CATHETHER ASSOCIATED UTI

Intro, Def, Epi:

A urinary tract infection (UTI) is an infection involving any part of the urinary system, including
urethra, bladder, ureters, and kidney. UTIs are the most common type of healthcare-associated
infection reported to the National Healthcare Safety Network (NHSN). Among UTIs acquired in the
hospital, approximately 75% are associated with a urinary catheter, which is a tube inserted into the
bladder through the urethra to drain urine. Between 15-25% of hospitalized patients receive urinary
catheters during their hospital stay. The most important risk factor for developing a catheterassociated UTI (CAUTI) is prolonged use of the urinary catheter. Therefore, catheters should only be
used for appropriate indications and should be removed as soon as they are no longer needed.
Urinary tract infections (UTI) associated with urinary catheters are the leading cause of secondary
health care-associated bacteremia. Approximately 20 percent of hospital-acquired bacteremias arise
from the urinary tract, and the mortality associated with this condition is about 10 percent [1].
DEFINITIONS Because the presence of bacteria in a urine sample may represent contamination
by bacteria colonizing the periurethral area in addition to bladder bacteriuria, thresholds for bacterial
growth from a urine sample that is likely to represent true bladder bacteriuria in specific contexts have
been suggested by various expert groups. The Infectious Diseases Society of America (IDSA)
guidelines define catheter-associated bacteriuria as follows [2]:
Symptomatic bacteriuria (urinary tract infection [UTI]) Culture growth of 103 colony
forming units (cfu)/mL of uropathogenic bacteria in the presence of symptoms or signs
compatible with UTI without other identifiable source in a patient with indwelling urethral,
indwelling suprapubic, or intermittent catheterization. Compatible symptoms include fever,
suprapubic or costovertebral angle tenderness, and otherwise unexplained systemic symptoms
such as altered mental status, hypotension, or evidence of a systemic inflammatory response
syndrome.
Asymptomatic bacteriuria Culture growth of 105 cfu/mL of uropathogenic bacteria in the
absence of symptoms compatible with UTI in a patient with indwelling urethral, indwelling
suprapubic, or intermittent catheterization.
Patients who are no longer catheterized but had urethral, suprapubic, or condom catheters within the
past 48 hours are also considered to have catheter-associated UTI or asymptomatic bacteriuria if they
meet these definitions.
Because periurethral contamination is less likely in catheterized specimens, a relatively low threshold
for bacteria growth in a symptomatic patient is likely to represent true bladder bacteriuria. Although
the IDSA guidelines acknowledge that growth as low as 102 cfu/mL has been associated with bladder
bacteriuria in the setting of symptoms, the threshold of 103 cfu/mL was chosen since many labs do not
quantify growth below that threshold.
In contrast, use of a higher threshold in asymptomatic patients is reasonable given the low rate of
complications is this setting and the desire for increased specificity to reduce the overuse of
antimicrobials, even if bacterial growth does represent bladder bacteriuria.
These definitions are different from those used by the United States Centers for Disease Control and
Prevention (CDC) National Health Safety Network (NHSN), which were created for surveillance
purposes, not specifically for clinical care. The NHSN uses the same basic definition for asymptomatic

bacteriuria but defines catheter-associated UTI as the presence of fever, suprapubic tenderness, or
costovertebral angle pain in the setting of urine culture with bacterial counts 10 5 cfu/mL of no more
than two organism species. The NHSN definition does not allow for other attribution of fever, so it
may overestimate the rate of clinically relevant catheter-related bacteriuria [4]. The NHSN definitions
also make attempts to distinguish between hospital-acquired and pre-existing UTIs in order to allow
attribution to the institution where the urine was collected or to another facility.

An indwelling urinary catheter is 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. Alternative methods of urinary
drainage may be employed in some patients. Intermittent ("in-and-out") catheterization involves brief
insertion of a catheter into the bladder through the urethra to drain urine at intervals. An external
catheter is a urine containment device that fits over or adheres to the genitalia and is attached to a
urinary drainage bag. The most commonly used external catheter is a soft flexible sheath that fits over
the penis ("condom" catheter). A suprapubic catheter is surgically inserted into the bladder through an
incision above the pubis.
EPIDEMIOLOGY
Incidence Bacteriuria in patients with indwelling bladder catheters occurs at a rate of
approximately 3 to 10 percent per day of catheterization. Of those with bacteriuria, 10 to 25 percent
develop symptoms of urinary tract infection (UTI) [7-9].
This translates into a substantial burden of catheter-associated UTIs in hospitalized patients. In the
United States, based on surveillance data reported to the CDC National Healthcare Safety Network,
the incidence of catheter-associated UTIs in 2012 was 1.4 to 1.7 per 1,000 catheter days in inpatient
adult and pediatric medical/surgical floors [10].
Once a catheter is placed, the daily incidence of bacteriuria is 3-10%. Between 10% and 30% of
patients who undergo short-term catheterization (ie, 2-4 days) develop bacteriuria and are
asymptomatic. Between 90% and 100% of patients who undergo long-term catheterization develop
bacteriuria. About 80% of nosocomial UTIs are related to urethral catheterization; only 5-10% are
related to genitourinary manipulation.
MICROBIOLOGY/CAUSATIVE AGENTS
Catheter-related urinary tract infection (UTI) occurs because urethral catheters inoculate organisms
into the bladder and promote colonization by providing a surface for bacterial adhesion and causing
mucosal irritation.[1] The presence of a urinary catheter is the most important risk factor for bacteriuria.
The presence of potentially pathogenic bacteria and an indwelling catheter predisposes to the
development of a nosocomial UTI. The bacteria may gain entry into the bladder during insertion of the
catheter, during manipulation of the catheter or drainage system, around the catheter, and after
removal.
Spectrum of organisms The causative pathogens in catheter-associated urinary tract infection
(UTI) and asymptomatic bacteriuria are similar to those that are associated with complicated cystitis in
general. Specifically, Escherichia coli and other Enterobacteriaceae are common, but Pseudomonas
aeruginosa, enterococci, staphylococci, and fungi are also significant causes.

As an example, of approximately 20,000 catheter-associated UTIs reported by acute care hospitals and
long-term acute care facilities to the US National Healthcare Safety Network (NHSN) between 2009
and 2010, the most common causative pathogens identified were [24]:
E. coli present in 27 percent of cases
Enterococcus spp 15 percent
Candida spp 13 percent
P. aeruginosa 11 percent
Klebsiella spp 11 percent
Ambulatory patients with indwelling catheters tend to acquire urinary bacteria similar to those found
in hospitalized patients rather than the types usually seen in the outpatient setting. Prolonged
catheterization can be associated with polymicrobial bacteriuria or changing urinary flora.

Some of these organisms associated with catheter-related bacteriuria or funguria may lack some of the
virulence factors that allow the usual uropathogens to adhere to uroepithelium, but they take advantage
of easy access to the bladder via the catheter. A good example of such an organism is Candida spp,
which almost never cause UTI in the absence of an indwelling catheter. In contrast, candiduria is a
common finding in patients with indwelling bladder catheters, particularly in those who are taking
antimicrobials or are diabetic [25]. However, most patients are asymptomatic, funguria merely
represents colonization, and progression to candidemia is uncommon (1.3 percent in one series) [25].
This problem is discussed in detail separately. (See "Candida infections of the bladder and kidneys",
section on 'Infection versus colonization'.)
Antimicrobial resistance Organisms that cause catheter-associated UTI and asymptomatic
bacteriuria are increasingly resistant to antimicrobial agents.
Of the 5660 E. coli catheter-associated isolates reported to the US NHSN between 2009 and 2010, 31
percent were resistant to fluoroquinolones, and 12 percent to advanced generation anti-pseudomonal
cephalosporins (ie, cefepime and ceftazidime) [24]. Of 2300 Klebsiella isolates, 12.5 percent were
resistant to carbapenems.
Risk factors The duration of catheterization (prolonged usage/longer duration) is an important risk
factor for catheter-associated bacteriuria and UTI and is a major target of prevention efforts.
Other risk factors include
Female sex
Older age
Diabetes mellitus
Bacterial colonization of the drainage bag

Errors in catheter care (eg, errors in sterile technique, not maintaining a closed drainage system,
etc.)

diarrhea,

absence of antibiotics,

renal insufficiency,

catheterization late in the hospital course,

immunocompromised or debilitated states.

PATHOGENESIS Urinary tract infection (UTI) associated with catheterization may be

extraluminal or intraluminal. Extraluminal infection occurs via entry of bacteria into the bladder along
the biofilm that forms around the catheter in the urethra [16-19]. Intraluminal infection occurs due to
urinary stasis because of drainage failure, or due to contamination of the urine collection bag with
subsequent ascending infection. Extraluminal is more common than intraluminal infection (66 versus
34 percent in one study)

Symptoms
Abnormal urine color (cloudy urine)
Blood in the urine (hematuria)
Foul or strong urine odor
Frequent and strong urge to urinate
Pressure, pain, or spasms in your back or the lower part of your belly
Leakage of urine around the catheter
Other symptoms that may occur with a UTI:

Chills
Fatigue
Fever
Flank pain
Mental changes or confusion (these may be the only signs of a UTI in an elderly person)
Vomiting
Symptoms and signs Symptoms of catheter-associated urinary tract infection (UTI) are protean
and do not necessarily refer to the urinary tract. Fever is the most common symptom [2,7,26].
Localizing symptoms may include flank or suprapubic discomfort, costovertebral angle tenderness,
and catheter obstruction. Nonspecific findings include new-onset delirium or other systemic
manifestations that suggest the possibility of infection.
However, many catheterized patients without evidence of UTI or even bacteriuria may have similar
symptoms. As an example, in an observational study that included 89 hospitalized patients who
developed bacteriuria following placement of a urethral catheter, 18 percent had a temperature >38.5 C

(101.3 F) and only 6 percent each had dysuria or urinary urgency [7]. These symptoms were present in
the same proportion of 945 catheterized patients without bacteriuria.
Patients with spinal cord injury may have especially atypical and nonspecific symptoms, including
increased spasticity, malaise/lethargy, and autonomic dysreflexia. Individuals who develop UTI soon
after removal of a catheter may be more likely to have the typical urinary symptoms of dysuria,
frequency, and urgency.
Many patients believe that a cloudy appearance or foul smell of the urine is suggestive of the presence
of a UTI. However, neither of these findings has been demonstrated to be clearly associated with either
bacteriuria or a UTI [2,26].
Rarely, purple discoloration of the urine, collection bag, and tubing (purple urine bag syndrome
[PUBS]) can occur due to metabolic byproducts of certain bacteria that may be present in the system
[21]. Rarely, there can be purple discoloration of the urine, collecting bag, and tubing (the purple urine
bag syndrome) [21]. The purple color of the urine is due to metabolic products of biochemical
reactions formed by bacterial enzymes in the urine. Gastrointestinal tract flora break down the amino
acid tryptophan into indole, which is subsequently absorbed into the portal circulation and converted
into indoxyl sulfate. Indoxyl sulfate is then excreted into the urine, where it can be broken down into
indoxyl if the appropriate alkaline environment and bacterial enzymes (indoxyl sulfatase and indoxyl
phosphatase) are present. The breakdown products, indigo and indirubin, appear blue and red,
respectively [22,23]. Bacteria capable of producing these enzymes
include Providencia spp, Klebsiella, and Proteus.Risk factors include bacteriuria, constipation, and
female gender. PUBS is benign and has not been demonstrated to have any implication other than the
possibility of a UTI.
Laboratory findings Pyuria is a common finding in catheterized patients with bacteriuria, whether
they are symptomatic (ie, have UTI) or not. However, in a series of 761 catheterized patients,
quantitative urine WBC >10 cells/microL had low sensitivity for predicting growth of >105colony
forming units (cfu)/mL (47 percent) [27]. Specificity, on the other hand, was 90 percent. The vast
majority of these patients had no symptoms attributable to UTI.
By definition, all patients with catheter-associated UTI have bacteriuria or funguria. The vast majority
of patients with symptomatic bacteriuria (ie, UTI) have bacterial culture growth 10 5 cfu/mL or fungal
growth in urine, although occasionally bacterial counts as low as 10 2 cfu/mL have also been described
in individuals with UTI in the absence of a catheter [28,29]. The frequency of low count bacteriuria in
the setting of catheter-associated UTI is not clearly defined but expected to be very low [2,26]. The
spectrum of associated pathogens is discussed elsewhere.
Diagnosis - Urinary tract infection
Urinalysis and urine culture along with clinical findings are essential in differentiating asymptomatic
bacteriuria, cystitis and pyelonephritis. The presence of pyuria, bacteria, nitrites and leukocyte esterase
on urinalysis makes urinary tract infection likely.
Urinary tract infection is highly likely when the urine culture (obtained by transurethral
catheterization) is growing more than 100,000 colony-forming units/mL of a single organism. Urine
culture interpretation should be taken with caution as this may lead to overdiagnosis and subsequent
unnecessary evaluation and treatment. The following factors should be kept in mind when interpreting
urine cultures:

Number of colonies and species isolated

Method of sample collection
Time from collection to laboratory processing
Sex of the patient
Previous antibiotic use
Although imaging studies are controversial, they are recommended by most experts in evaluating
children with first-time urinary tract infection. Renal ultrasonography and voiding cystourethrography
are the 2 most commonly used modalities to evaluate for anatomical abnormalities. Renal
ultrasonography may also help detect abscesses or phlegmons in patients unresponsive to antibiotic
therapy.

Prevention
What are the recommended core strategies for prevention of CAUTI?

Insert catheters only for appropriate indications

Leave catheters in place only as long as needed
Ensure that only properly trained persons insert and maintain catheters
Insert catheters using aseptic technique and sterile equipment (acute care setting)
Following aseptic insertion, maintain a closed drainage system
Maintain unobstructed urine flow
Practice hand hygiene and standard (or appropriate isolation) precautions according to CDC
HICPAC guidelines

What are some examples of quality improvement programs that may ensure appropriate
urinary catheter utilization?
System of alerts or reminders to remove unnecessary catheters
Stop orders for urinary catheters
Protocols for nurse-directed removal of unnecessary catheters
Guidelines/algorithms for appropriate perioperative catheter management\
Are there new technologies that can help prevent CAUTI?
Portable ultrasound devices can be used to assess urine volume in order to reduce unnecessary
catheterizations in some patients. Currently, data supporting use of ultrasound bladder scanners are
limited; however, this is a promising technology for CAUTI prevention.
Antiseptic or antimicrobial-impregnated catheters, such as silver-alloy coated catheters, may also
reduce the risk of CAUTI. However, current data on the clinical benefit of such devices are also
limited. Antimicrobial/antiseptic-impregnated catheters should be considered if the CAUTI rate in
a facility is not decreasing despite implementing and documenting adherence to the core strategies
to reduce the risk of CAUTI. Certain high-risk patients may also benefit from these catheters, but
more research is needed.
Electronic medical record systems can also be utilized for CAUTI prevention efforts. Such systems
can be used to document indications for catheter placement and monitor dates and times of catheter

insertions and removals. Electronic alerts or reminders can also be used to prompt clinicians to
remove unnecessary catheters.
CATHETER CARE Ideal catheter care is easy to prescribe but difficult to achieve [82,83]. A
Danish study using questionnaires to assess knowledge of and adherence to optimal catheter
management protocols in hospitals and nursing homes showed moderate familiarity with written
guidelines but frequent irregularities in practice [84].
Meatal care Cleansing with soap and water around the catheter (periurethral, suprapubic) during
daily bathing is adequate for ongoing maintenance [56]. For urethral catheters, we do not use meatal
disinfectants or antibacterial urethral lubricants because they do not prevent infection, and may lead to
development of resistant bacteria at the meatus [85-88].
When the catheter or drainage system is manipulated for any reason, nonsterile gloves should be used
and then immediately discarded to limit transfer of pathogens from patient to patient. The bag should
be emptied regularly, avoiding contact of the drainage spigot with the collecting container [18,83].
Separate collecting containers should be used for each patient.
Managing leakage If leakage occurs around an established suprapubic catheter (>6 weeks after
placement) or transurethral catheter, the catheter can be replaced with a new catheter that is larger by 2
to 4 F.
Leakage can be due to detrusor overactivity/uninhibited bladder contractions, particularly in some
patients with neurologic conditions (eg, multiple sclerosis). In this setting, other approaches including
partially deflating the balloon, or treatment with antimuscarinic medications may be effective.
If leakage persists or the suprapubic catheter has been more recently placed, a urologist or
urogynecologist should be consulted.
Monitoring for obstruction/preventing backflow The catheter and collecting tubing should be
free from kinking and fixed to the patients leg by a strap or tape to prevent tugging or inadvertent
traumatic removal. The collection system must be positioned below the level of the bladder at all
times. Leg urinary collection bags that are strapped to the thigh are available for ambulatory use. If the
catheter or drainage system is manipulated to relieve an obstruction, gloves (nonsterile) should be
used.
Urine specimen collection Specimens should not be obtained from the drainage bag when
collecting urine for gram stain or culture. If specimens are required for other analysis (eg, creatinine
clearance) they can be obtained aseptically from the drainage bag [18,89,90]. Procedures for obtaining
urine samples for microbiologic analysis are discussed separately. (See "Catheter-associated urinary
tract infection in adults", section on 'Diagnosis'.)
Changing the catheter Indwelling catheters as a rule should not be replaced routinely; they should
not be changed if flow appears adequate [91]. Although there is a brief reduction in the density of
bacteria found in the urine following catheter replacement, this is a short-lived phenomenon of
uncertain benefit [92]. However, catheters with mechanical problems (poor drainage, encrusted) need
to be replaced.
Suprapubic catheters are generally managed by the operating surgeon and are not changed until a tract
between the bladder and abdominal wall is established, which usually requires four to six weeks. If the

catheter is accidentally pulled out within six weeks of its placement, the operating surgeon should be
notified.
Bladder irrigation Bladder irrigation is reserved for selected patients (eg, postoperative,
pharmacologic therapy) or for the management of hematuria. However, if a catheter is not draining
properly, it can be irrigated once with sterile saline [18]. If this is not effective, the catheter should be
replaced. If there is a suspicion that the latex catheter material contributed to the obstruction, the
catheter should be changed to a silicone catheter to reduce future encrustation.
Antimicrobial irrigation of the bladder does not appear to prevent or delay urinary tract infection;
rather, this practice may increase the risk for infection [93-95]. One randomized trial of 200
catheterized patients found no significant difference in the incidence of urinary tract infection for
patients treated with a neomycin-polymyxin bladder irrigant compared with no irrigation [93]. Patients
who received bladder irrigation were found to have more resistant organisms.
Other approaches to reduce the incidence of urinary tract infection associated with bladder catheters
include bacterial interference (purposeful inoculation of the bladder with nonpathogenic bacteria) and
use of bladder epithelial coating agents. Further investigation is required to determine whether these
are appropriate for routine use [96].
Catheter removal The simplest strategy for preventing catheter-related urinary tract infection is
catheter removal when the indication for insertion is no longer met. Removing an indwelling urethral
catheter is usually a matter of aspirating the balloon port with an empty syringe which deflates the
balloon; the catheter should then slip out. Suprapubic catheters are typically removed by the operating
surgeon once the indication for catheter placement has resolved. Beyond association with urinary tract
infection and the attendant complications, inappropriate use of indwelling catheters has been
associated with increased mortality, further highlighting the importance of catheter removal when it is
no longer needed. In a prospective study of 535 elderly hospitalized patients who had no medical
indication for catheterization, death within 90 days of hospital discharge was more likely among the
75 patients who received a catheter (25 versus 10 percent among those without a catheter) [97]. The
association remained despite adjustment for usual predictors of early mortality, suggesting that
catheters are hazardous in this setting, or more likely, there is a poorly defined but clear preference for
using catheters in patients who are likely to have a poor prognosis.
Following surgery, catheters should be removed as soon as possible (ideally in the recovery room) to
reduce the incidence of urinary tract infection [98,99]. A meta-analysis of 7 randomized trials found
fewer urinary tract infections when urinary catheters were removed within one day postoperatively
compared with three days (relative risk 0.50, 95% CI, 0.29-0.87) [99].
On occasion, clinicians may be unaware that their patient has a urinary catheter, especially if it had
been replaced after initial removal [100]. Reminders from nursing staff and implementation of
automatic stop orders reduce the duration of catheterization and incidence of catheter-associated
urinary tract infection [17,101]. A systematic review and meta-analysis of 14 studies that evaluated
reminder systems found a 52 percent reduction in the rate (episodes per 1000 catheter-days) of
catheter-associated urinary tract infection with the use of a reminder or stop order (rate ratio [RR]
0.48, 95% CI 0.28-0.69). The duration of catheterization was decreased by 37 percent [101].
Troubleshooting catheter removal The balloon of a urinary catheter may fail to deflate properly
due to a faulty valve mechanism or obstructed balloon channel. Obstruction is uncommon and is
typically due to the formation of crystals when saline rather than water is used to inflate the balloon,
and the catheter has been in place for a prolonged period of time.

The first line of action if the fluid within the balloon cannot be aspirated is to cut the valve (ie, balloon
port) from the catheter at its junction. This should result in immediate flow of water from the balloon.
To minimize the potential for urethral trauma, allow some time for the balloon to drain before
withdrawing the catheter. Rupturing the balloon by overinflation should not be attempted since balloon
fragmentation will result about 80 percent of the time requiring cystoscopy for retrieval [102]. If
cutting the valve fails to deflate the balloon, a urologist or urogynecologist should be consulted. He or
she will typically first try to maneuver a ureteric stylet through the inflation channel to dislodge the
obstruction. If this fails, the patient will need to be sedated and the balloon punctured sharply with a
spinal needle, using a transabdominal, transurethral, or transvaginal approach.
INDICATIONS FOR CATHETERIZATION The single most important factor for preventing
urinary catheter-related complications is limiting their use to appropriate indications (table 1) [5-7].
Urinary catheters are indicated in the following clinical situations:
Management of urinary retention with or without bladder outlet obstruction. (See "Clinical
manifestations and diagnosis of urinary tract obstruction and hydronephrosis" and "Acute urinary
retention", section on 'Options for bladder decompression'.)
Hourly urine output measurement in critically ill patients.
Daily urine output measurement for fluid management or diagnostic test.
During surgery to assess fluid status (ie, prolonged procedures, large volume fluid infusion).
During and following specific surgeries of the genitourinary tract or adjacent structures (ie,
urologic, gynecologic, colorectal surgery).
Management of hematuria associated with clots. (See "Etiology and evaluation of hematuria in
adults" and "Blunt genitourinary trauma: Initial evaluation and management".)
Management of immobilized patients (eg, stroke, pelvic fracture).
Management of patients with neurogenic bladder. (See "Chronic complications of spinal cord
injury and disease".)
Management of open wounds located in the sacral or perineal regions in patients who are
incontinent. (See "Clinical staging and management of pressure-induced injury".)
Intravesical pharmacologic therapy (eg, bladder cancer). (See "Treatment of primary nonmuscle invasive urothelial bladder cancer".)
Improved patient comfort for end of life care. (See "Palliative care: Issues specific to geriatric
patients".)
Management of patients with urinary incontinence following failure of conservative,
behavioral, pharmacologic and surgical therapy [8]. (See "Treatment of urinary incontinence in
women".)

Indwelling catheters should be removed if possible, to avoid persistence and recurrence of infection. In
some cases, removal of catheter may result in spontaneous resolution of bacteriuria or asymptomatic
cystitis.
Empiric antibiotic and antifungal therapy should be considered to avoid major complications,
including pyelonephritis, renal damage, and bloodstream infections. Duration of therapy is
controversial. Most experts recommend at least 10-14 days of therapy for children with sepsis,
pyelonephritis, or urinary tract abnormalitie

Antimicrobial therapy Antimicrobial therapy of catheter-associated UTI is similar to that for

acute complicated cystitis. This is discussed in detail elsewhere. (See "Acute complicated cystitis and
pyelonephritis", section on 'Treatment'.)
Antimicrobial selection should be based upon the culture results when available. However, in some
cases (eg, in septic or otherwise seriously ill patients, in the presence of major comorbidities) prompt
treatment is warranted prior to the availability of culture data. In such cases, empiric antimicrobial
choice should be tailored to results of past cultures, use of prior antimicrobial therapy, community
prevalence of antimicrobial resistance, and antimicrobial allergies of the patient. Urine Gram stain, if
available, can also guide empiric antimicrobial choice. If not available, empiric therapy should provide
coverage against gram-negative bacilli.
If the patient is not seriously ill, and one does not suspect multi-drug resistance, gram-negative bacilli
may be treated empirically with a third-generation cephalosporin (eg, ceftriaxone 1 g IV once daily
or cefotaxime 1 g IV every eight hours) or a fluoroquinolone (eg, ciprofloxacin at 500 mg PO or 400
mg intravenously twice a day or levofloxacin 250 to 500 mg PO or IV once daily). If the patient is
more seriously ill or if presence of multi-drug resistance is suspected (eg, any patient in the ICU or a
patient who has been in the hospital for several days), then broader spectrum empiric regimens should
be used. As an example, if P. aeruginosa is suspected, treatment with ciprofloxacin, ceftazidime (1 g
IV every eight hours) or cefepime (1 g IV every 12 hours) may be administered. If an extendedspectrum beta-lactamase (ESBL) producing organism is suspected (usually based on prior cultures),
treatment options are generally limited to a carbapenem. (See "Acute complicated cystitis and
pyelonephritis", section on 'Treatment'.)
Gram positive cocci on urine Gram stain may represent enterococci or staphylococci; empiric
management with vancomycin is generally appropriate pending further susceptibility data.
(See "Treatment of enterococcal infections".)
Once culture and susceptibility results are available, the antimicrobial regimen should be tailored to
the specific organism isolated. The optimal duration of therapy is uncertain. Depending on the clinical
response, the infecting organism, and the agent used for treatment, 7 to 14 days of therapy is generally
appropriate (with use of the longer end of this range for patients who respond slowly) [2]. Oral therapy
can be used for some or all of the treatment course if the organism is susceptible and the patient is well
enough to take oral medication with adequate absorption.
Antibiotics not recommended for asymptomatic bacteriuria with indwelling urethral catheter Remove
or change catheter if possible. Only consider antimicrobial treatment if bacteriuria persists 48hrs after
catheter removal

Acute
Uncomplicated
Pyelonephritis

If unhopitalised,
Ciprofloxacin (oral)
500mg every 12 hours for 7 days
with/ without an initial
Ciprofloxacin 400mg stat IV

Amoxycillin/Clavulanate (Oral)
625mg every 8 hours for 2 weeks

If hospitalised,
Ceftriaxone (Intravenous)
1-2g every 24 hours for 2 weeks
with/without aminoglycoside

Ciprofloxacin (Intravenous)
400mg every 12 hours for 7 days

OR
Amoxycillin/Clavulanate
(Intravenous)
1.2g every 8 hours for 2 weeks
Acute
Complicated
Pyelonephritis

If hospitalized
Amoxycillin/Clavulanate
(Intravenous)
1.2g every 8 hours
PLUS
Gentamicin (Intravenous)
5mg/kg every 24 hours

Ciprofloxacin (Intravenous)
200 - 400mg every 12 hours

OR
Cefoperazone (Intravenous)
1g every 12 hours

Other Hospital Acquired Infections (Nosocomial Infections)

Hospital-acquired infections are caused by viral, bacterial, and fungal pathogens; the most common
types are bloodstream infection (BSI), pneumonia (eg, ventilator-associated pneumonia [VAP]),
urinary tract infection (UTI), and surgical site infection (SSI).
Essential update: Study reports falling VAP and BSI rates in critically ill children
The incidence of central line-associated BSI and VAP declined significantly between 2007 and 2012 in
critically ill pediatric patients, according to a national cohort study of patients admitted to 173 neonatal
intensive care units (NICUs) and 64 pediatric intensive care units (PICUs). [1, 2] No change was
observed, however, in the rate of catheter-associated UTI.
In the NICUs, the rate of central line-associated BSI decreased from 4.9 to 1.5 per 1000 central-line
days during the study period; in the PICUs, the rate fell from 4.7 to 1.0 per 1000 central-line days.
[2]
The rate of VAP decreased from 1.6 to 0.6 per 1000 ventilator days in the NICUs and from 1.9 to 0.7
per 1000 ventilator days in the PICUs.

Signs and symptoms

Risk factors for catheter-associated BSI in neonates include the following [3] :

Catheter hub or exit-site colonization

Catheter insertion after the first week of life
Duration of parenteral nutrition
Extremely low birth weight (< 1000 g) at catheter insertion
Disruption of catheter dressings [4]
Pediatric ICU: Neutropenia, prolonged catheter dwell time (>7 days), percutaneously placed
central venous lines, frequent manipulation of lines [5]
Risk factors for candidemia in neonates include the following [6] :

Gestational age of less than 32 weeks

5-minute Apgar scores below 5
Shock, disseminated intravascular coagulation
Prior intralipid use
Parenteral nutrition, central venous line placement
H2 blocker administration
Intubation
Hospital stay longer than 7 days
Risk factors for VAP in pediatric patients include the following [7, 8] :

Reintubation
Genetic syndromes
Immunodeficiency, immunosuppression
Prior BSI [9]
Risk factors for hospital-acquired UTI in pediatric patients include the following [10] :

Bladder catheterization
Prior antibiotic therapy
Cerebral palsy
The source of infection may be suggested by the instrumentation, as follows:

Endotracheal tube: Sinusitis, tracheitis, pneumonia

Intravascular catheter: Phlebitis, line infection
Foley catheter: UTI
Patients with pneumonia may have the following:

Fever, cough, purulent sputum

Abnormal chest auscultatory findings (eg, decreased breath sounds, crackles, wheezes)
Patients with UTI may have the following:

Fever or normal temperature

Tenderness, suprapubic (cystitis) or costovertebral (pyelonephritis)

Cloudy, foul-smelling urine

See Clinical Presentation for more detail.
Diagnosis
Because not all bacterial or fungal growth on a culture is pathogenic and because such growth may
reflect simple microbial colonization, interpretation of cultures should take into account the following:

Clinical presentation of the patient

Reason for obtaining the test
Process by which the specimen was obtained
Presence or absence of other supporting evidence of infection
Methods used to diagnose and characterize BSIs include the following:

Suspected catheter-associated BSI: Differential time to positivity of paired blood cultures

(simplest) [11] ; quantitative culture of blood obtained from the catheter and peripheral vein;
quantitative culture of catheter segment
Suspected fungal infection: Fungal cultures
Possible thrombosis or vegetations: Imaging studies such as echocardiography
Immunocompromised patients: Occasional special studies (eg, cultures forNocardia, atypical
mycobacteria, cytomegalovirus [CMV], and CMV antigenemia)
Tests used to identify pneumonia include the following:

Acute-phase reactants
Oxygen saturation and hemodynamic studies
Chest radiography
Sputum Gram stain and culture (if necessary, samples can also be obtained through
bronchoalveolar lavage or thoracocentesis)
Rapid diagnostic tests, in specific cases
Urinalysis and urine culture, along with clinical findings, are essential for differentiating between
asymptomatic bacteriuria, cystitis, and pyelonephritis. The following factors should be kept in mind in
the interpretation of urine cultures:

Number of colonies and species isolated

Method of sample collection
Time from collection to laboratory processing
Sex of the patient
Previous antibiotic use
Although imaging studies are controversial, they are recommended by most experts in evaluating
children with first-time UTI.
See Workup for more detail.

Management
Medical care includes symptomatic treatment of shock, hypoventilation, and other complications,
along with empiric broad-spectrum antimicrobial therapy.
Management of BSI may include the following:

Line removal as appropriate [11]

Antibiotic therapy covering gram-positive and gram-negative organisms, started empirically
and then tailored according to specific susceptibility patterns
Antifungal therapy as appropriate
Antiviral therapy as appropriate
Prevention through use of catheter disinfection caps
Management of pneumonia includes the following:

Initial empiric broad-spectrum antibiotic therapy, later streamlined on the basis of identified
organisms and susceptibilities, with attention to the risk of multidrug-resistant (MDR) pathogens
Antiviral medications against influenza for symptomatic patients and patients with
immunodeficiency or chronic lung diseases to limit morbidity and mortality
Management of UTI includes the following:

Removal of indwelling catheters if possible

Empiric antibiotic and antifungal therapy
Management of SSI includes the following:

Surgical debridement
Antibiotic therapy