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Urinary Tract Infection (UTI) Event for Long-term Care Facilities
Background: The urinary tract is one of the most common sites of healthcare-associated
infections, accounting for 20-30% of infections reported by long-term care facilities (LTCFs). In
the LTC resident, risk factors for developing bacteriuria and UTI include age-related changes to
the genitourinary tract, comorbid conditions resulting in neurogenic bladder, and instrumentation
required to manage bladder voiding. The point prevalence of asymptomatic bacteriuria in LTC
residents can range from 25-50%. Although the incidence of symptomatic UTI is lower, it still
comprises a significant proportion of infections manifesting in LTCFs and results in a large
amount of antibiotic use.
Though prevalence of indwelling urinary catheter use in LTCFs is lower than in the acute care
setting, catheter-associated UTI (CAUTI) can lead to such complications as cystitis,
pyelonephritis, bacteremia, and septic shock. These complications associated with CAUTI can
result in decline in resident function and mobility, acute care hospitalizations, and increased
mortality. Prevention of CA-UTIs is discussed in the CDC/HICPAC document, Guideline for
Prevention of Catheter-associated Urinary Tract Infections1.
1: Healthcare Infection Control Practices Advisory Committee (HICPAC) approved guidelines for the
Prevention of catheter-associated urinary tract infections, 2009. Available at www.cdc.gov/hicpac/pdf/CAUTI/
CAUTIguideline2009final.pdf

Settings: UTI Event reporting is currently available for certified skilled nursing facilities/nursing
homes (LTC:SKILLNURS), and intermediate/chronic care facilities for the developmentally
disabled (LTC:DEVDIS). Infection surveillance for UTIs should be performed facility-wide
(FacWideIN).
NOTE: If a resident is transferred from an acute care facility and develops signs/symptoms of a
UTI within the first 2 calendar days of admission (where date of admission = day 1) to the
LTCF, it would be considered present at the time of transfer to the LTCF. An event present at the
time of transfer should be reported back to the transferring facility and not reported to NHSN as
a LTCF UTI event. Only UTI events presenting > 2 calendar days after admission (where date of
admission= day 1) are considered facility onset events.

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Example: NHSN Classification of reportable LTCF UTI Events
Admission date
June 4th

June 5th

June 6th

June 7th

June 8th

day 1

day 2

day 3

day 4

day 5

Not a LTCF reportable UTI event

LTCF reportable UTI event

Requirements: Facilities must indicate their surveillance for UTI in the Monthly Reporting Plan
for LTCF (CDC 57.141). UTI surveillance must be reported for at least 6 consecutive months to
provide meaningful measures.
Definitions:
Date of Event is defined as the date when the first clinical evidence (signs/symptoms) of the UTI
appeared or the date the specimen was collected that was used to make or confirm the diagnosis,
whichever comes first.
Urinary tract infections (UTI) are defined using a combination of clinical signs and symptoms
and laboratory criteria (See Figure 1 and Table 1).
Symptomatic UTI (SUTI) events occur when the resident manifests signs and symptoms such as
acute dysuria, new and/or marked increase in urinary frequency, suprapubic tenderness, etc.
which localize the infection to the urinary tract. These events can occur in residents without
urinary devices or managed with urinary devices other than indwelling urinary catheters, such as
suprapubic catheters, straight in-and-out catheters and condom catheters. Events occurring in
residents with indwelling urinary catheters (defined below) are a sub-set of SUTIs referred to as
catheter-associated SUTI (CA-SUTI) events.
Catheter-associated SUTIs (CA-SUTI) events occur when a resident develops signs and
symptoms localizing to the urinary tract while having an indwelling urinary catheter in place or
removed within the 2 calendar days prior to the date of event (where day of catheter removal =
day 1).
NOTE: An indwelling urinary catheter should be in place for a minimum of 2 calendar days
before infection onset (where day of catheter insertion = day 1) in order for the SUTI to be
catheter-associated.
Indwelling urinary catheter: a drainage tube that is inserted into the urinary bladder through the
urethra, is left in place, and is connected to a closed collection system; also called a Foley
catheter. Indwelling urinary catheters do not include straight in-and-out catheters or suprapubic
catheters.
NOTE: UTIs in residents managed with suprapubic, in and out, or condom (males only)
catheters will be captured as SUTIs, not CA-SUTIs.
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Asymptomatic Bacteremic UTI (ABUTI) events occur when the resident has NO signs or
symptoms localizing to the urinary tract but has urine and blood cultures positive for at least one
common organism (See Table 1) regardless of whether a catheter is in place or not.
Table 1. Examples of ‘‘sameness’’ by organism speciation
Culture

Companion Culture

Report as.

S epidermidis

Coagulase-negative
staphylococci

S epidermidis

Klebsiella oxytoca

Klebsiella spp.

K oxytoca

S salivarius

Strep viridans

S salivarius

Numerator and Denominator Data:
Numerator Data: The Urinary Tract Infection (UTI) for LTCF form (CDC 57.140) is used to
collect and report each SUTI, CA-SUTI or ABUTI that is identified during the month selected
for surveillance. The Tables of Instructions includes information on how to complete this form.
The UTI form includes resident demographic information and information on whether or not a
catheter (or other urinary device) was present. Additional data include the specific clinical
criteria evidence (signs and symptoms) and laboratory and diagnostic testing that were used for
identifying the UTI; whether the resident developed a secondary bloodstream infection; whether
the resident was transferred to an acute care facility for any reason within 7 days of the UTI
event or died from any cause within 30 days of the UTI event; and the organisms isolated from
cultures and their antimicrobial susceptibilities.
Denominator data: Catheter-days and resident-days are used for denominators. Catheter-days,
defined as the number of residents with an indwelling urinary (Foley) catheter, are collected
daily for all residents in the facility using the Denominators for LTCF form (CDC 57.142).
Resident-days are calculated using the daily census of residents in the facility each day of the
month. These daily counts are summed and only the total for the month is entered into NHSN,
under Summary Data. None of the following urinary management devices should be included
when counting indwelling catheter-days: suprapubic catheters, straight in-and-out catheters or
condom catheters.
NOTE: If a resident is transferred to an acute care facility for a suspected UTI, no additional
indwelling catheter-days are reported after the day of transfer.

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Data Analyses:
Line lists of UTI events and UTI events by catheter status will be available as part of the UTI
event within the NHSN LTCF component. Below are measures and calculations which will be
incorporated into the analytics output that will be available for use in 2013.
Calculated UTI Rates and Metrics
Data will be stratified by time (e.g., month, quarter) and aggregated across the entire facility.
Total UTI incidence rate/1,000 resident-days = Number of UTI Events (i.e., SUTI+CASUTI+ABUTI) / Total resident-days x 1,000.
Percent that is SUTI = Number of SUTI Events / Total number of UTI Events x 100.
Percent that is CA-SUTI = Number of CA-SUTI Events / Total number of UTI Events x
100.
Percent that is ABUTI = Number of ABUTI Events / Total number of UTI Events x 100.

SUTI incidence rate/1,000 resident-days = Number of SUTI Events / (Total resident-days –
catheter-days) x 1,000.
NOTE: Only SUTIs which are NOT catheter-associated will be included in the SUTI incidence
rate.
CA-SUTI incidence rate/1,000 catheter-days = Number of CA-SUTI events/ Catheter-days x
1,000
NOTE: Only symptomatic events which develop at the time an indwelling catheter is in place or
recently removed (within last 2 calendar days) will contribute to the CA-SUTI rate.
Urinary Catheter Utilization Ratio = Total urinary catheters-days / Total resident-days.

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Figure 1: Criteria for Defining UTI Events in NHSN LTCF Component.

Resident without an indwelling catheter (Meets criteria 1a OR 2a OR 3a):
SUTI – Criteria 1a

SUTI – Criteria 2a

SUTI – Criteria 3a

Either of the following:
1. Fever a
2. Leukocytosis b
AND
ONE or more of the following:
 Costovertebral angle pain or
tenderness
 New or marked increase in
suprapubic tenderness
 Gross hematuria
 New or marked increase in
incontinence
 New or marked increase in urgency
 New or marked increase in frequency

Either of the following:
1. Acute dysuria
2. Acute pain, swelling
or tenderness of the
testes, epididymis or
prostate

TWO or more of the following:
 Costovertebral angle pain or
tenderness
 New or marked increase in
suprapubic tenderness
 Gross hematuria
 New or marked increase in
incontinence
 New or marked increase in urgency
 New or marked increase in frequency

AND
Either of the following:

5

1. A voided urine culture with ≥ 10 CFU/ml of no more than 2 species of microorganisms
2
2. Positive culture with ≥ 10 CFU/ml of any microorganisms from straight in/out catheter specimen

SUTI
a
b

o

o

o

o

o

o

Fever: Single temperature ≥ 37.8 C (>100 F), or > 37.2 C ((>99 F) on repeated occasions, or an increase of >1.1 C ((>2 C) over baseline
3
3
Leukocytosis: >14,000 cells/mm , or Left shift (> 6% or 1,500 bands/mm

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Resident with an indwelling catheter:
CA-SUTI – Criteria
ONE or more of the following with no alternate source:
 Fever a
 Rigors
 New onset hypotension, with no alternate site of infection.
 New onset confusion/functional decline AND Leukocytosis b
 New costovertebral angle pain or tenderness
 New or marked increase in suprapubic tenderness
 Acute pain, swelling or tenderness of the testes, epididymis or prostate
 Purulent discharge from around the catheter

AND
Any of the following:
If urinary catheter removed within last 2 calendar days:
5

1. A voided urine culture with ≥ 10 CFU/ml of no more than 2 species of microorganisms
2
2. Positive culture with ≥ 10 CFU/ml of any microorganisms from straight in/out catheter specimen
If urinary catheter in place:
3. Positive culture with ≥ 105 CFU/ml of any microorganisms from indwelling catheter specimen

CA-SUTI
a
b

o

o

o

o

o

o

Fever: Single temperature ≥ 37.8 C (>100 F), or > 37.2 C ((>99 F) on repeated occasions, or an increase of >1.1 C ((>2 C) over baseline
3
3
Leukocytosis: >14,000 cells/mm , or Left shift (> 6% or 1,500 bands/mm

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Resident with or without an indwelling catheter:
ABUTI –Criteria
Resident has no localizing urinary signs or symptoms (i.e., no urgency, frequency, acute dysuria, suprapubic
tenderness, or costovertebral angle pain or tenderness). If no catheter is in place, fever alone would not
exclude ABUTI if other criteria are met.

AND
Any of the following:

5

1. A voided urine culture with ≥ 10 CFU/ml of no more than 2 species of microorganisms
2
2. Positive culture with ≥ 10 CFU/ml of any microorganisms from in/out catheter specimen
3. Positive culture with ≥ 105 CFU/ml of any microorganisms from indwelling catheter specimen

AND
Positive blood culture with at least 1 matching organism in urine culture

ABUTI

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Table 1. Criteria for Defining UTI Events in NHSN LTCF Component.
Criterion Symptomatic Urinary Tract Infection (SUTI)
For residents without an indwelling catheter:
Either of the following (Signs & Symptoms):
1a
1. Acute dysuria
2. Acute pain, swelling, or tenderness of the testes, epididymis, or prostate
AND

2a

Either of the following (Laboratory and Diagnostic Testing):
1. A voided urine culture with ≥ 105 CFU/ml of no more than 2 species of
microorganisms
2. Positive culture with ≥ 102 CFU/ml of any microorganisms from in/out catheter
specimen
Either of the following:
1. Fever (Signs and Symptoms) [Single temperature ≥ 37.8°C (>100°F), or >37.2°C (>
99°F) on repeated occasions, or an increase of >1.1oC (>2oF) over baseline]
2. Leukocytosis (Laboratory and Diagnostic Testing) (>14,000 cells/mm3) or Left shift
(>6% or 1,500 bands/mm3)
AND
One or more of the following (New and/or marked increase):
1. Costovertebral angle pain or tenderness,
2. Suprapubic tenderness,
3. Visible (Gross) hematuria,
4. New or marked increase incontinence
5. New or marked increase urgency
6. New or marked increase frequency
AND
Either of the following (Laboratory and Diagnostic Testing):
1. A voided urine culture with ≥ 105 CFU/ml of no more than 2 species of
microorganisms.
2. Positive culture with ≥ 102 CFU/ml of any microorganisms from in/out catheter
specimen.

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3a

Two or more of the following (New and/or marked increase):
1. Costovertebral angle pain or tenderness,
2. New or marked increase incontinence
3. New or marked increase urgency
4. New or marked increase frequency
5. Suprapubic tenderness
6. Visible (gross) hematuria
AND

Either of the following (Laboratory and Diagnostic Testing):
1. A voided urine culture with ≥ 105 CFU/ml of no more than 2 species of
microorganisms
2. Positive culture with ≥ 102 CFU/ml of any microorganisms from in/out catheter
specimen
Criterion Cather-associated Symptomatic Urinary Tract Infection (SUTI) – CA-SUTI
For residents with an indwelling catheter in place or removed within 2 calendar days prior
to event onset
One or more of the following (Signs and Symptoms and Laboratory and Diagnostic
Testing):
1.
2.
3.
4.

Fever
Rigors
New onset hypotension, with no alternate site of infection.
New onset confusion/functional decline with no alternate diagnosis AND
leukocytosis
5. New onset suprapubic pain or costovertebral angle pain or tenderness
6. Acute pain, swelling, or tenderness of the testes, epididymis, or prostate.
7. Purulent discharge from around the catheter

AND
Any of the following:
If urinary catheter removed within last 2 calendar days:
5

1. A voided urine culture with ≥ 10 CFU/ml of no more than 2 species of microorganisms
2
2. Positive culture with ≥ 10 CFU/ml of any microorganisms from straight in/out catheter
specimen
If urinary catheter in place:
3. Positive culture with ≥ 105 CFU/ml of any microorganisms from indwelling catheter
specimen

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Criterion Asymptomatic Bacteremic Urinary Tract Infection (ABUTI)
Resident with or without an indwelling urinary catheter
No signs or symptoms (i.e., no urgency, frequency, acute dysuria, suprapubic tenderness, or
1
costovertebral angle pain or tenderness). If no catheter is in place, fever alone would not
exclude ABUTI if other criteria are met.
AND
One of the following:
5

1. A voided urine culture with ≥ 10 CFU/ml of no more than 2 species of microorganisms
2
2. Positive culture with ≥ 10 CFU/ml of any microorganisms from in/out catheter
specimen
3. Positive culture with ≥ 105 CFU/ml of any microorganisms from indwelling catheter.
AND
A positive blood culture with at least 1 matching organism in urine culture.

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