction. (No
recommendation/unresolved issue)

1A.4. Consider alternatives to chronic indwelling
catheters, such as intermittent catheterization,
in spinal cord injury patients. (Category II)

1A.5. Consider intermittent catheterization in
children with myelomeningocele and
neurogenic bladder to reduce the risk of urinary
tract deterioration. (Category II)

1B.2. Insert catheters only for appropriate
indications, and leave in place only as long as
needed. (Category IB)

1B.3. Minimize urinary catheter use and
duration of use in all patients, particularly
those at higher risk for CAUTI such as
women, the elderly, and patients with
impaired immunity. (Category IB)

1B.4. Ensure that only properly trained
persons (e.g., hospital personnel, family
members, or patients themselves) who know
the correct technique of aseptic catheter
insertion and maintenance are given this
responsibility. (Category IB)

1B.5. Maintain unobstructed urine flow.
(Category IB)

1C.1. Minimize urinary catheter use and
duration in all patients, particularly those
who may be at higher risk for mortality due to
catheterization, such as the elderly and
patients with severe illness. (Category IB)

2A.1. Consider using external catheters as an
alternative to indwelling urethral catheters in
cooperative male patients without urinary
retention or bladder outlet obstruction.
(Category II)

2A.2. Intermittent catheterization is preferable to
indwelling urethral or suprapubic catheters in
patients with bladder emptying dysfunction.
(Category II)

2A.3. If intermittent catheterization is used,
perform it at regular intervals to prevent bladder
over-distension. (Category IB)

2A.4. For operative patients who have an
indication for an indwelling catheter, remove
the catheter as soon as possible postoperatively,
preferably within 24 hours, unless there are
appropriate indications for continued use.
(Category IB)
2A.5. Further research is needed on the risks and
benefits of suprapubic catheters as an
alternative to indwelling urethral catheters in
selected patients requiring short- or long-term
catheterization, particularly with respect to
complications related to catheter insertion or
the catheter site.
(No recommendation/unresolved issue)


2A.6. In the non-acute care setting, clean
(i.e., non-sterile) technique for intermittent
catheterization is an acceptable and more
practical alternative to sterile technique for
patients requiring chronic intermittent
catheterization. (Category IA)

2B.1. If the CAUTI rate is not decreasing after
implementing a comprehensive strategy to
reduce rates of CAUTI, consider using
antimicrobial/antiseptic-impregnated catheters.
The comprehensive strategy should include, at a
minimum, the high priority recommendations for
urinary catheter use, aseptic insertion, and
maintenance (Category IB)
2B.1.a. Further research is needed on the effect
of antimicrobial/antiseptic-impregnated
catheters in reducing the risk of symptomatic
UTI, their inclusion among the primary
interventions, and the patient populations most
likely to benefit from these catheters.
(No recommendation/unresolved issue)




2B.2. Hydrophilic catheters might be preferable to
standard catheters for patients requiring
intermittent catheterization. (Category II)
2B.3. Following aseptic insertion of the urinary
catheter, maintain a closed drainage system.
(Category IB)
2B.4. Complex urinary drainage systems (utilizing
mechanisms for reducing bacterial entry such as
antiseptic-release cartridges in the drain port) are
not necessary for routine use. (Category II)

2B.5. Urinary catheter systems with preconnected, sealed catheter-tubing junctions are
suggested for use. (Category II)
2B.6. Further research is needed to clarify the
benefit of catheter valves in reducing the risk of
CAUTI and other urinary complications.
(No recommendation/unresolved issue)



2C.1. Unless clinical indications exist (e.g., in
patients with bacteriuria upon catheter removal
post urologic surgery), do not use systemic
antimicrobials routinely as prophylaxis for UTI in
patients requiring either short or long-term
catheterization. (Category IB)
2C.2.a. Further research is needed on the use of
urinary antiseptics (e.g., methanamine) to prevent
UTI in patients requiring short-term
catheterization. (No recommendation/unresolved issue)



2C.2.b. Further research is needed on the use of
methanamine to prevent encrustation in patients
requiring chronic indwelling catheters who are at
high risk for obstruction. (No recommendation/unresolved issue)
2C.3.a. Unless obstruction is anticipated (e.g., as
might occur with bleeding after prostatic or
bladder surgery), bladder irrigation is not
recommended. (Category II)
2C.3.b. Routine irrigation of the bladder with
antimicrobials is not recommended. (Category II)

2C.4. Routine instillation of antiseptic or
antimicrobial solutions into urinary drainage
bags is not recommended. (Category II)

2C.5.a. Do not clean the periurethral area with
antiseptics to prevent CAUTI while the catheter is
in place. Routine hygiene (e.g., cleansing of the
meatal surface during daily bathing)


2C.5.b. Further research is needed on the use of
antiseptic solutions vs. sterile water or saline for
periurethral cleaning prior to catheter insertion.
(No recommendation/unresolved issue)
2C.6. Changing indwelling catheters or drainage
bags at routine, fixed intervals is not
recommended. Rather, catheters and drainage
bags should be changed based on clinical
indications such as infection, obstruction, or when
the closed system is compromised. (Category II)

2C.7.a. Use a sterile, single-use packet of lubricant
jelly for catheter insertion.(Category IB)

2C.7.b. Routine use of antiseptic lubricants is not
necessary. (Category II)

2C.8. Further research is needed on the use of
bacterial interference to prevent UTI in patients
requiring chronic urinary catheterization.
(No recommendation/unresolved issue)

2C.9. Further research is needed on optimal
cleaning and storage methods for catheters used
for clean intermittent catheterization. (No
recommendation/unresolved issue)

2C.10.a. Clamping indwelling catheters prior to
removal is not necessary. (Category II)
2C.10.b. Insert catheters only for appropriate
indications, and leave in place only as long as
needed. (Category IB)



2C.10.c. For operative patients who have an
indication for an indwelling catheter, remove the
catheter as soon as possible postoperatively,
preferably within 24 hours, unless there are
appropriate indications for continued use.
(Category IB)
2C.11.a. Consider using a portable ultrasound
device to assess urine volume in patients
undergoing intermittent catheterization to assess
urine volume and reduce unnecessary catheter
insertions. (Category II)
2C.11.b. Further research is needed on the use of
a portable ultrasound device to evaluate for
obstruction in patients with indwelling catheters
and low urine output.
(No recommendation/unresolved issue)



2D.1.a. Ensure that healthcare personnel and
others who take care of catheters are given
periodic in-service training stressing the correct
techniques and procedures for urinary catheter
insertion, maintenance, and removal. (Category IB)
2D.1.b. Implement quality improvement (QI)
programs or strategies to enhance appropriate
use of indwelling catheters and to reduce the risk
of CAUTI based on a facility risk assessment.
(Category IB)

2D.2. Routine screening of catheterized patients
for asymptomatic bacteriuria is not
recommended. (Category II)

2D.3. Perform hand hygiene immediately before
and after insertion or any manipulation of the
catheter site or device. (Category IB)

2D.5. Maintain unobstructed urine flow. (Category IB)

2D.6. Further research is needed on the benefit of spatial
separation of patients with urinary catheters to prevent
transmission of pathogens colonizing urinary drainage
systems. (No recommendation/unresolved issue)

2D.7. When performing surveillance for CAUTI, consider
providing regular (e.g., quarterly) feedback of unit-specific
CAUTI rates to nursing staff and other appropriate clinical
care staff. (Category II)

Urinary Tract Obstruction and Neurogenic Bladder

Urologic Study/Surgery

Urine monitoring in critically ill patients

Assistance in pressure ulcer management for
incontinent patients

Exception – Patient request to improve comfort

Incontinence

Immobility

Patient/Staff Convenience

Obtaining Periodic Urine Specimens
 Sterile gloves
 Sterile drapes
 Site cleaning supplies
 Sterile lubricant
 Sterile catheter attached to drainage bag (seal)

Hand Hygiene & Aseptic Technique






Avoid unnecessary urinary catheters; insert urinary
catheters in the presence of an appropriate indication
Peri-operative use for selected surgical procedures
Urine output monitoring in critically ill patients
Managing acute urinary retention and urinary
obstruction
Assisting with pressure ulcer healing for incontinent
patients
As an exception, at patient request to improve comfort


Maintain urinary catheters based on
recommended guidelines:
Tamper-evident seal is intact
 Collection bag is not on the floor
 Collection bag is secured to the leg
 Every patient with a catheter has a labeled urine
collection container at the bedside

Review urinary catheter necessity daily and
remove promptly

Risk of CAUTI is 5% per day catheter is in situ

Increases to 25% after 1 week in situ

Increases to 100% after 1 month in situ
Point Prevalence
=
# of patients with urinary catheters
------------------------------------------# of patients at a point in time
Nursing Care Unit
MICU`
Foley Catheters
Indwelling
Total Patients
Foley Catheter
Utilization Rate
10
5
50%
L&D
1
1
100%
NS72
12
1
8%
CTICU
4
2
50%
CCU
6
1
17%
PACU
2
2
100%
NS62
33
4
12%
NS61
34
2
6%
NS81
21
3
14%
CPCU
38
1
3%
161
22
14%
TOTAL
UNIT
CENSUS
# WITH DEVICE
PREVELANCE RATE
ED ADULT
ED PED
NS31
NS32
NS24
NS26
NS33
NS42
NS43
NS61
NS62
NS71/73
708
715
NS72
NS74
NS81
TOTAL
17
4
13
20
9
6
10
9
4
28
33
21
4
4
14
13
41
250
0
0
2
0
4
2
6
0
0
2
4
1
0
1
1
0
2
25
0
0
15.4%
0
44.4%
33.3%
60%
0
0
7.1%
12.1%
4.8%
0
25%
7.1%
0
4.9%
10%
Unit
Observation
s
% with
Securement
% Seal
Intact
% Below
level of
bladder
% Not touching floor
MSICU
5
60%
0%
100%
100%
L &D
1
100%
0%
100%
100%
NS72
1
0%
100%
100%
100%
CTICU
2
50%
50%
100%
100%
CCU
1
100%
0%
100%
100%
PACU
2
100%
0%
100%
100%
NS62
4
75%
50%
100%
100%
NS61
2
100%
100%
1005
100%
Ns81
3
67%
67%
100%
100%
CPCU
1
100%
100%
100%
100%
73%
41%
100%
100%
Overall 22
National Healthcare
Safety Network
(NHSN)
Healthcare – Associated Infection (HAI)
A localized or systemic condition resulting from an
adverse reaction to the presence of an infectious
agent(s) or its toxin(s) that:

Occur in a patient in a healthcare setting and

Was not present or incubating at the time of
admission, unless the infection was related to a
previous admission
Indwelling Catheter
A drainage tube that is inserted into the urinary
bladder through the urethra, is left connected to
a closed collection system.


Also called a Foley catheter
Does not include (among others):
 Straight in and out catheters
 Suprapubic catheters
 Nephrostomy tubes
A UTI in a patient who had an indwelling
urinary catheter is in place at the time of or
within 48 hours prior to infection onset.
NOTE: There
is no minimum period of time that
the catheter must be in place in order for the
UTI to be considered catheter-associated
Location
CAUTIs are attributed to inpatient location at
time of urine collection or symptom onset,
whichever comes first.
Exception: If a CAUTI develops within 48 hours
of transfer from one inpatient location to
another in the same facility or a new facility, the
infection is attributed to the transferring
location (Transfer Rule).
Transfer Rule:
Mr. Smith is transferred from SICU with a
Foley and 36 hours after transfer has a fever of
38.20C. The next day a urine culture collected
has >105 CFU/ml of E. coli.
This CAUTI is attributed to the SICU
There are two criteria than can be applied for
identifying a CAUTI
▪ Symptomatic UTI (SUTI)
▪ Asymptomatic Bacteremic UTI (ABUTI)
NOTE: The specific site “Other Urinary Tract Infection” (OUTI)
can also be used to identify an infection in the urinary tract,
however OUTI are not associated with urinary catheters and
therefore cannot be CAUTI events.
1a . Patient had an indwelling urinary catheter in
place at the time of specimen collection and at
least 2 of the following signs or symptoms with
no other recognized cause: fever (>380C),
suprapubic tenderness, or costovertebral angle
pain or tenderness and a positive urine culture
of ≥ 105 colony-forming units (CFU)/ml with no
more than 2 species of microorganisms.
---------------------OR-----------------------------------------Patient had indwelling urinary catheter removed
within 48 hours prior to specimen collection and at
least 1 of the following signs or symptoms with no other
recognized cause: fever (>380C), urgency, frequency,
dysuria, suprapubic tenderness, or costovertebral angle
pain or tenderness and a positive urine culture of ≥105
colony-forming units (CFU)/ml with no more than 2
species of microorganisms
2a. Patient had an indwelling urinary catheter in place at the time
of specimen collection and at least 2 of the following signs or
symptoms with no other recognized cause: fever (>380C),
suprapubic tenderness, or costovertebral angle pain or tenderness
and a positive urinalysis demonstrated by at least 1 of the
following findings:
a. Positive dipstick for leukocyte esterase and/or nitrite
b. Pyuria (urine specimen with ≥ 10 white blood [WBC]/mm3 of
unspun urine or ≥3 WBC/high power field of spun urine)
c. Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ≥103 and <105 CFU/ml with no more
than 2 species of microorganisms.
-------------------------------OR------------------------------------------Patient had indwelling urinary catheter removed within 48
hours prior to specimen collection and at least 1 of the following
signs or symptoms with no other recognized cause: fever (>380C),
urgency, frequency, dysuria, suprapubic tenderness, or
costovertebral angle pain or tenderness and a positive urinalysis
demonstrated at least 1 of the following findings:
a. Positive dipstick for leukocyte esterase and/or nitrite
b. Pyuria (urine specimen with ≥ 10 white blood [WBC]/mm3 of
unspun urine or ≥3 WBC/high power field of spun urine)
c. Microorganisms seen on Gram stain of unspun urine and a
positive urine culture of ≥103 and <105 CFU/ml with no more
than 2 species of microorganisms.
3.
Patient ≤ 1 year of age with or without an
indwelling urinary catheter has at least 1 of the
following signs or symptoms with no other
recognized cause: fever (>380C core),
hypothermia (<360C core), apnea, bradycardia,
dysuria, lethargy, or vomiting and a positive
urine culture of ≥ 105 CFU/ml with no more than
2 species of microorganisms.
4. Patient ≤ 1 year of age with or with an indwelling urinary catheter
has at least 1 of the following signs or symptoms with no other
recognized cause: fever (>380C core), hypothermia (<360C core),
apnea, bradycardia, dysuria, lethargy, or vomiting and a positive
urinalysis demonstrated by at least one of the following findings:
a. Positive dipstick for leukocyte esterase and/or nitrite
b. Pyuria (urine specimen with ≥ 10 white blood [WBC]/mm3 of
unspun urine or ≥3 WBC/high power field of spun urine)
c. Microorganisms seen on Gram stain of unspun urine and
a positive urine culture of ≥103 and <105 CFU/ml with no more than
2 species of microorganisms.
Patient with or without an indwelling urinary catheter with no
signs or symptoms (i.e., for any age patient, no fever (>380C ),
urgency, frequency, dysuria, suprapubic tenderness, or
costovertebral angle pain or tenderness, OR hypothermia
(<360C core), apnea, bradycardia, dysuria, lethargy, or
vomiting) and a positive urine culture of > 105 CFU/ml with
no more than 2 species of uropathogen microorganisms and
a positive blood culture with at least 1 matching uropathogen
microorganism to the urine culture, or at least 2 matching
blood cultures drawn on separate occasions if the matching
pathogen is a common skin contaminant.
Note: All ABUTIs will have a secondary bloodstream infection
Uropathogen microorganisms are: Gram-negative bacilli,
Staphylococcus spp., yeasts, beta hemolytic Streptococcus
spp., Enterococcus spp., G. Vaginalis, Aerococcus urinae, and
Corynebacterium (urease positive).
Report Corynebacterium (urease positive) as either
Corynebacterium species unspecified (COS) or as C.
urealyticum (CORUR) if so speciated.
The indwelling urinary catheter was in place within 48
hours prior to specimen collection (January 2012 Release)
Note: All ABUTIs will have a secondary
bloodstream infection

50 year old, end stage pancreatic cancer, liver & bone mets
admitted with advance directive for comfort care & antibiotics
only; foley catheter, peripheral IV & nasal cannula inserted

Day 4: patient is febrile to 38.0°C & has suprapubic tenderness; IV
ampicillin started after urine obtained for culture

Day 5: difficulty breathing; CXR = infiltrate L lung base

Day 6: urine culture results = 105 CFU/ml E coli

Day 7: WBC/mm3 = 3400; patchy infiltrates in both lung bases;
continued episodes of dyspnea; rales noted in LLL

Day 11: Patient expired

1.Yes. SUTI Criterion 1a.

2.Yes, SUTI Criterion 2a.

3.Yes, ABUTI.

4.No UTI.
–(fever 38°C not high enough for criteria)

POD 3: 66 y.o. patient in the ICU with a Foley catheter
s/p exploratory lap; patient noted to be febrile (38.9°)
and complained of diffuse abdominal pain

WBC increased to 19,000. He had cloudy, foul-smelling
urine and urinalysis showed 2+ protein, + nitrite, 2+
leukocyte esterase, WBC – TNTC, and 3+ bacteria.
Culture was 10,000 CFU/ml E. coli. The abdominal pain
seemed localized to surgical area

No UTI.

2.Yes, SUTI Criterion 1b.

3.Yes, SUTI Criterion 2a.

4.Yes, ABUTI.

84 year old patient is hospitalized with GI bleed

Day 3: Patient has indwelling catheter in place
and no signs or symptoms of infection

Day 9: Patient becomes unresponsive, is
intubated and CBC shows WBC of 15,000. Temp
38.0°C. Patient is pan-cultured. Blood culture
and urine both grow Streptococcus pyogenes –
urine >105 CFU/ml.

No. Because the blood seeded the urine and
therefore there is no UTI.

2.Yes, ABUTI.

3.Yes, SUTI Criterion 1a with secondary BSI.
ABUTI:

–No signs or symptoms (fever not > 38°C)

–Positive blood culture with at least 1
uropathogen matching to the urine culture
For any questions or inquires about NHSN
Criteria and Definitions:
Email: nhsn@cdc.gov
Website: www.cdc.gov/nhsn