Urinary Tract Infections and
Catheter-Associated Urinary Tract Infections
A urinary tract infection (UTI) is an infection of the bladder, kidneys, ureters, or urethra that occurs when bacteria enter the urinary system. As a result of the infection, a person’s urine, which is normally sterile, will contain bacteria. This type of infection occurs more often in females versus males, due to the anatomy of the bladder and urethra.
A urinary catheter is a thin tube placed in the bladder to drain urine. Urine drains through the tube into a bag that collects the urine. Catheter-associated urinary tract infections (CAUTIs) are infections caused by bacteria that have entered the urinary tract during the catheter's insertion, through the catheter tube, or through the catheter’s external surface.
Common symptoms of UTIs may include burning during urination, burning and pain in the lower abdomen, fever, and cloudy or bloody urine. In some cases, a person may have a CAUTI and not experience any symptoms.
Some patients may be at higher risk for developing a UTI due to older age, poor hygiene, or poor hydration (not drinking enough fluids). Female sex, older age, method of catheterization, duration of catheterization, and quality of catheter care are risk factors for CAUTI. (citation) It is important that both the patient and the healthcare providers take the appropriate steps to help prevent an infection.
Estimated burden of CAUTIs in healthcare facilities in the United States:
- UTIs are the fourth most common type of HAI in the United States (citation)
- 13% of HAIs reported, comprising an estimated 93,300 infections annually.
- Approximately two-thirds (68%) of UTIs in acute care hospital settings are estimated to be catheter-associated.
- According to the latest CDC National and State HAI Progress Report, in 2013, acute care hospitals experienced a 6% increase in catheter-associated urinary tract infections compared to 2009.
- Virginia hospitals experienced a 5% increase in catheter-associated urinary tract infections between 2009 and 2013.
- CAUTIs lead to longer length of hospital stay.
- CAUTI is the leading cause of secondary bloodstream infection.
- Using antibiotics to treat UTIs without symptoms contributes to antibiotic resistance and can lead to the development of Clostridium difficile infection
- Urinary catheters and UTIs
- An estimated 15-25% of hospitalized patients will have a urinary catheter at some time during their hospital stay. (citation)
- Catheter use is less common in long-term care facilities (~5%). (citation)
- Studies have found a strong correlation between catheter use greater than six days and the development of a CAUTI. (citation)
- An estimated 13,000 deaths (mortality rate 2.3%) are attributed to UTIs annually in the United States. (citation)
- The mortality rate increases to approximately 10% when the patient also has a secondary bacteremia (bloodstream infection as a result of the UTI). (citation)
- Costs (citation)
- Estimated cost per infection ranges from $750-$1,000
- Estimated total cost in the United States ranges from $340 million - $450 million annually
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In January 2012, the Centers for Medicare and Medicaid Services (CMS) began requiring acute care hospitals participating in their Hospital Inpatient Quality Reporting Program to report CAUTIs in adult and pediatric intensive (critical) care units. In January 2015, CMS began requiring acute care hospitals to report CAUTIs in adult and pediatric medical, surgical, and medical/surgical inpatient wards. Critical care data are currently available and inpatient ward data will soon be available to the public on Hospital Compare.
In September 2015, the VDH reporting regulations were updated to align state reporting requirements with the CMS Hospital Inpatient Quality Reporting Program. Under the new regulations, hospitals are reporting CAUTI data to VDH through the National Healthcare Safety Network (NHSN) for adult, pediatric, and neonatal critical care units and adult and pediatric medical, surgical, and medical/surgical inpatient wards. For more information on these data and the state regulation mandating their reporting, please see Public Reporting page.
Other CMS quality reporting programs require CAUTI reporting from long-term acute care hospitals (adult and pediatric critical care units and ward locations – October 2012 to present) and inpatient rehabilitation facilities (adult and pediatric wards – October 2012 to present).
VDH HAI Program activities to address CAUTIs and UTIs:
- UTI prevention collaborative (June 2011 – November 2011): Twelve nursing homes in the Eastern region participated in this project that focused on sharing strategies for effective prevention, treatment, and surveillance of UTIs and CAUTIs. Implemented by VDH in partnership with the Virginia Health Care Association (VHCA). Piloted surveillance using a form developed by VDH and the collaborative participants. Gerontology and infectious disease experts from the Eastern Virginia Medical School (EVMS) engaged to provide education to collaborative facility staff and local physicians.
- March 21, 2012: How to Use the Successful Strategies for the Prevention of Urinary Tract Infections in Long-Term Care Toolkit (webinar slides)
- In this one-hour webinar, Carol Jamerson (Nurse Epidemiologist, VDH) provided an overview of each of the documents in the UTI toolkit and how they may be used in long-term care facilities. Adriana Agnew (Director of Quality Management/Infection Preventionist, Fairfax Nursing Center) described how her facility has used and plans to use the tools to enhance current policies and practices.
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Prevention Strategies for Healthcare Providers
To prevent CAUTIs, doctors, nurses, and other healthcare providers should follow CDC infection prevention guidelines including:
- Insert catheters only for appropriate indications.
- Remove the catheter as soon as it is no longer needed. The sooner a catheter is removed, the less likely the chance of infection.
- Ensure that only properly trained persons insert and maintain catheters.
- Insert catheters using aseptic technique and sterile equipment (acute care setting).
- Properly secure catheters after insertion to prevent movement.
- Following aseptic insertion, maintain a closed drainage system.
- Maintain unobstructed urine flow.
- Keep catheter and collecting tube free from kinking.
- Keep collecting bag below level of bladder at all times.
- Empty collecting bag regularly using a separate, clean container for each patient.
- Comply with CDC hand hygiene recommendations and Standard Precautions
Diagnosis, Prevention, and Treatment of Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America
Guideline for Prevention of Catheter-Associated Urinary Tract Infections, 2009
SHEA/IDSA Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals - CAUTI
CDC CAUTI toolkit – contains background on epidemiology of CAUTIs as well as core and supplemental prevention strategies
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Tools and Resources
APIC Guide to the Elimination of Catheter-Associated Urinary Tract Infections, 2008
– Developing and Applying Facility-Based Prevention Interventions in Acute and Long-Term Care Settings
CAUTI FAQ (CDC website)
CAUTI Prevention in Critically Ill Patients (APIC infographic)
Comprehensive Unit-Based Safety Program (CUSP) – safety project designed to improve safety culture and reduce CAUTIs in participating hospitals.
Guide to Patient Safety (GPS) Tool – self-assessment tool to help facilities guide their approach to CAUTI prevention. Designed for use by hospitals that have already initiated some CAUTI prevention activities but are not achieving their desired success.
Infectious Diseases Society of America Guidelines for the Diagnosis and Treatment of Asymptomatic Bacteriuria in the Adult
NHSN Device-Associated Module – protocol and instructions, training, and forms” with “NHSN CAUTI protocol, training, forms, analysis resources, and support materials – click on the appropriate healthcare setting and select the CAUTI link (or urinary tract infections, if a long-term care facility) to access the materials
SHEA Patient Education Guide (CAUTI) – fact sheet that educates patients and their families about 7 types of HAIs (including CAUTIs) and how to work with healthcare professionals to prevent them.
Targeted Assessment for Prevention (TAP) CAUTI Toolkit Implementation Resources (CDC) – Links to resources in multiple domains to aid hospitals in implementing the TAP Strategy
- Assisted living facilities and nursing homes
For more patient resources, please see the Consumer and Public Information or go to the CDC CAUTI website.
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Successful Strategies for the Prevention of Urinary Tract Infections in Long-Term Care TOOLKIT (Fall 2011)
This urinary tract infections (UTI) toolkit contains infection prevention presentations, resources, and tools that have been adapted for long-term care facilities (LTCFs). The toolkit was developed as a result of a collaborative effort between 12 nursing homes in the Eastern region of Virginia, the Virginia Department of Health (VDH) Healthcare-Associated Infections (HAI) Program, and the Virginia Health Care Association (VHCA) to impart best practices in the prevention of UTIs within the long-term care (LTC) population.
These documents have been developed from published literature reviews, evidence-based research, standards of practice, or recommendations obtained from the Centers for Disease Control and Prevention (CDC), Healthcare Infection Control Practices Advisory Committee (HICPAC), Centers for Medicare and Medicaid Services (CMS), licensing agencies, professional organizations, or other recognized sources. Materials and information from other organizations in this toolkit that use hospital-centered language also apply to LTC settings.
UTIs are very common in residents in long-term care facilities and consequently result in a significant amount of antimicrobial use within the resident population. It is our hope that the toolkit will be used to support best practices for the prevention of urinary tract infections and promote strategies to improve resident care including the judicious use of antimicrobials.
The toolkit is meant to introduce and summarize guidelines and best practices, and does not replace published standards and regulations. Refer to the toolkit component, “UTI Prevention Resources and References”, to help access the official guidelines and regulations and contact the VDH HAI Program with questions.
We would appreciate any feedback on the materials including which resources are most helpful and which have areas for improvement. Please check our website periodically for updates on toolkit materials.
Download the entire toolkit. Individual toolkit components can be downloaded below.
Centers for Medicare & Medicaid Services (CMS) Regulatory Guidance
UTI Prevention Policy Templates
Resources Addressing Antibiotic Use in Long-Term Care Settings
UTI Panel of Experts: Presentations
* Note: To download audio files, Right-click, Save Target As/Save Link As
UTI Prevention Resources and References
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Warren JW. Catheter-associated urinary tract infections. Int J Antimicrob Agents. 2001;17(4):299-303; Weinstein JW, Mazon D, Pantelick E, Reagan-Cirincione P, Dembry LM, Hierholzer WJ,Jr. A decade of prevalence surveys in a tertiary-care center: Trends in nosocomial infection rates, device utilization, and patient acuity. Infect Control Hosp Epidemiol. 1999;20(8):543-548.
Rogers MA, Mody L, Kaufman SR, Fries BE, McMahon LF,Jr, Saint S. Use of urinary collection devices in skilled nursing facilities in five states. J Am Geriatr Soc. 2008;56(5):854-861.
Maki PG and Tambyah PA. Engineering Out the Risk of Infection with Urinary Catheters. Emerg Infect Dis 2001; 7 (2), 178-183.
Weinstein MP, Towns ML, Quartey SM, et al. The clinical significance of positive blood cultures in the 1990s: A prospective comprehensive evaluation of the microbiology, epidemiology, and outcome of bacteremia and fungemia in adults. Clin Infect Dis. 1997;24(4):584-602.