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Catheter-associated urinary tract infection

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Updated 2024 EAU guidelines for the diagnosis and management of catheter-associated urinary tract infection.

Background

Overview

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.
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Pathophysiology
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.
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Disease course
Clinical manifestations include fever, urethritis, cystitis, acute pyelonephritis, renal scarring, calculus formation, and bacteremia. Disease progression may lead to urosepsis and death.
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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.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of catheter-associated urinary tract infection are prepared by our editorial team based on guidelines from the European Association of Urology (EAU 2024), the Spanish Society of Clinical Microbiology and Infectious Diseases (SEIMC 2017), and the Infectious Diseases Society of America (IDSA 2010)....
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Screening and diagnosis

Diagnostic criteria
As per SEIMC 2017 guidelines:
Diagnose CA-UTI in patients:
with indwelling urethral, indwelling suprapubic, or intermittent catheterization
symptomatic UTI
growth of ≥ 10³ 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
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View any number of bacteria in bladder urine obtained by suprapubic aspiration as significant.
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  • Microbiological etiologies

Diagnostic investigations

Clinical history: as per EAU 2024 guidelines, Do not use the presence or absence of odorous or cloudy urine alone to differentiate CA-ASB from CA-UTI.
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  • Urinalysis

  • Gram stain

  • Urine culture

Medical management

General principles
As per EAU 2024 guidelines:
Treat symptomatic CA-UTIs according to the recommendations for complicated UTIs.
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Manage any urological abnormality and/or underlying complicating factors.
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  • Antibiotic therapy

  • Duration of antibiotics

Therapeutic procedures

Catheter removal: as per EAU 2024 guidelines, Replace or remove the indwelling catheter before starting antimicrobial therapy.
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Specific circumstances

Patients with asymptomatic bacteriuria
As per EAU 2024 guidelines:
Do not treat CA-ASB in general.
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Treat CA-ASB before traumatic urinary tract interventions, such as TURP.
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  • Patients with urosepsis

Preventative measures

Minimization of catheter use: as per EAU 2024 guidelines, Keep the catheterization duration as short as possible.
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  • Alternatives to indwelling catheters

  • Catheter insertion technique

  • Closed catheter systems

  • Antimicrobial-coated catheters

  • Routine catheter change

  • Catheter irrigation technique

  • Meatal care

  • Antibiotic prophylaxis with catheter placement/removal

  • Systemic antibiotic prophylaxis

  • Topical antimicrobial prophylaxis

  • Drainage bag antimicrobials

  • Methenamine salt prophylaxis

  • Cranberry products

Quality improvement

Infection prevention: as per IDSA 2010 guidelines, 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.
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