Att G4_Catheter-Associated Urinary Tract Infection

Device-associated Module
UTI

Urinary Tract Infection (Catheter-Associated Urinary Tract Infection
[CAUTI] and Non-Catheter-Associated Urinary Tract Infection [UTI]) and
Other Urinary System Infection [USI]) Events
Introduction: Urinary tract infections (UTIs) are the fourth most common type of
healthcare-associated infection, with an estimated 93,300 UTIs in acute care hospitals in
2011and account for more than 12% of infections reported by acute care hospitals1. Virtually
all healthcare-associated UTIs are caused by instrumentation of the urinary tract.
CAUTI can lead to such complications as prostatitis, epididymitis, and orchitis in males, and
cystitis, pyelonephritis, gram-negative bacteremia, endocarditis, vertebral osteomyelitis,
septic arthritis, endophthalmitis, and meningitis in all patients. Complications associated with
CAUTI cause discomfort to the patient, prolonged hospital stay, and increased cost and
mortality2. It has been estimated that each year, more than 13,000 deaths are associated with
UTIs.3
Prevention of CAUTI is discussed in the CDC/HICPAC document, Guideline for Prevention
of Catheter-associated Urinary Tract Infection4.
Settings: Surveillance may occur in any inpatient location(s) where denominator data can be
collected, such as critical intensive care units (ICU), specialty care areas (SCA), step- down
units, wards, inpatient rehabilitation locations, and long term acute care locations. Neonatal
ICUs may participate, but only off plan (not as a part of their monthly reporting plan). A
complete listing of inpatient locations and instructions for mapping can be found in the CDC
Locations and Descriptions chapter.
Note: Surveillance for CAUTIs after the patient is discharged from the facility is not
required. However, if discovered, any CAUTIs with a date of event on the day of discharge
or the next day is attributable to the discharging location and should be included in any
CAUTIs reported to NHSN for that location (see Transfer Rule). No additional indwelling
catheter days are reported.

Definitions:
Present on Admission (POA): Infections that are POA, as defined in Chapter 2, are not
considered HAIs and therefore are never reported to NHSN.
Healthcare-associated infections (HAI): All NHSN site specific infections must first meet the
HAI definition as defined in Chapter 2 before a site specific infection (e.g., CAUTI) can be
reported to NHSN.

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Urinary tract infections (UTI) are defined using Symptomatic Urinary Tract Infection (SUTI)
criteria, Asymptomatic Bacteremic UTI (ABUTI), or Urinary System Infection (USI) criteria
(See Table 1 and Figure 3).
Date of event (DOE): For a UTI, the date of event is the date when the first element used to
meet the UTI infection criterion occurred for the first time within the 7-day Infection
Window Period. See definition of Infection Window Period in Chapter 2.
Synonyms: infection date, event date.
Indwelling catheter: A drainage tube that is inserted into the urinary bladder through the
urethra, is left in place, and is connected to a drainage bag (including leg bags). These
devices are also called Foley catheters. Condom or straight in-and-out catheters are not
included nor are nephrostomy tubes, ileoconduits, or suprapubic catheters unless a Foley
catheter is also present. Indwelling urethral catheters that are used for intermittent or
continuous irrigation are included in CAUTI surveillance.
Catheter-associated UTI (CAUTI): A UTI where an indwelling urinary catheter was in place
for >2 calendar days on the date of event, with day of device placement being
Day 1,
AND

an indwelling urinary catheter was in place on the date of event or the day before. If an
indwelling urinary catheter was in place for > 2 calendar days and then removed, the date of
event for the UTI must be the day of discontinuation or the next day for the UTI to be
catheter-associated.
Example of Associating Catheter Use to UTI:
A patient in an inpatient unit has a Foley catheter inserted and the following day is the date of
event for a UTI. Because the catheter has not been in place >2 calendar days on the date of
event, this is not a CAUTI. However, depending on the date of admission, this may be a
healthcare-associated UTI.
Notes:
 SUTI 1b and USI cannot be catheter-associated.
 Indwelling urinary catheters that are removed and reinserted: If, after indwelling
urinary catheter removal, the patient is without an indwelling urinary catheter for at
least 1 full calendar day (NOT to be read as 24 hours), then the urinary catheter day
count will start anew. If instead, a new indwelling urinary catheter is inserted before a
full calendar day has passed without an indwelling urinary catheter being present, the
urinary catheter day count will continue.

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Figure 1: Associating Catheter Use to UTI

Patient A

Patient B

March 31
(Hospital day 3)
Foley
Day 3

April 1

April 2

April 3

April 4

April 5

April 6

Foley
Day 4

Foley
removed
Day 8

No
Foley

Foley
Day 4

Foley
replaced
(Foley
Day 6)
No
Foley

Foley
Day 7

Foley
Day 3

Foley
removed
(Foley
Day 5)
Foley
removed
(Foley
Day 5)

Foley
replaced
(Foley
Day 1)

Foley
Day 2

Foley
Day 3

Rationale: NHSN surveillance for infection is not aimed at a specific device. Instead
surveillance is aimed at identifying risk to the patient that is the result of device use in
general.
 In the examples above, Patient A is eligible for a CAUTI beginning on March 31,
through April 6th, since a Foley was in place for some portion of each calendar day
until April 6th. A UTI with date of event on April 6th would be a CAUTI since the
catheter had been in place greater than 2 days and was removed the day before the
date of event.
 Patient B is eligible for a CAUTI on March 31 (Foley Day 3) through April 3. The
catheter had been in place > 2 days and an HAI occurring on the day of device
discontinuation or the following calendar day is considered a device-associated
infection.
 IF the patient did not have a CAUTI by April 3, the patient is not eligible for a
CAUTI until April 6, when the second indwelling urinary catheter had been in place
for greater than 2 days. (Note: NHSN will not require the UTI to be attributed to a
specific indwelling urinary catheter when reporting.)
Location of attribution: The inpatient location where the patient was assigned on the date of
the UTI event. See Date of Event definition (above). See Exception to Location of
Attribution (below).

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Exception to Location of Attribution
Transfer Rule: If the date of event for a UTI is on the date of transfer or discharge, or the
next day, the infection is attributed to the transferring/discharging location. This is called the
Transfer Rule and examples are shown below. Receiving facilities should share
information about such HAIs with the transferring location or facility to enable accurate
reporting.
Examples of the Transfer Rule:
 Patient is transferred in the morning to the medical ward from the MSICU after having
the Foley catheter removed, which had been in place for 6 days. The day of transfer is the
date of event for the CAUTI. This is reported to NHSN as a CAUTI for the MSICU
because the date of event (date when the first element of UTI criteria first appeared
during the infection window) was the day of transfer from that location.
 On Monday, patient with a Foley catheter in place is transferred from the medical ward to
the coronary care unit (CCU). Wednesday in the CCU, patient has a fever and urine
culture collected that day is positive for 100,000 CFU/ml of E. coli. This is reported to
NHSN as a CAUTI for the CCU, because the UTI date of event is LATER THAN the
day after transfer.
 A patient has a Foley catheter removed on catheter day 5 and is discharged the same day
from hospital A’s urology ward. The next day, the IP from Hospital B calls to report that
this patient has been admitted to Hospital B meeting UTI criteria. This CAUTI should be
reported to NHSN for Hospital A and attributed to the urology ward because the date of
event is the next day after transfer.
 Patient in the MICU with a Foley catheter, which has been in place for 4 days, is
transferred to the medical ward. The day after transfer is determined to be the date of
event for a catheter-associated ABUTI. This is reported to NHSN as an ABUTI for the
MICU because the date of event was the next day after transfer.
Multiple Transfers
In instances where a patient has been transferred to more than one location on the date of a
UTI, or the day before, attribute the UTI to the first location in which the patient was housed
the day before the UTI’s date of event.
Figure 2: Multiple Transfers within the Transfer Rule Time Frame
Locations in
which patient
was housed

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3/22
Unit A

3/23
Unit A
Unit B
Unit C

3/24
Unit C
Unit D
This is also the date of event for a CAUTI.
CAUTI is attributed to Unit A since Unit A
was the first location in which the patient
was housed the day before the date of event.

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Table 1. Urinary Tract Infection Criteria
Criterion

Urinary Tract Infection (UTI)
Symptomatic UTI (SUTI)
Must meet at least one of the following criteria:

SUTI 1a

Patient must meet 1, 2, and 3 below:

Catheterassociated
Urinary
Tract
Infection
(CAUTI)

1. Patient had an indwelling urinary catheter that had been in place for > 2 days
on the date of event (day of device placement = Day 1) AND was either:
 Present for any portion of the calendar day on the date of event†, OR
 Removed the day before the date of event‡
2. Patient has at least one of the following signs or symptoms:
• fever (>38.0°C)
• suprapubic tenderness*
• costovertebral angle pain or tenderness*
• urinary urgency ^
• urinary frequency ^
• dysuria ^
3. Patient has a urine culture with no more than two species of organisms
identified, at least one of which is a bacterium of ≥105 CFU/ml (See
Comment Section on page 7-8). All elements of the UTI criterion must occur
during the Infection Window Period (See Definition Chapter 2 Identifying
HAIs in NHSN).
†

When entering event into NHSN choose “INPLACE” for Risk Factor for Urinary
Catheter
‡ When entering event into NHSN choose “REMOVE” for Risk Factor for Urinary
Catheter
*With no other recognized cause (see Notes below)
^ These symptoms cannot be used when catheter is in place
Notes:
 An indwelling urinary catheter in place could cause patient complaints of
“frequency” “urgency” or “dysuria” and therefore these cannot be used as
symptoms when catheter is in place.


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Fever is a non-specific symptom of infection and cannot be excluded from UTI
determination because it is clinically deemed due to another recognized cause.

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SUTI 1b
NonCatheterassociated
Urinary
Tract
Infection
(NonCAUTI)

Patient must meet 1, 2, and 3 below:
1. One of the following is true:
 Patient has/had an indwelling urinary catheter but it has/had not been in
place >2 calendar days on the date of event†
OR
 Patient did not have a urinary catheter in place on the date of event nor
the day before the date of event †
2. Patient has at least one of the following signs or symptoms:
•
•
•
•
•
•
3.

fever (>38°C) in a patient that is ≤ 65 years of age
suprapubic tenderness*
costovertebral angle pain or tenderness*
urinary frequency ^
urinary urgency ^
dysuria ^

Patient has a urine culture with no more than two species of organisms
identified, at least one of which is a bacterium of ≥105 CFU/ml. (See
comment section on page 7-8) All elements of the SUTI criterion must occur
during the Infection Window Period (See Definition Chapter 2 Identifying
HAIs in NHSN).

†

When entering event into NHSN choose “NEITHER” for Risk Factor for Urinary
Catheter
*With no other recognized cause (see Notes below)
^These symptoms cannot be used when catheter is in place.
Notes:
 An indwelling urinary catheter in place could cause patient complaints of
“frequency” “urgency” or “dysuria” and therefore these cannot be used as
symptoms when catheter is in place.


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Fever is a non-specific symptom of infection and cannot be excluded from
UTI determination because it is clinically deemed due to another recognized
cause.

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SUTI 2

Patient must meet 1, 2, and 3 below:
1. Patient is ≤1 year of age (with‡ or without an indwelling urinary catheter)

CAUTI
or NonCAUTI in
patients 1
year of
age or
less

2. Patient has at least one of the following signs or symptoms:
• fever (>38.0°C)
• hypothermia (<36.0°C)
• apnea*
• bradycardia*
• lethargy*
• vomiting*
• suprapubic tenderness*
3.

Patient has a urine culture with no more than two species of organisms
identified, at least one of which is a bacterium of ≥105 CFU/ml. (See
comment section on page 7-8) All elements of the SUTI criterion must occur
during the Infection Window Period (See Definition Chapter 2 Identifying
HAIs in NHSN).

‡

If patient had an indwelling urinary catheter in place for >2 calendar days, and
catheter was in place on the date of event or the previous day the CAUTI criterion is
met. If no such indwelling urinary catheter was in place, UTI (non-catheter
associated) criterion is met.
*With no other recognized cause
Note: Fever and hypothermia are non-specific symptoms of infection and cannot be
excluded from UTI determination because they are clinically deemed due to another
recognized cause.

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Asymptomatic Bacteremic Urinary Tract Infection (ABUTI)
Patient must meet 1, 2, and 3 below:
1. Patient with* or without an indwelling urinary catheter has no signs or
symptoms of SUTI 1 or 2 according to age (Note: Patients > 65 years of age
with a non-catheter-associated ABUTI may have a fever and still meet the
ABUTI criterion)
2. Patient has a urine culture with no more than two species of organisms
identified, at least one of which is a bacterium of ≥105 CFU/ml (see
Comment section below)
3. Patient has organism identified** from blood specimen with at least one
matching bacterium to the bacterium identified in the urine specimen, or
meets LCBI criterion 2 (without fever) and matching common commensal(s)
in the urine. All elements of the ABUTI criterion must occur during the
Infection Window Period (See Definition Chapter 2 Identifying HAIs in
NHSN).
*Patient had an indwelling urinary catheter in place for >2 calendar days, with day of
device placement being Day 1, and catheter was in place on the date of event or the
day before.
** Organisms identified by a culture or non-culture based microbiologic testing
method which is performed for purposes of clinical diagnosis or treatment (e.g., not
Active Surveillance Culture/Testing (ASC/AST).
Comment

“Mixed flora” is not available in the pathogen list within NSHN. Therefore it cannot
be reported as a pathogen to meet the NHSN UTI criteria. Additionally, “mixed
flora” represent at least two species of organisms. Therefore, an additional organism
recovered from the same culture would represent >2 species of microorganisms. Such
a specimen also cannot be used to meet the UTI criteria.
The following excluded organisms cannot be used to meet the UTI definition:





January 2016

Candida species or yeast not otherwise specified
mold
dimorphic fungi or
parasites

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An acceptable urine specimen may include these organisms as long as one
bacterium of greater than or equal to 100,000 CFU/ml is also present.
Additionally, these non-bacterial organisms identified from blood cannot be
deemed secondary to a UTI since they are excluded as organisms in the UTI
definition.

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Table 2. Urinary System Infection Criteria
Criterion

Urinary System Infection (USI) (kidney, ureter, bladder, urethra, or tissue
surrounding the retroperitoneal or perinephric space)
Other infections of the urinary system must meet at least one of the following
criteria:
1. Patient has microorganisms identified** from fluid (excluding urine)
or tissue from affected site
2. Patient has an abscess or other evidence of infection on gross
anatomical exam, during invasive procedure, or on histopathologic
exam
3. Patient has at least one of the following signs or symptoms:



fever (>38.0°C)
localized pain or tenderness*
And at least one of the following:

a) purulent drainage from affected site
b) organisms identified** from blood and imaging test evidence of
infection (e.g., ultrasound, CT scan, magnetic resonance imaging
[MRI], or radiolabel scan [gallium, technetium])
1. Patient <1 year of age has at least one of the following signs or
symptoms:
•
•
•
•
•
•

fever (>38.0°C)
hypothermia (<36.0°C)
apnea*
bradycardia*
lethargy*
vomiting*
And at least one of the following:
a) purulent drainage from affected site
b) organisms identified** from blood and imaging test evidence
of infection, (e.g., ultrasound, CT scans, magnetic resonance
imaging [MRI], or radiolabel scan [gallium, technetium])

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* With no other recognized cause
** Organisms identified by a culture or non-culture based microbiologic testing
method which is performed for purposes of clinical diagnosis or
treatment (e.g., not Active Surveillance Culture/Testing (ASC/AST).
Notes:


Comments 



January 2016

Fever and hypothermia are non-specific symptoms of infection and cannot
be excluded from USI determination because they are clinically deemed due
to another recognized cause.
All elements of the USI criterion must occur during the Infection Window
Period (See Definition Chapter 2 Identifying HAIs in NHSN).
Report infections following circumcision in newborns as SST-CIRC.
If patient meets USI criteria and they also meet UTI criteria, report UTI
only, unless the USI is a surgical site organ/space infection, in which case,
only USI should be reported.
For NHSN reporting purposes, Urinary System Infection (USI) cannot be
catheter associated, therefore, USI will only present as specific event type if
urinary catheter status is marked “Neither”.

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Figure 3: Identifying SUTI and ABUTI Flowchart

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Numerator Data: The Urinary Tract Infection (UTI) form is used to collect and report each
CAUTI that is identified during the month selected for surveillance. The Instructions for
Completion of Urinary Tract Infection form include brief instructions for collection and entry
of each data element on the form. USIs are never included in CAUTI data and are reported
separately on the HAI Custom Event Form. The UTI form includes patient demographic
information and information on whether or not an indwelling urinary catheter was present.
Additional data include the specific criteria met for identifying the UTI, whether the patient
developed a secondary bloodstream infection, whether the patient died, and the organisms
isolated from cultures and their antimicrobial susceptibilities.
Reporting Instructions:
If no CAUTIs are identified during the month of surveillance, the” Report No Events” box
must be checked on the appropriate denominator summary screen, (e.g., Denominators for
Intensive Care Unit (ICU)/Other Locations (Not NICU or SCA/ONC).
Denominator Data: Device days and patient days are used for denominators (See Key
Terms chapter).The method of collecting device-day denominator data may differ depending
on the location of patients being monitored. The following methods may be used:
Denominator Data
Collection Method
Manual, Daily (i.e.,
collected at the same
time every day of the
month)

Manual, sampled
once/week (i.e.,
collected at the same
time on the same
designated day, once
per week)

January 2016

Details
Denominator data are collected at the same time, every day, per
location.
Indwelling urinary catheter days, which are the number of patients
with an indwelling urinary catheter device, are collected daily, at the
same time each day, according to the chosen location using the
appropriate form (CDC 57.117 and 57.118). These daily counts are
summed and only the total for the month is entered into NHSN.
Indwelling urinary catheter days and patient days are collected
separately for each of the locations monitored.
For locations other than specialty care areas/oncology (SCA/ONC)
and NICUs (e.g., ICUs, step-down units, wards), the denominator
sampling method can be used.
To reduce staff time spent collecting surveillance data, once weekly
sampling of denominator data to generate estimated urinary catheter
days may be used as an alternative to daily collection in nononcology ICUs and wards. The number of patients in the location
(patient-days) and the number of patients with an indwelling urinary
catheter (urinary catheter-days) is collected on a designated day each
week (e.g., every Tuesday), at the same time during the month.

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Denominator Data
Collection Method

Details
Evaluations of this method have repeatedly shown that use of
Saturday or Sunday generate the least accurate estimates of
denominator data, and, therefore, these days should not be selected as
the designated day.5-7 If the day designated for the collection of
sampled data is missed, collect the data on the next available day
instead.
The following must be collected and entered into NHSN:
1. The monthly total for patient-days, based on collection daily
2. The sampled total for patient-days
3. The sampled total urinary catheter-days
When these data are entered, the NHSN application will calculate an
estimate of urinary catheter-days.
Notes:
• To ensure the accuracy of estimated denominator data
obtained by sampling, only ICU and ward location types with
an average of 75 or more urinary catheter-days per month are
eligible to use this method. A review of each location’s
urinary catheter denominator data for the past 12 months in
NHSN will help determine which locations are eligible.
• The accuracy of estimated denominator data generated by
sampling can be heavily influenced by incorrect or missing
data. Careful implementation of data collection following the
guidance in this protocol is essential to avoid erroneous
fluctuations in rates or Standardized Infection Ratios (SIRs).

Electronic

For any location, when denominator data are available from
electronic sources (e.g., urinary catheter days from electronic
charting), these sources may be used as long as the counts are not
substantially different (+/- 5%) from manually-collected, once a day
counts, pre-validated for a minimum of three months.
The validation of electronic counts should be performed for each
location separately.

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Data Analyses: The Standardized Infection Ratio (SIR) is calculated by dividing the
number of observed infections by the number of predicted infections. The number of
predicted infections is calculated using CAUTI rates from a standard population during a
baseline time period, which represents a standard population’s CAUTI experience.8, 9
Notes:
• The SIR will be calculated only if the number of predicted CAUTIs (numExp) is ≥1
to help enforce a minimum precision criterion.
• In the NHSN application, “predicted” is referred to as “expected”.

SIR = Observed (O) HAIs
Expected (E) HAIs

While the CAUTI SIR can be calculated for single locations, the measure also allows you to
summarize your data by multiple locations, adjusting for differences in the incidence of
infection among the location types. For example, you will be able to obtain one CAUTI SIR
adjusting for all locations reported. Similarly, you can obtain one CAUTI SIR for all ICUs in
your facility.
Note: Only those locations for which baseline data have been published will be included in
the SIR calculations. For acute care hospitals, the baseline time period is 2009; for long term
acute care hospitals and inpatient rehabilitation facilities (IRFs) and IRF units, the baseline
time period is 2013.8,9
The CAUTI rate per 1000 urinary catheter days is calculated by dividing the number of
CAUTIs by the number of catheter days and multiplying the result by 1000. The Urinary
Catheter Utilization Ratio is calculated by dividing the number of urinary catheter days by
the number of patient days. These calculations will be performed separately for the different
types of ICUs, specialty care areas, and other locations in the institution, except for neonatal
locations.
Descriptive analysis output options of numerator and denominator data, such as line listings,
frequency tables, and bar and pie charts are available in the NHSN application. SIRs and
CAUTI rates and run charts are also available. Guides on using NHSN analysis features are
available at: http://www.cdc.gov/nhsn/PS-Analysis-resources/reference-guides.html.

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REFERENCES
1

Magill SS., Edwards, JR., Bamberg, W., et al. “Multistate Point-Prevalence Survey of Health CareAssociated Infections, 2011”. New England Journal of Medicine. 370: (2014): 1198-1208.

2

Scott Rd. The Direct Medical Costs of Healthcare-Associated Infections in U.S.
Hospitals and the Benefits of Prevention, 2009. Division of Healthcare Quality Promotion,
National Center for Preparedness, Detection, and Control of Infectious Diseases,
Coordinating Center for Infectious Diseases, Centers for Disease Control and Prevention,
February 2009.
3
Klevens, RM., Edward, JR., et al. “Estimating Healthcare-associated Infections and
Deaths in U.S. Hospitals”. Public Health Reports 122: (2007):160-166.
4
Gould, CV., Umscheid, CA., Agarwal, RK., Kuntz, G., Pegues, DA. “Guideline for
Prevention of Catheter-associated Urinary Tract Infections”. Infection Control Hospital
Epidemiology. 31: (2010): 319-26.
5
Klevens, RM., et al. “Sampling for Collection of Central Line Day Denominators in
Surveillance for Healthcare-associated Bloodstream Infections”. Infection Control Hospital
Epidemiology. 27: (2006):338-42.
6
Thompson, ND., et al.” Evaluating the Accuracy of Sampling to Estimate Central Line–
Days: Simplification of NHSN Surveillance Methods”. Infection Control Hospital
Epidemiology. 34(3): (2013): 221-228.
7
See, I., et al. ID Week 2012 (Abstract #1284): Evaluation of Sampling Denominator
Data to Estimate Urinary Catheter- and Ventilator-Days for the NHSN. San Diego,
California. October 19, 2012.
8
Dudeck, MA., Horan, TC., Peterson, KD. National Healthcare Safety Network (NHSN)
Report, Data Summary for 2009, “Device-associated Module”, American Journal of Infection
Control 39: (2011): 349-67.
9
Dudeck, MA., et al. National Healthcare Safety Network (NHSN) Report, Data
Summary for 2013, Device-associated Module. American Journal of Infection Control 43(3):
(2015): 206-221.

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