Att G15_LTCF Urinary Tract Infection

NHSN Long-term Care Facility Component
Urinary Tract Infection

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 up to 20% of infections reported by long-term care facilities (LTCFs)1.
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 20-50%. 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 CAUTIs is discussed in the CDC/HICPAC document, Guideline for
Prevention of Catheter-associated Urinary Tract Infections2.
Efforts to examine antibiotic use practices for UTI have demonstrated a discrepancy
between the number UTI events identified through the application of evidence-based
surveillance criteria with the numbers of clinically identified and treated UTI3,4. Consistent
tracking and reporting symptomatic UTIs using surveillance criteria identify opportunities to
examine, understand and address larger differences between surveillance events and clinically
identified events.

References:
1. Genao L, Buhr GT. Urinary tract infections in older adults residing in long-term care facilities. Annals
of Long-term Care. 2012;20 (4):33-38.
2. 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
3. Juthani-Mehta M et al. Diagnostic Accuracy of Criteria for Urinary Tract Infection
in a Cohort of Nursing Home Residents. Journal of the American Geriatrics Society. 2007; 55: 1072-77.
4. Wang L. et al. Infection rate and colonization with antibiotic-resistant organisms in skilled nursing
facility residents with indwelling devices. European Journal of Clinical Microbiology & Infectious
Diseases. 2012. 31(8):1797-804).

January 2016

Page 1 of 13

NHSN Long-term Care Facility Component
Urinary Tract Infection

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). Surveillance for UTIs should be performed facility-wide.
Only UTI events presenting > 2 calendar days after admission (where date of admission= day 1)
are considered facility onset events.
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

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 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.
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 2).
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 those 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.

January 2016

Page 2 of 13

NHSN Long-term Care Facility Component
Urinary Tract Infection

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
NOTE: If a resident is transferred to your facility with an indwelling urinary catheter and
you replace that catheter with a new one while the resident is in your care, then the date
of insertion of the device corresponds to the date the new catheter was placed in your
facility.
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.
Asymptomatic Bacteremic UTI (ABUTI) events occur when the resident has NO signs or
symptoms localizing to the urinary tract but has matching urine and blood cultures positive for at
least one 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
staphylococcus

S. epidermidis

Klebsiella oxytoca

Klebsiella spp.

K. oxytoca

S. salivarius

Streptococcus
viridans

S. salivarius

January 2016

Page 3 of 13

NHSN Long-term Care Facility Component
Urinary Tract Infection

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 Table 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 or died from any cause within
7 days of the UTI event; and the organisms isolated from cultures and their antimicrobial
susceptibilities.
NOTE: When a urine specimen is being collected from a resident with a chronic indwelling
urinary catheter (in place >14 days), it is recommended that the original catheter be changed
prior to specimen collection. Failure to change the catheter prior to specimen collection does not
exclude a specimen from being used to meet the UTI criteria.
Denominator data: Catheter-days, resident-days, and new antibiotic starts for UTI indication
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). The Table of Instructions includes information on
how to complete this form.
NOTE: 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.
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.
New antibiotic starts for UTI indication may be collected daily or summarized at the end of each
month. A “new antibiotic start” refers to a new prescription for an antibiotic ordered for a
resident who is suspected or diagnosed with having a urinary tract infection (both catheterassociated and not catheter associated) regardless of whether that UTI meets the NHSN event
definition. There is no minimum number of doses or days of therapy which define a new
antibiotic start—count all new orders. Include only antibiotics which are started while the
resident is receiving care in your facility, either by clinical providers working in the facility or by
outside physicians who see the resident in an outpatient clinic or Emergency department. Do not

January 2016

Page 4 of 13

NHSN Long-term Care Facility Component
Urinary Tract Infection

include antibiotic courses started by another healthcare facility prior to the resident’s admission
or readmission back to your facility even if the resident continues to take that antibiotic while in
the facility.
Data Analyses:
Line lists of UTI events and UTI events by catheter status are available as part of the UTI event
within the NHSN LTCF component. Below are measures and calculations that are incorporated
into the analytics output.
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 are SUTI = Number of SUTI Events / Total number of UTI Events x 100.
Percent that are CA-SUTI = Number of CA-SUTI Events / Total number of UTI Events
x 100.
Percent that are 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.
UTI treatment ratio = New antibiotic starts for UTI / Total UTI Count (SUTI + ABUTI + CASUTI)

January 2016

Page 5 of 13

NHSN Long-term Care Facility Component
Urinary Tract Infection

NOTE: When the UTI treatment ratio is <1, there are fewer reported antibiotic starts for
UTI than symptomatic UTI events submitted; when the UTI treatment ratio equals 1,
there are the same number of new antibiotic starts for UTI and symptomatic UTI events
submitted; when the UTI treatment ratio is >1, there are more reported antibiotic starts
for UTI than symptomatic UTI events submitted.

January 2016

Page 6 of 13

NHSN Long-term Care Facility Component
Urinary Tract Infection

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 2a

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

OR

Either of the following:
1. Fever+ a
2. Leukocytosisb
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

SUTI - Criteria 3a
OR

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:
1. Specimen collected from clean catch voided urine and positive culture with no more than 2 species of microorganisms, at least one of which is bacteria of
≥105 CFU/ml
2. Specimen collected from in/out straight catheter and positive culture with any microorganism, at least one of which is bacteria of ≥102 CFU/ml
NOTE: Yeast and other microorganisms, which are not bacteria, are not acceptable UTI pathogens

SUTI
+

Fever can be used to meet SUTI criteria even if the resident has another possible cause for the fever (e.g., pneumonia)
Fever: Single temperature ≥ 37.8oC (>100oF), or > 37.2oC (>99oF) on repeated occasions, or an increase of >1.1oC (>2oF) over baseline
b
Leukocytosis: >14,000 cells/mm3, or Left shift (> 6% or 1,500 bands/mm3)
a

January 2016

Page 7 of 13

NHSN Long-term Care Facility Component
Urinary Tract Infection

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

Resident with an indwelling catheter:
CA-SUTI – Criteria
ONE or more of the following:
 Fever+ a
 Rigors
 New onset hypotension, with no alternate noninfectious cause
 New onset confusion/functional decline AND Leukocytosisb
 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:
1. Specimen collected from clean catch voided urine and positive culture with no more than 2 species of microorganisms, at least one of which is
bacteria of ≥105 CFU/ml
2. Specimen collected from in/out straight catheter and positive culture with any microorganism, at least one of which is bacteria of ≥102 CFU/ml
If urinary catheter in place:
3. Specimen collected from indwelling catheterc and positive culture with any microorganism, at least one of which is bacteria of ≥ 105 CFU/ml
NOTE: Yeast and other microorganisms, which are not bacteria, are not acceptable UTI pathogens

CA-SUTI
+

Fever can be used to meet SUTI criteria even if the resident has another possible cause for the fever (e.g., pneumonia)
Fever: Single temperature ≥ 37.8oC (>100oF), or > 37.2oC (>99oF) on repeated occasions, or an increase of >1.1oC (>2oF) over baseline
b
Leukocytosis: >14,000 cells/mm3, or Left shift (> 6% or 1,500 bands/mm3)
c
Indwelling urinary catheters which have been in place for >14 days should be changed prior to specimen collection, but failure to change catheter does not exclude a UTI for
surveillance purposes
a

January 2016

Page 8 of 13

NHSN Long-term Care Facility Component
Urinary Tract Infection

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

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 as only sign would not exclude ABUTI if other positive culture criteria are met.

AND
Any of the following:
1. Specimen collected from clean catch voided urine and positive culture with no more than 2 species of microorganisms, at least one of which is
bacteria of ≥105 CFU/ml
2. Specimen collected from in/out straight catheter and positive culture with any microorganism, at least one of which is bacteria of ≥102
CFU/ml
3. Specimen collected from indwelling catheter and positive culture with any microorganism, at least one of which is bacteria of ≥105
CFU/ml
NOTE: Yeast and other microorganisms which are not bacteria, are not acceptable UTI pathogens

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

ABUTI

January 2016

Page 9 of 13

NHSN Long-term Care Facility Component
Urinary Tract Infection

Table 2. Criteria for Defining UTI Events in NHSN LTCF Component.
Criterion
1a

Symptomatic Urinary Tract Infection (SUTI)
For residents without an indwelling catheter:
Either of the following (Signs & Symptoms):
1. Acute dysuria
2. Acute pain, swelling, or tenderness of the testes, epididymis, or prostate
AND
Either of the following (Laboratory and Diagnostic Testing):
1. Specimen collected from clean catch voided urine and positive culture
with no more than 2 species of microorganisms, at least one of which is
bacteria of ≥105 CFU/ml
2. Specimen collected from in/out straight catheter and positive culture with
any microorganism, at least one of which is bacteria of ≥102 CFU/ml

2a

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. Specimen collected from clean catch voided urine and positive culture
with no more than 2 species of microorganisms, at least one of which is
bacteria of ≥105 CFU/ml
2. Specimen collected from in/out straight catheter and positive culture with
any microorganism, at least one of which is bacteria of ≥102 CFU/ml

January 2016

Page 10 of 13

NHSN Long-term Care Facility Component
Urinary Tract Infection

Criterion
3a

Symptomatic Urinary Tract Infection (SUTI)
For residents without an indwelling catheter:
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. Specimen collected from clean catch voided urine and positive culture
with no more than 2 species of microorganisms, at least one of which is
bacteria of ≥105 CFU/ml
2. Specimen collected from in/out straight catheter and positive culture with
any microorganism, at least one of which is bacteria of ≥102 CFU/ml
+ Fever

can be used to meet SUTI criteria even if the resident has another
possible cause for the fever (e.g., pneumonia)

January 2016

Page 11 of 13

NHSN Long-term Care Facility Component
Urinary Tract Infection

Criterion

Catheter-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):
Fever+
Rigors
New onset hypotension, with no alternate non-infectious cause
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
1.
2.
3.
4.

AND
Any of the following:
If urinary catheter removed within last 2 calendar days:
1. Specimen collected from clean catch voided urine and positive culture with
no more than 2 species of microorganisms, at least one of which is bacteria
of ≥105 CFU/ml
2. Specimen collected from in/out straight catheter and positive culture with
any microorganism, at least one of which is bacteria of ≥102 CFU/ml
If urinary catheter in place:
3. Specimen collected from indwelling catheter and positive with any
microorganism, at least one of which is bacteria of ≥105 CFU/ml
+ Fever

can be used to meet SUTI criteria even if the resident has another possible
cause for the fever (e.g., pneumonia)

January 2016

Page 12 of 13

NHSN Long-term Care Facility Component
Urinary Tract Infection

Criterion

Asymptomatic Bacteremic Urinary Tract Infection (ABUTI)
Resident with or without an indwelling urinary catheter

1

No 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
One of the following:
1. Specimen collected from clean catch voided urine and positive culture with
no more than 2 species of microorganisms, at least one of which is bacteria
of ≥105 CFU/ml
2. Specimen collected from in/out straight catheter and positive culture with
any microorganism, at least one of which is bacteria of ≥102 CFU/ml
3. Specimen collected from indwelling catheter and positive culture with any
microorganism, at least one of which is bacteria of ≥105 CFU/ml
AND
A positive blood culture with at least 1 matching bacteria to the urine culture

COMMENTS
1. “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” often
represents contamination and likely represents presence of multiple organisms in culture.
2. Yeast and other microorganisms, which are not bacteria, are not acceptable UTI
pathogens.
3. Presence of a fever, even if due to another cause (e.g., pneumonia), should still be
counted as part of meeting a UTI definition. This change to the protocol is being made to
remove subjectivity about whether a fever is attributable to a UTI event.

January 2016

Page 13 of 13