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Catheter-Associated Urinary Tract Infections in Intensive Care Unit Patients

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Catheter-Associated Urinary Tract Infections in Intensive Care Unit

Patients

Rudy Tedja, Jean Wentink, John C O’Horo, Rodney Thompson and Priya Sampathkumar

Infection Control & Hospital Epidemiology / FirstView Article / July 2015, pp 1 - 5

DOI: 10.1017/ice.2015.172, Published online: 20 July 2015

Link to this article: http://journals.cambridge.org/abstract_S0899823X15001725

How to cite this article:

Rudy Tedja, Jean Wentink, John C O’Horo, Rodney Thompson and Priya Sampathkumar Catheter-Associated Urinary Tract
Infections in Intensive Care Unit Patients. Infection Control & Hospital Epidemiology, Available on CJO 2015 doi:10.1017/
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 infection control & hospital epidemiology

original article

Catheter-Associated Urinary Tract Infections in Intensive

Care Unit Patients

Rudy Tedja, DO;1 Jean Wentink, RN, MPH;3 John C O’Horo, MD;2 Rodney Thompson, MD;2,3 Priya Sampathkumar, MD2,3

objective. To delineate the epidemiology of catheter-associated urinary tract infections (CAUTIs) and to better understand the value of
urine cultures for evaluation of fever in the intensive care unit (ICU) setting
design. Two-year retrospective review (2012–2013)
setting. A single tertiary center with 1,200 hospital beds and 158 adult ICU beds
patients. ICU patients with a CAUTI event
methods. The cohort was identified from a prospective infection prevention database. Charts were reviewed to characterize the patients.
CAUTI rates and device utilization ratio (DUR) were calculated. Clinical outcomes were recorded.
results. A total of 105 CAUTIs were identified using the National Health and Safety Network (NHSN) definition. Fever was the primary
indication for obtaining urine culture in 102 patients (97%). Of these 105 patients, 51 (51%) had an alternative infection to explain the fever,
with pneumonia (55%) being the most common followed by bloodstream infection (22%). A total of 18 patients (18%) had fever due to
noninfectious cause, and 32 patients (32%) had no alternative explanation. Of these, 66% received appropriate empiric antimicrobial therapy,
but no targeted therapy changes were made based on urine culture results. The other 34% did not receive antimicrobial therapy at all. Only 6%
of all CAUTIs resulted in blood cultures positive for the same organism within 2 days. The urinary tract was not definitely established as the
source of bloodstream infection.
conclusions. Urine cultures obtained for evaluation of fever form the basis for identification of CAUTIs in the ICU. However, most
patients with CAUTIs are eventually found to have alternative explanations for fever. CAUTI is associated with a low complication rate.
Infect Control Hosp Epidemiol 2 0 15 ;0 0 (0 ): 1– 5

Indwelling urinary catheters are frequently used in critically ill
patients. Approximately 66% of patients in intensive care have
urinary catheters in place.1 Almost 50% of all ICU patients
have a fever during their ICU stay.2 Presence of an indwelling
urinary catheter, fever, and bacteriuria together satisfy the
National Healthcare Safety Network (NHSN) surveillance
definition of catheter-associated urinary tract infection
(CAUTI), which is used by participating hospitals nationwide
to report CAUTI to the NHSN program. CAUTI rates are
available to the public and are considered an indicator
of hospital quality. Institutions with high CAUTI rates may
incur revenue reductions through pay-for-performance
programs such as value-based purchasing and healthcare-
associated conditions programs. The 2015 CDC healthcare-
associated infection (HAI) progress report based on NHSN
data indicates that CAUTI is the only monitored HAI that has
increased during the 2010–2013 time period. This finding
has led to an increased commitment to reduction initiatives
nationwide.
CAUTI reduction, however, is challenging and outcomes
have been inconsistent. The lack of specificity of the NHSN
definition, particularly in critically ill patients, has been a
major limitation. In addition, the surveillance definition does
not always reflect the clinical practices of intensivists or
infectious disease consultants.3 Here, we sought to delineate
the epidemiology of CAUTIs to better understand the value of
obtaining urine cultures during fever in the ICU setting.
methods
Mayo Clinic is a 1,200-bed hospital with 158 adult intensive
care beds. CAUTIs identified using the 2012 and 2013 NHSN
surveillance definition form the basis for our cohort.4,5

Affiliations: 1. Division of Critical Care Medicine, Mayo Clinic, Rochester, Minnesota; 2. Division of Infectious Disease, Mayo Clinic, Rochester, Minnesota;
3. Infection Prevention and Control, Mayo Clinic, Rochester, Minnesota.
Received March 30, 2015; accepted June 24, 2015
© 2015 by The Society for Healthcare Epidemiology of America. All rights reserved. DOI: 10.1017/ice.2015.172
2 infection control & hospital epidemiology

The most commonly applied NHSN definition required an methods and performed analysis with JMP 10 software (SAS
indwelling urinary catheter in place for >2 calendar days, a Institute, Cary, NC).
positive urine culture with ≤2 species of microorganisms,
and at ≥1 of the clinical signs or symptoms (fever >38°C,
suprapubic tenderness, or costovertebral angle pain or
resul ts
tenderness).4,5 Our study cohort was comprised of all patients A total of 105 ICU CAUTIs were identified in 6 adult ICUs in
with CAUTI attributed to ICU stay between January 1, 2012, 2012 and 2013, for a CAUTI rate of 2.5 per 1,000 catheter days.
and December 31, 2013. We performed chart reviews to The observation period included 42,461 catheter days and
abstract information on urinary catheters, indications for 72,799 patient days for a device utilization ratio (DUR) of 0.58.
urine culture, symptoms, antimicrobial therapy, and patient A total of 5,243 urine cultures were performed on catheterized
outcomes. When fever was the primary indication for urine urine specimens in this cohort (72 urine cultures per 1,000
culture, we performed a chart review to ascertain the cause of patient days, 194 urine cultures per 1,000 ICU admissions).
fever. Fever evaluation varied according to the complexity of Descriptive characteristics of the cohort can be found in
each case. It included history and physical exam, laboratory Table 1a. CAUTI rates and DUR by ICU type are reported in
tests, blood, urine and, lower respiratory tract cultures, Table 1b. The most common organisms identified by urine
and in some patients, lumbar puncture or imaging studies. culture were yeast (50%), E. coli (18%), Enterococcus spp.
Patients were followed until death or discharge from the (12%), and Pseudomonas spp. (6%) (Table 2). The primary
hospital. The primary outcomes were hospital mortality, indication for urine culture was fever (102 of 105 patients,
hospital and ICU length of stay, and bloodstream infection as a 97%). In the majority of patients, a possible alternative
result of CAUTI. We used standard descriptive statistical explanation of fever was identified. Infection other than
CAUTI was found in 51 of 102 patients (51%), which included
pneumonia (n = 28, 55%), followed by bloodstream infection
table 1a. Baseline Demographics for 105 ICU Patients with a (n = 11, 22%). The diagnosis of pneumonia was made on
CAUTI Event clinical grounds that included a clinical assessment, lower
Patient Characteristics n (%) respiratory tract cultures, and radiography. The diagnosis of
bloodstream infection was based on positive blood cultures. In
Median age, y 64 (range, 2–94) 18 of 102 patients (18%), a potential noninfectious cause was
Age ≥65 years old 52 (50)
identified. Intracranial bleed was the most common potential
Male 36 (34)
Mean APACHE III scores ± SD 71 ± 28 noninfectious cause (n = 6, 33%), followed by postoperative
Median SOFA scores [IQR] 6 [4–9.5] fever (n = 4, 22%).
Comorbidities Only 32 of the 102 patients (32%) had no alternative
Diabetes mellitus 23 (22) explanation for fever. Of these 32 patients, 21 (66%) initially
Stroke/intracranial hemorrhage 20 (19) received empiric antimicrobial therapy at onset of fever, but no
Chronic kidney disease 7 (7) targeted antimicrobial therapy changes were made based on
End-stage liver disease 5 (5) the urine culture results. The other 11 patients (34%) did not
Transplant recipients 10 (10) receive antimicrobial therapy at all. Most of these patients
NOTE. ICU, intensive care unit; CAUTI, catheter-associated urinary (73%) had candiduria.
tract infection; SD, standard deviation; APACHE Acute Physiology Finally, only 6% of all ICU CAUTIs resulted in blood
and Chronic Health Evaluation; SOFA, Sequential Organ Failure cultures positive with same organism within 2 days (Table 3).
Assessment. The median ICU length of stay for the patients with CAUTI

table 1b. CAUTI rates and DUR per ICU Type in 105 ICU Patients with a CAUTI Event in 2012 and 2013
Type of ICU Admissions CAUTI events, n (%) Catheter days Patient days CAUTI ratea DUR
Coronary care unit 2,645 3 (3) 2,392 7,956 1.25 0.30
Cardiac surgery ICU 4,596 12 (11) 8,670 13,207 1.38 0.66
Medical ICU 5,618 26 (25) 7,573 11,859 3.43 0.64
Surgical ICUb 6,235 30 (29) 12,571 22,005 2.39 0.57
Mixed medical/surgical/transplant ICU 3,283 13 (12) 4,676 7,356 2.78 0.64
Neurological ICU 4,270 23 (22) 6,579 10,416 3.50 0.63
Total 26,647 105 (100) 42,461 72,799 2.47 0.58
NOTE. CAUTI, catheter-associated urinary tract infection; DUR, device utilization ratio; ICU, intensive care unit.
a
CAUTI rate is reported per 1,000 patient days.
b
Surgical ICU includes general, vascular, thoracic, trauma ICUs.
 cauti in the icu 3

was 10 days (interquartile range: 6–16 days). In-hospital Fever in the ICU is at times felt to be equivalent with infection,
all-cause mortality was 28%. triggering cultures from multiple sites including blood, spu-
tum, and urine cultures.
Any unexplained fever warrants a thorough clinical evalua-
d i s c u s s io n tion that includes a complete history and physical examination.
We performed a 2-year retrospective cohort analysis of adult The 2009 IDSA guideline for the diagnosis of CAUTI suggested
ICU patients who met the NHSN surveillance definition that catheterized patients be thoroughly evaluated for alternative
for CAUTI. The majority of patients in our ICUs had urine sources, before attributing symptoms including fever to the
cultures performed as a part of the clinical evaluation for fever. urinary tract.9 Laboratory tests should be ordered only after a
A minority of patients had urine cultures sent based on other clinical evaluation indicates a reasonable pre-test probability
symptoms other than fever. that infection might be present.10 Because of the high frequency
In most patients with CAUTI, fever could most often be of asymptomatic bacteriuria, positive urine cultures often
attributed to another source: pneumonia, bloodstream infec- mislead, if not confuse, clinicians in management of the patient.
tion, or an intracranial bleed. This finding is consistent with Previous studies have reported that fever in the ICU is repre-
previous studies.6–8 Fever is extremely common in critically ill sented equally by infectious and noninfectious causes, with the
patients, and its significance varies depending on clinical context. infectious causes usually being infection of the lower respiratory
tract, blood, and abdomen.11,12 Catheter-associated bacteriuria
or candiduria usually represents colonization and is rarely
table 2. CAUTI Pathogens symptomatic.13
Organisms n (N = 111) % The NHSN surveillance definition is promoted as an
objective measure of performance and a marker of quality of
Yeast 56 50
E. coli 20 18
care. Limitations of the definition are widely recognized.
Enterococcus spp 13 12 Hanna et al3 found that the NHSN definition of CAUTI did
Vancomycin-resistant 7 7 not co-relate with clinical practice of either non-infectious
K. pneumoniae 3 3 disease or infectious disease physicians. In 2009, the NHSN
P. mirabilis 2 2 eliminated catheter-associated asymptomatic bacteriuria as
E. cloacae 4 4 part of the definition. As a result, a significant decrease in the
P. aeruginosa 7 6 incidence of CAUTI was observed, although overall it still did
Coagulase-negative Staphylococcus spp. 2 2 not change the rate of subsequent antibiotic use in patients
Othera 4 4 with positive urine cultures.14 In 2013, the NHSN definition
NOTE. CAUTI, catheter-associated urinary tract infection; was revised again in relation to fever alone as a symptom.4
a Fever is attributed to CAUTI regardless of an alternative
Streptococcus Group B, M. morganii, Acinetobacter spp.,
Citrobacter spp. explanation. Almost 66% of our cohort had a potential

table 3. ICU Patients with CAUTIs that Resulted in Blood Cultures Positive with the Same Organism Within 2 days
Blood Cultures History Interpretation
1 Enterobacter cloacae (single blood 75-year-old woman with aortic valve replacement for BSI with possible source of urinary tract
culture) infective endocarditis, polymicrobial urine culture
(Enterobacter and Morganella spp.)
2 VRE (single blood culture) 61-year-old woman with ARDS, pneumonia, on BSI with possible source of urinary tract
ECMO
3 VRE (single blood culture) 71-year-old woman with CNS lymphoma with BSI with possible source of urinary tract
neurologic complications of chemotherapy
4 Pseudomonas aeruginosa 77-year-old man with subarachnoid hemorrhage, BSI with possible source of urinary tract
(multiple cultures) aneurysm, and sepsis
5 P. aeruginosa (multiple cultures) 62-year-old woman with T-cell leukemia, allogeneic BSI preceded positive urine cultures
HSCT recipient, complicated with GvHD of skin,
gut, pneumonia
6 VRE (multiple cultures) 57-year-old woman with non-Hodgkin’s lymphoma Possible translocation from bowel
who underwent chemotherapy and had
neutropenic fever
NOTE. ICU, intensive care unit; CAUTI, catheter-associated urinary tract infection; BSI, bloodstream infection; VRE, vancomycin-resistant
enterococcus; ARDS, acute respiratory distress syndrome; ECMO, extracorporeal membrane oxygenation; CNS, central nervous system;
HSCT, hematopoietic stem cell transplantation; GvHD, graft-versus-host disease.
4 infection control & hospital epidemiology
alternative cause of fever. Even in patients with no other
identified cause of fever, urine cultures were not acted upon in
34% of cases. Of these patients, 66% had received appropriate
empiric antibiotics in their early febrile course, and no targeted
change in antimicrobial therapy was made after the results of
urine cultures. This finding suggests that urine cultures in ICU
patients rarely help clinicians manage overall patient care.
Yeast has been known to frequently colonize urinary
catheters. Approximately 50% of isolated organisms in our
cohort were yeast. The 2015 NHSN definition has eliminated
reporting of candiduria.15 Although this definition has
increased specificity, the window during which the non-
specific signs or symptoms including fever count toward the
CAUTI definition has increased. With the high frequency of
fever in ICU, the definition will cause the overestimation of the
incidence of clinically significant CAUTI and is unlikely to be a
good measure of hospital quality. Further studies are needed
to address the non-specific relationship between fever and
bacteriuria to improve the specificity of the NHSN definition
in ICU patients.
We identified only 6 patients (6%) in our cohort who had
blood cultures positive with the same organism isolated from
urine specimen within 2 days (Table 3). It was difficult to
differentiate whether the bloodstream infection originated from
the urinary tract, was filtered from the bloodstream into the
urinary tract, or whether the bladder was an unrelated reservoir.
In 2 of the patients, the urinary tract was unlikely to be the
source. One patient had vancomycin-resistant Enterococcus
(VRE) bacteremia in the setting of neutropenia, and the blood-
stream infection was possibly related to the translocation of the
enteric pathogen across the compromised colonic mucosa.
The other patient had persistently positive blood cultures for
P. aeruginosa prior to the positive urine culture, which suggests
likely filtration of the pathogen into the genitourinary system.
Our findings highlight the low number of complications
associated with CAUTI in the ICU patients, which is consistent
with previous studies.16 This finding brings into question the
utility of surveillance for this low-frequency, low-morbidity HAI,
which does not serve as a valuable patient-centered outcome.
Our study has several limitations. First, it was performed in
a single tertiary-care hospital with multiple ICU populations,
which may not be representative of other settings. Second, due
to the retrospective nature of our study, we relied on the
clinical judgment of clinicians caring for the patient in inves-
tigating the cause of fever. Third, our cohort was limited to
a 2-year study period. Fourth, half of our cohort had yeast as
the predominant organism, and with the recent 2015 NHSN
definition change that eliminates yeast, our findings are less
relevant. However, the frequency of fever in ICU patients will
remain high, and as long as clinicians continue culturing urine
as part of the clinical evaluation of fever, CAUTI rates will
remain high. Further study of the impact of the 2015 NHSN
definition changes is needed.
In conclusion, we have demonstrated that most ICU
CAUTIs identified by the NHSN surveillance definition are not
clinically significant. The practice of obtaining “pan cultures”
in response to fever results in CAUTIs. Reducing catheter
utilization is a laudable goal because the catheterized bladder
serves as a reservoir for bacteria and yeast. However, CAUTIs,
as currently defined by NHSN (even with the 2015 definition
changes), are not clinically relevant, and efforts to reduce
CAUTI may be better directed at other more serious healthcare
infections. CAUTI rates are a reflection of institutional
culturing practices, and the current emphasis on CAUTI as a
measure of a hospitals quality may be misguided.
acknowledgments
Financial support. This manuscript was developed and completed in the
absence of an outside funding source.
Potential conflicts of interest. At the time of the study, all authors were
employed by Mayo Clinic. All authors report no conflicts of interest relevant to
this article.
Address correspondence to Rudy Tedja, 200 First Street SW, Marian Hall
2-115, Rochester, MN 55905 (tedja.rudy@mayo.edu).
ref e ren ces
1. Dudeck MA, Horan TC, Peterson KD, et al. National Healthcare
Safety Network report, data summary for 2011, device-associated
module. Am J Infect Control 2013;41:286–300.
2. Laupland KB, Shahpori R, Kirkpatrick AW, Ross T, Gregson DB,
Stelfox HT. Occurrence and outcome of fever in critically
ill adults. Crit Care Med 2008;36:1531–1535.
3. Al-Qas Hanna F, Sambirska O, Iyer S, Szpunar S, Fakih MG.
Clinician practice and the National Healthcare Safety Network
definition for the diagnosis of catheter-associated urinary tract
infection. Am J Infect Control 2013;41:1173–1177.
4. Catheter-associated urinary tract infection (CAUTI) event.
Centers for Disease Control and Prevention website. http://www.
cdc.gov/nhsn/PDFs/pscManual/validation/pscManual_july2013.
pdf. Published 2013. Accessed May 16, 2015.
5. Catheter-Associated Urinary Tract Infection (CAUTI) event.
Centers for Disease Control and Prevention website. http://
onthecuspstophai.org/wp-content/uploads/2012/04/CDC-CAUTI-
Event-Definition-Criterion-Form.pdf. Published 2012. Accessed
March 24, 2015.
6. Hartley S, Valley S, Kuhn L, et al. Inappropriate testing for
urinary tract infection in hospitalized patients: an opportunity for
improvement. Infect Control Hosp Epidemiol 2013;34:1204–1207.
7. Neelakanta A, Sharma S, Kesani VP, et al. Impact of changes
in the NHSN Catheter-Associated Urinary Tract Infection
(CAUTI) surveillance criteria on the frequency and epidemiology
of CAUTI in Intensive Care Units (ICUs). Infect Control Hosp
Epidemiol 2015;36:346–349.
8. Meddings J, Reichert H, McMahon LF Jr. Challenges and pro-
posed improvements for reviewing symptoms and catheter use to
identify National Healthcare Safety Network catheter-associated
urinary tract infections. Am J Infect Control 2014;42:S236–S241.
9. 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;50:625–663.

10. O’Grady NP, Barie PS, Bartlett JG, et al. Guidelines for evaluation
of new fever in critically ill adult patients: 2008 update from
the American College of Critical Care Medicine and the
Infectious Diseases Society of America. Crit Care Med 2008;36:
1330–1349.
11. Circiumaru B, Baldock G, Cohen J. A prospective study of fever
in the intensive care unit. Intensive Care Med 1999;25:668–673.
12. Rehman T, Deboisblanc BP. Persistent fever in the ICU. Chest
2014;145:158–165.
13. Tambyah PA, Maki DG. Catheter-associated urinary tract infection
is rarely symptomatic: a prospective study of 1,497 catheterized
patients. Arch Intern Med 2000;160:678–682.
View publication stats
cauti in the icu 5
14. Press MJ, Metlay JP. Catheter-associated urinary tract infection:
does changing the definition change quality? Infect Control Hosp
Epidemiol 2013;34:313–315.
15. Urinary tract infection (catheter-associated urinary tract infec-
tion [CAUTI] and non-catheter-associated urinary tract infection
[UTI] and other urinary system infection [USI]) events. Centers
for Disease Control and Prevention website. http://www.cdc.gov/
nhsn/pdfs/pscManual/7pscCAUTIcurrent.pdf. Published 2015.
Accessed February 15, 2015.
16. Kizilbash QF, Petersen NJ, Chen GJ, Naik AD, Trautner BW.
Bacteremia and mortality with urinary catheter–associated
bacteriuria. Infect Control Hosp Epidemiol 2013;34:1153–1159.