Guideline sources The following summarized guidelines for the evaluation and management of catheter-associated urinary tract infection (CA-UTI) are prepared by our editorial team based on guidelines from the European Association of Urology (EAU 2022), the Spanish Society of Clinical Microbiology and Infectious Diseases (SEIMC 2017), and the Infectious Diseases Society of America (IDSA 2010). 1 2 3 4 4 5 5 6 Definition CA-UTI is a common hospital-acquired infection characterized by various medical complications such as catheter encrustation, bladder stones, septicemia, endotoxic shock, and pyelonephritis. 4 Epidemiology Colonization of the urinary catheter and/or uroepithelial cells, evasion of host defenses, replication, and damage to host cells by uropathogens are involved in the development of CA-UTI. Common microbiological agents include E. coli, P. mirabilis, P. aeruginosa, S. aureus, S. epidermidis, K. pneumoniae, P. vulgaris, C. freundii, Providentia rettgeri, and C. albicans. 4 5 Disease course https://web.pathway.md/diseases/recTmo3LUw5Ng0Y4Q 1/8 6/29/23, 3:45 AM Catheter-associated urinary tract infection Pathway Clinical manifestations include fever, urethritis, cystitis, acute pyelonephritis, renal scarring, calculus formation, and bacteremia. Disease progression may lead to urosepsis and death. 5 Prognosis and risk of recurrence Several studies report an association between catheter-associated infection, increased mortality, and prolonged length of stay in acute care facilities. 6 Guidelines 1. Screening and diagnosis Diagnostic criteria: As per SEIMC 2017 guidelines: Diagnose catheter-associated UTI in patients: with indwelling urethral, indwelling suprapubic, or intermittent catheterization symptomatic UTI growth of 10 CFU/mL of a bacterial species in a single catheter urine specimen or a midstream voided urine specimen from a patient whose urethral, suprapubic, or condom catheter has been removed within the previous 48 hours. B View any number of bacteria in bladder urine obtained by suprapubic aspiration as significant. B As per IDSA 2010 guidelines, diagnose catheter-associated UTI in patients with: an indwelling urethral or suprapubic catheter, or intermittent catheterization presence of symptoms or signs compatible with UTI with no other identified focus of infection growth of 10 CFU/mL of 1 bacterial species in a single catheter urine specimen or in a midstream voided urine specimen from a patient whose urethral, suprapubic, or condom catheter has been removed within the previous 48 hours. B Microbiological etiologies: Recognize that: UTI in patients with short-term catheterization is usually monomicrobial and frequently caused by Enterobacteriaceae UTI in patients with long-term catheterization is usually polymicrobial and frequently caused by antimicrobial-resistant bacteria. B 2. Diagnostic investigations Clinical history: As per EAU 2022 guidelines, do not use the presence or absence of odorous or cloudy urine alone to differentiate catheter-associated asymptomatic bacteriuria from catheter-associated UTI. D https://web.pathway.md/diseases/recTmo3LUw5Ng0Y4Q 2/8 6/29/23, 3:45 AM Catheter-associated urinary tract infection Pathway As per SEIMC 2017 guidelines, recognize that signs and symptoms compatible with catheter- associated UTI include fever, rigors, altered mental state or malaise with no other identifiable cause, as well as focal signs in the urinary tract, such as flank or pelvic pain, costovertebral angle tenderness, and acute hematuria. B Show 5 more As per IDSA 2010 guidelines, recognize that signs and symptoms compatible with catheter- associated UTI include new onset or worsening of fever, rigors, altered mental status, malaise, or lethargy with no other identified cause; flank pain; costovertebral angle tenderness; acute hematuria; pelvic discomfort; and in cases where catheters have been removed, dysuria, urgent or frequent urination, or suprapubic pain or tenderness. B Show 2 more Urinalysis: As per EAU 2022 guidelines, do not use pyuria as a sole indicator for catheter-associated UTI. D As per IDSA 2010 guidelines, do not interpret pyuria as diagnostic of catheter-associated asymptomatic UTI or asymptomatic bacteriuria. D Show 3 more Gram stain: consider obtaining urine Gram stain to guide empiric antibiotic therapy in catheterized patients with severe UTI. C Urine culture: As per EAU 2022 guidelines: Do not obtain routine urine culture in asymptomatic catheterized patients. D Obtain urine culture before initiating antimicrobial therapy in catheterized patients, if the catheter has been removed. A As per SEIMC 2017 guidelines: Remove the catheter before obtaining urine for culture if the indwelling catheter has been in place for > 2 weeks. B Obtain a urine culture in patients with indwelling catheters residing in long-term care facilities in the presence of fever, costovertebral angle tenderness, rigors, or new-onset delirium with no other obvious source. B As per IDSA 2010 guidelines, obtain a urine culture before initiating antimicrobial therapy for presumed catheter-associated UTI, given the wide spectrum of potential infecting organisms and the increased likelihood of antimicrobial resistance. B Show 2 more 3. Medical management General principles: Treat symptomatic catheter-associated UTIs according to the recommendations for complicated UTIs. A https://web.pathway.md/diseases/recTmo3LUw5Ng0Y4Q 3/8 6/29/23, 3:45 AM Catheter-associated urinary tract infection Pathway Manage any urological abnormality and/or underlying complicating factors. A Antibiotic therapy: As per EAU 2022 guidelines, administer any of the following regimens as empirical therapy in patients with complicated pyelonephritis with systemic symptoms: amoxicillin and an aminoglycoside second-generation cephalosporin and an aminoglycoside IV third-generation cephalosporin. A Show 2 more As per SEIMC 2017 guidelines: Initiate antimicrobial therapy in patients with symptomatic infection or clinical signs of sepsis. B Administer parenteral broad-spectrum antibiotics adapted to the local resistance patterns of uropathogens in patients with symptomatic UTI and criteria for severe sepsis. B Duration of antibiotics: As per SEIMC 2017 guidelines, complete 7 days of antimicrobial therapy in patients with catheter-associated UTI with prompt resolution of symptoms, and in patients with cystitis following urinary catheterization. B Show 3 more As per IDSA 2010 guidelines, complete 7 days of antimicrobial therapy in patients with catheter- associated UTI exhibiting prompt resolution of symptoms. B Show 3 more 4. Therapeutic procedures Catheter removal: As per EAU 2022 guidelines, replace or remove the indwelling catheter before starting antimicrobial therapy. A As per IDSA 2010 guidelines: Replace indwelling catheters that have been in place for > 2 weeks at the onset of catheter- associated UTI, to hasten resolution of symptoms and to reduce the risk of subsequent catheter-associated asymptomatic bacteriuria and catheter-associated UTI. A Remove the indwelling catheter if its use can be discontinued. A 5. Specific circumstances Patients with asymptomatic bacteriuria: As per EAU 2022 guidelines: Do not treat catheter-associated asymptomatic bacteriuria in general. D https://web.pathway.md/diseases/recTmo3LUw5Ng0Y4Q 4/8 6/29/23, 3:45 AM Catheter-associated urinary tract infection Pathway Treat catheter-associated asymptomatic bacteriuria before traumatic urinary tract interventions, such as TURP. A As per IDSA 2010 guidelines, do not screen for catheter-associated asymptomatic bacteriuria except in research studies evaluating interventions designed to reduce the incidence of catheter-associated asymptomatic bacteriuria or catheter-associated UTI and in selected clinical situations, such as pregnant patients and patients undergoing urologic procedures for which visible mucosal bleeding is anticipated. D Show 6 more Patients with urosepsis: use the qSOFA score to identify patients with potential sepsis. A Show 5 more 6. Preventative measures Minimization of catheter use: As per EAU 2022 guidelines, keep the catheterization duration as short as possible. A As per SEIMC 2017 guidelines: Place indwelling catheters only when indicated. B Remove indwelling catheters as soon as they are no longer required, in order to reduce the risk of catheter-associated asymptomatic bacteriuria A and catheter-associated UTI. B As per IDSA 2010 guidelines, place indwelling catheters only when indicated. B Show 2 more Alternatives to indwelling catheters: As per SEIMC 2017 guidelines, consider offering appropriate alternatives to short-term urethral catheterization for reducing catheter-associated asymptomatic bacteriuria, such as condom catheterization B intermittent catheterization B , and suprapubic catheterization. B Show 2 more As per IDSA 2010 guidelines, consider offering condom catheterization, if urinary catheterization is indicated, as an alternative to short-term B and long-term indwelling catheterization to reduce catheter-associated asymptomatic bacteriuria in cognitively non-impaired male patients with minimal postvoid residual urine. C Show 4 more Catheter insertion technique: As per SEIMC 2017 guidelines, insert indwelling catheters using aseptic techniques and sterile equipment. B As per IDSA 2010 guidelines, use aseptic techniques and sterile equipment for the insertion of indwelling catheters. B Show 4 more Closed catheter systems: https://web.pathway.md/diseases/recTmo3LUw5Ng0Y4Q 5/8 6/29/23, 3:45 AM Catheter-associated urinary tract infection Pathway As per SEIMC 2017 guidelines, maintain a closed catheter drainage system in patients with short-term or long-term catheters to reduce catheter-associated asymptomatic bacteriuria B and catheter-associate UTI. B As per IDSA 2010 guidelines, maintain a closed catheter drainage system, with ports in the distal catheter for needle aspiration of urine, to reduce catheter-associated asymptomatic bacteriuria (A-II) and catheter-associated UTI in patients with short-term indwelling urethral or suprapubic catheters and to reduce catheter-associated asymptomatic bacteriuria and catheter- associated UTI in patients with long-term indwelling urethral or suprapubic catheters. B Show 3 more Antimicrobial-coated catheters: As per EAU 2022 guidelines, use hydrophilic-coated catheters to reduce catheter-associated UTIs. A As per SEIMC 2017 guidelines, consider using antimicrobial (antibiotic or silver alloy)-coated urinary catheters to reduce or delay the onset of catheter-associated-asymptomatic bacteriuria in patients undergoing short-term catheterization. C As per IDSA 2010 guidelines, consider using antimicrobial-coated urinary catheters, such as silver alloy- or antibiotic-coated catheters, in patients with short-term indwelling urethral catheterization, to reduce or delay the onset of catheter-associated bacteriuria. C Insufficient evidence to support whether the use of such catheters reduces catheter-associated asymptomatic bacteriuria or catheter-associated UTI in patients with long-term catheterization. Routine catheter change: insufficient evidence to support whether routine catheter change reduces the risk of catheter-associated asymptomatic bacteriuria or catheter-associated UTI in patients with functional long-term indwelling urethral or suprapubic catheters, even in patients experiencing repeated early catheter blockage from encrustation. I Catheter irrigation technique: do not perform catheter irrigation with antimicrobials routinely to reduce or eradicate catheter-associated asymptomatic bacteriuria D or catheter-associated UTI in patients with indwelling catheters. D Show 2 more Meatal care: Do not offer daily meatal cleansing with povidone-iodine solution, silver sulfadiazine, polyantibiotic ointment or cream, or green soap and water to reduce catheter-associated asymptomatic bacteriuria in patients with indwelling urethral catheters. D Insufficient to support whether meatal cleansing reduces the risk of catheter-associated UTI. Antibiotic prophylaxis with catheter placement/removal: As per SEIMC 2017 guidelines, do not administer systemic antibiotic prophylaxis during catheter replacement since the risk of symptomatic bacteremia is low, D but consider administering it in cases of traumatic replacement associated with hematuria. D As per IDSA 2010 guidelines, do not administer prophylactic antimicrobials routinely, given systemically or by bladder irrigation, in patients at the time of catheter placement to reduce https://web.pathway.md/diseases/recTmo3LUw5Ng0Y4Q 6/8 6/29/23, 3:45 AM Catheter-associated urinary tract infection Pathway catheter-associated UTI D or at the time of catheter removal D or replacement to reduce catheter-associated asymptomatic bacteriuria. D Systemic antibiotic prophylaxis: As per EAU 2022 guidelines: Do not administer antimicrobial prophylaxis to prevent catheter-associated UTIs. D Do not administer antimicrobial prophylaxis routinely to prevent clinical UTI after urethral catheter removal or in patients performing intermittent self-catheterization. D As per IDSA 2010 guidelines, do not administer systemic antimicrobial prophylaxis routinely to reduce catheter-associated asymptomatic bacteriuria or catheter-associated UTI in patients with short-term D or long-term catheterization, including patients undergoing surgical procedures. D Topical antimicrobial prophylaxis: do not apply topical antiseptics or antimicrobials to the catheter, urethra, or meatus. D Drainage bag antimicrobials: do not administer antimicrobials or antiseptics to the drainage bag of catheterized patients to reduce catheter-associated asymptomatic bacteriuria or catheter- associated UTI. D Methenamine salt prophylaxis: do not use methenamine salts routinely to reduce catheter- associated asymptomatic bacteriuria or catheter-associated UTI in patients with long-term intermittent D or long-term indwelling urethral or suprapubic catheterization D Show 3 more Cranberry products: do not use cranberry products routinely to reduce catheter-associated asymptomatic bacteriuria or catheter-associated UTI in patients with neurogenic bladder managed with intermittent or indwelling catheterization. D Insufficient evidence to support the use of cranberry products to reduce catheter-associated asymptomatic bacteriuria or catheter-associated UTI in other groups of catheterized patients, including patients using condom catheters. 7. Quality improvement Infection prevention: ensure that hospitals and long-term care facilities develop, maintain, and promulgate policies and procedures for recommended catheter insertion indications, insertion and maintenance techniques, discontinuation strategies, and replacement indications, and include education and training of their staff relevant to these policies and procedures. B Show 7 more References 1. G. Bonkat, R. Bartoletti, F. Bruy re et al. EAU Guidelines on Urological Infections. EAU. 2022. Open 2. de Cueto M, Aliaga L, Al s JI et al. Executive summary of the diagnosis and treatment of urinary tract infection: Guidelines of the Spanish Society of Clinical Microbiology and Infectious Diseases SEIMC . Enferm Infecc Microbiol Clin. 2017 May;35 5 314 320. Open https://web.pathway.md/diseases/recTmo3LUw5Ng0Y4Q 7/8 6/29/23, 3:45 AM Catheter-associated urinary tract infection Pathway 3. Hooton TM, Bradley SF, Cardenas DD et al. 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. Open 4. Yvonne J Cortese, Victoria E Wagner, Morgan Tierney et al. Review of Catheter-Associated Urinary Tract Infections and In Vitro Urinary Tract Models. J Healthc Eng. 2018 Oct 14;2018 2986742.2018 Oct 14;2018 2986742. Open 5. S M Jacobsen, D J Stickler, H L T Mobley et al. Complicated catheter-associated urinary tract infections due to Escherichia coli and Proteus mirabilis. Clin Microbiol Rev. 2008 Jan;21 1 26 59.2008 Jan;21 1 26 59. Open 6. Lindsay E Nicolle. Catheter associated urinary tract infections. Antimicrob Resist Infect Control. 2014 Jul 25;3 23.2014 Jul 25;3 23. Open 7. American Academy of Neurology. Choosing Wisely AAN recommendations. Choosing Wisely. 2018. Open 8. Yvonne J. Cortese, Victoria E. Wagner, Morgan Tierney et al. Review of Catheter-Associated Urinary Tract Infections and In Vitro Urinary Tract Models. J Healthc Eng. 2018; 2018 2986742. Open 9. Anggreiny Anggi, Dadik Wahyudi Wijaya, and Oke Rina Ramayani. Risk Factors for Catheter-Associated Urinary Tract Infection and Uropathogen Bacterial Profile in the Intensive Care Unit in Hospitals in Medan, Indonesia. Open Access Maced J Med Sci. 2019 Oct 30; 7 20 3488 3492. Open 10. S. M. Jacobsen, D. J. Stickler, H. L. T. Mobley et al. Complicated Catheter-Associated Urinary Tract Infections Due to Escherichia coli and Proteus mirabilis. Clin Microbiol Rev. 2008 Jan; 21 1 26 59. Open 11. Aina Gomila, Jordi Carratal , Noa Eliakim-Raz et al. Clinical outcomes of hospitalised patients with catheter-associated urinary tract infection in countries with a high rate of multidrug-resistance: the COMBACTE MAGNET RESCUING study. Antimicrob Resist Infect Control. 2019; 8 198. Open https://web.pathway.md/diseases/recTmo3LUw5Ng0Y4Q 8/8