Catheter-Associated Urinary Tract Infections in Adults: Diagnosis, Treatment, and Prevention

For all CAUTIs, an indwelling urinary catheter should be removed as soon as possible. If an indwelling urinary catheter remains necessary, but the existing catheter has been in place longer than two weeks, a new catheter should be placed before initiating antibiotic therapy¹⁴ to accelerate symptom resolution and reduce the likelihood of relapse or recurrence.³²

Urinary tract agents such as fosfomycin and nitrofurantoin are recommended as first-line agents for simple cystitis in women and can be used in patients with lower UTI and sufficient renal function to achieve adequate drug concentration in urine. Upper UTIs require antibiotics with good penetration into renal parenchyma such as ceftriaxone. If empiric antimicrobial therapy is needed before culture results are available, then previous urine culture results, local antibiograms, or practice guidelines can guide selection. Definitive antimicrobial therapy should be based on urine culture results. It is important to narrow empiric therapy¹⁴ to reduce risk of Clostridioides difficile infection and emergence of other resistant bacteria. Fluoroquinolones should be avoided for lower UTIs because of these risks and multiple United States Food and Drug Administration warnings.^38-40

The optimal duration of antimicrobial therapy for a CAUTI is unclear;¹⁴ however, most patients can be treated with a relatively short duration of therapy (≤7 days) if they respond promptly to therapy. Patients with a slow response to therapy may require 10-14 days of treatment.¹⁴ (Table 2 summarizes best practices for the treatment of CAUTI).

Since CAUTI is predicated on the presence of an indwelling urinary catheter, the simplest way to reduce CAUTI is to avoid placing or retaining unnecessary catheters. Some examples of appropriate indications⁹ for placement and maintenance of an indwelling urinary catheter are listed below:

1. Accurate measurement of urinary output in severely ill patients;

2. Improved comfort for patients receiving end-of-life care;

3. Acute urinary retention or bladder outlet obstruction;

4. Need for a period of prolonged immobilization (eg, potentially unstable lumbar or thoracic spine, or has multiple traumatic injuries);

5. Selected surgical procedures, such as urologic procedures and those that are expected to have a prolonged duration, require intraoperative monitoring of urine output, require the administration of either large volumes of intravenous infusions or diuretics;

6. To promote healing of open perineal or sacral wounds in patients with incontinence;

7. Neurogenic bladder; and

8. Hematuria with clots.

To increase the timely removal of urinary catheters that are no longer indicated, daily assessment of catheter necessity must be an integral part of clinicians’ workflow.^32,33 Alternatives, such as external catheters or intermittent catheterization, should be considered before indwelling urinary catheter placement since both options are associated with a reduced CAUTI risk.^41-44 Although indwelling urinary catheters can be seen as being more convenient for both patients and healthcare providers, many patients have expressed a preference for the use of intermittent catheterization compared with indwelling urinary catheterization.⁴³

For urinary retention, bladder scanning can noninvasively assess the amount of residual urine in a patient’s bladder and can avoid unnecessary insertion of an indwelling urinary catheter. However, if indwelling urinary catheters are ultimately needed, they must be inserted and maintained appropriately. Of note, the use of antibiotic-impregnated catheters has not been shown to reduce CAUTI rates significantly.⁴⁵

CAUTI prevention requires a multidisciplinary collaborative approach. Nurse-driven protocols and checklists to remove indwelling urinary catheters that are no longer indicated can be very effective.^46,47 Automatic stop orders and catheter removal reminders are useful for reducing the duration of catheter placement.^26,48 Both of these approaches require appropriate, consistent documentation with input from bedside nurses, physicians, advanced practice providers, and information technology. (Table 3 summarizes best practices for the prevention of CAUTI).

Importantly, CAUTI prevention supports broader antimicrobial stewardship. Over 55% of inpatients receive at least one dose of an antibiotic during their hospital stay.^48,49 In 2015, the White House released the National Action Plan for Combating Antibiotic-Resistant Bacteria with the goals of slowing the emergence of resistant bacteria, preventing the spread of antibiotic-resistant infections, and setting a target of a 20% reduction in the inappropriate use of antibiotics for hospitalized patients.⁵⁰ Hospitalists care for a substantial number of inpatients and, in turn, can drive actions to decrease CAUTIs, and promote stewardship efforts. Through actions to decrease CAUTIs, hospitalists can promote these stewardship efforts.