3/3/2019 Infección del tracto urinario asociada con catéter en adultos - UpToDate

Autor: Thomas Fekete, MD

Editor de la sección: Stephen B Calderwood, MD
Editor Adjunto: Allyson Bloom, MD

Divulgaciones del contribuyente

Todos los temas se actualizan a medida que se dispone de nueva evidencia y se completa nuestro proceso de
revisión por pares .

Revisión de literatura vigente hasta: febrero 2019. | Este tema se actualizó por última vez: 2 de octubre de
2018.

INTRODUCCIÓN Los

catéteres urinarios se colocan por varios motivos, incluidos los diagnósticos y terapéuticos, así
como por conveniencia. La presencia de un catéter aumenta el riesgo de bacteriuria, que puede
ser clínicamente benigna o progresar a una infección grave. Existe una falta general de
consenso sobre el enfoque óptimo para las infecciones del tracto urinario asociadas con el
catéter, además de la eliminación de los catéteres cuando ya no son necesarios.

Los temas relacionados con la IU sintomática y la bacteriuria asintomática en pacientes con

catéteres de vejiga residentes se revisarán en este tema.

Las cuestiones relacionadas con la bacteriuria asintomática y la cistitis en otras circunstancias, y

las indicaciones para la colocación, los métodos de cateterización y el manejo y las
complicaciones de los catéteres de vejiga se tratan por separado. (Consulte "Aproximación al
adulto con bacteriuria asintomática" y "Cistitis aguda aguda en mujeres" y "Cistitis aguda aguda
en hombres" y "Colocación y tratamiento de catéteres de vejiga urinaria en adultos" y
"Complicaciones de catéteres de vejiga urinaria y estrategias preventivas" y "Infección aguda
aguda del tracto urinario (incluida la pielonefritis) en adultos" .

DEFINICIONES

Debido a que la presencia de bacterias en una muestra de orina puede representar

contaminación por bacterias que colonizan el área periuretral además de la bacteriuria de
vejiga, varios expertos han sugerido umbrales para el crecimiento bacteriano de una muestra de
orina que probablemente represente bacteriuria de vejiga verdadera en contextos específicos.

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grupos Las pautas de la Sociedad de Enfermedades Infecciosas de América (IDSA) definen la

bacteriuria asociada con el catéter de la siguiente manera [ 1 ]:

● 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. (See 'Asymptomatic
bacteriuria' below.)

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 [2]. 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 ≥105 cfu/mL of no more than two organism species (and does not include fungal
isolates or minor pathogens). The NHSN definition does not allow for other attribution of fever, so
it may overestimate the rate of clinically relevant catheter-related bacteriuria [3]. Furthermore,
because the NHSN definition sometimes changes, it can be difficult to compare infection rates
across time. As an example, one hospital-based study noted that the measured infection rate as
determined retroactively by the updated definition fell by half compared with the rate reported
using the old definition [4].

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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.

EPIDEMIOLOGY

Incidence — Bacteriuria in patients with indwelling bladder catheters occurs at a rate of

approximately 3 to 10 percent per day of catheterization [5,6]. 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].

Risk factors — The duration of catheterization is an important risk factor for catheter-associated
bacteriuria and UTI and is a major target of prevention efforts [11,12]. (See 'Prevention' below.)

Other risk factors include [13-15]:

● 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.)

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) [20].

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

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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.

MICROBIOLOGY

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 UTI in general. Specifically, Escherichia coli and other Enterobacteriaceae are
common, but Pseudomonas aeruginosa, enterococci, staphylococci, and fungi are also
significant causes. (See "Acute complicated urinary tract infection (including pyelonephritis) in
adults", section on 'Microbiology'.)

As an example, of approximately 154,000 catheter-associated UTIs reported by acute care

hospitals and long-term acute care facilities to the US National Healthcare Safety Network
(NHSN) between 2011 and 2014, the most common causative pathogens identified were [24]:

● E. coli — present in 24 percent of cases

● Candida spp (or yeast, not otherwise specified) — 24 percent
● Enterococcus spp — 14 percent
● P. aeruginosa — 10 percent
● Klebsiella spp — 10 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.
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Of the 10,800 E. coli catheter-associated isolates reported to the US NHSN in 2014, 35 percent
were resistant to fluoroquinolones, and 16 percent to advanced generation anti-pseudomonal
cephalosporins (ie, cefepime and ceftazidime) [24]. Of 4700 Klebsiella isolates, 9.5 percent were
resistant to carbapenems.

CLINICAL FEATURES

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
[1,7,26]. 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), 6 percent had dysuria, and 6 percent had 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 [1,26].

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]. 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. (See
'Pathogenesis' above.)

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
>105 colony 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.

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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 ≥105
cfu/mL or fungal growth in urine, although occasionally bacterial counts as low as 102 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 [1,26]. The spectrum of associated pathogens is discussed
elsewhere. (See 'Spectrum of organisms' above.)

DIAGNOSIS

General approach — The diagnosis of a catheter-associated UTI is made by the finding of

bacteriuria in a catheterized patient who has signs and symptoms that are consistent with UTI or
systemic infection that are otherwise unexplained. A UTI diagnosed in a patient who had a
catheter removed within the past 48 hours is also considered a catheter-associated UTI. (See
'Definitions' above.)

Consistent findings may be specific to the urinary tract (eg, costovertebral angle tenderness) or
may be more general, such as fever, leukocytosis, fall in blood pressure, metabolic acidosis, or
respiratory alkalosis. If the diagnosis is based on such nonspecific findings, the evaluation
should rule out the possibility of other infections (eg, bacteremia, pneumonia, skin or soft tissue
infection) prior to attributing them to a catheter-associated UTI.

Because the symptoms and signs of catheter-associated UTI can be nonspecific, a fair amount
of clinical judgment and individualization is required. As an example, although urine bacterial
counts as low as 102 cfu/mL have been associated with UTI without catheterization, the vast
majority of patients with catheter-associated UTI have counts ≥105 cfu/mL; thus it is reasonable
to have a higher threshold for attributing nonspecific symptoms to a UTI in the setting of lower
bacterial counts, particularly if the isolated organisms are not Enterobacteriaceae.

Certain findings, such as pyuria and the appearance or smell of the urine, should not be used to
diagnose a UTI when found in isolation. Pyuria is frequently found in catheterized patients with
bacteriuria, whether they have symptoms or not, and odorous or cloudy urine has not been
demonstrated to be indicative of either bacteriuria or UTI. On the other hand, the absence of
pyuria in a symptomatic catheterized patient suggests a diagnosis other than UTI. (See 'Clinical
features' above.)

Specimen collection — Ideally urine samples for culture should be obtained by removing the
indwelling catheter and obtaining a midstream specimen. If ongoing catheterization is needed,
the catheter should be replaced prior to collecting a urine sample for culture, to avoid culturing
bacteria present in the biofilm of the catheter but not in the bladder.

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Many systems have a "needleless" site that can be cleansed prior to specimen collection. If a
sample is being collected without catheter removal, urine should be obtained from the port in the
drainage system (figure 1) [30]. For circumstances in which the above approaches are not
possible, the culture should be obtained by separating the catheter from the drainage system.
Although this approach is associated with some risk of introducing microbes into the closed
system, culture results from urine collected from the drainage bag cannot be used to guide
treatment.

In the setting of condom catheters, it can be difficult to distinguish true infection from skin and
mucosal contamination [17,31]. In these cases, a clean catch midstream specimen should be
obtained, or urine should be collected from a freshly applied condom catheter after cleaning the
glans [31]. (See "Sampling and evaluation of voided urine in the diagnosis of urinary tract
infection in adults".)

TREATMENT

The approach to treatment of catheter-associated urinary tract infection (UTI) includes

antimicrobial therapy and catheter management.

Antimicrobial therapy — The approach to empiric antimicrobial therapy for patients with
catheter-associated UTI depends in part on the presentation and whether there are features that
suggest an infection that has extended beyond the bladder (which we use to distinguish acute
complicated UTI from acute simple cystitis). Most patients with catheter-associated UTI come to
clinical attention because of fever, flank pain, costovertebral angle tenderness, or systemic signs
or symptoms of infection in the setting of pyuria and bacteriuria; such cases are consistent with
acute complicated UTI and are managed as such. (See "Acute complicated urinary tract
infection (including pyelonephritis) in adults", section on 'Management'.)

Some patients, in particular those who have recently had catheter removal, present with isolated
symptoms of cystitis (eg, dysuria, urinary frequency or urgency) in the absence of fever or
features of ascending infection or prostatitis. Such patients can be managed as having acute
simple cystitis. (See "Acute simple cystitis in women" and "Acute simple cystitis in men".)

Antibiotic selection for both acute complicated UTI and acute simple cystitis takes into account
risk factors for resistant infection (informed by past urine cultures, use of antimicrobial therapy,
health care exposures, community prevalence of antimicrobial resistance) and antibiotic
allergies.

Once culture and susceptibility results are available, the antimicrobial regimen should be tailored
to the specific organism isolated. The approach to management of Candida UTIs is discussed
elsewhere. (See "Candida infections of the bladder and kidneys", section on 'Treatment'.)

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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) [1]. 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.

Catheter management — The optimal approach to catheter management in the setting of

urinary tract infection (UTI) is uncertain, although minimization of the use of indwelling catheters,
when possible, is preferred. In general, patients who no longer require catheterization should
have the catheter removed and receive appropriate antimicrobial therapy [32,33]. Patients who
require extended catheterization should be managed with intermittent catheterization, if possible.
(See "Placement and management of urinary bladder catheters in adults", section on 'Catheter
removal' and "Placement and management of urinary bladder catheters in adults", section on
'Clean intermittent catheterization'.)

Intermittent catheterization is associated with a lower rate of bacteriuria and UTI than long term
indwelling catheterization [34]. If long term catheterization is needed and intermittent
catheterization is not feasible, the catheter should be replaced at the initiation of antimicrobial
therapy [35]. Catheter replacement is associated with fewer and later relapses than retaining the
original catheter, as biofilm penetration of most antimicrobials is poor [36].

COMPLICATIONS

Important complications of catheter-associated urinary tract infections (UTIs) include sepsis,

bacteremia, and involvement of the upper urinary tract.

Approximately 20 percent of health care-associated bacteremias arise from the urinary tract, and
the mortality associated with this condition is about 10 percent [37]. In the intensive care unit
setting, a lower proportion of bacteremia is attributable to catheter-associated UTIs [1].

Upper tract infection is another important consequence of catheter associated urinary tract
infection. In an autopsy series of 75 nursing home patients, the incidence of renal parenchymal
inflammation was higher in those with a catheter in place at the time of death than in those who
were not catheterized (38 versus 5 percent) [38]. The implications of this finding are not known.

ASYMPTOMATIC BACTERIURIA

Bacteriuria in the absence of symptoms is very common among catheterized patients [7].
Treatment of asymptomatic bacteriuria does not affect patient outcomes, including the risk of
complications and or the subsequent development of UTI symptoms, and increases the
likelihood of emergence of resistant bacteria [1,39,40]. Thus, with few exceptions, screening and
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treatment for asymptomatic bacteriuria in catheterized patients is not indicated. (See "Approach
to the adult with asymptomatic bacteriuria", section on 'Whom not to treat'.)

Evaluating for asymptomatic bacteriuria in patients with indwelling catheters is warranted only in
the setting of pregnancy or prior to urologic procedures for which mucosal bleeding is anticipated
because of very specific risks of bacteriuria in these particular populations. (See "Urinary tract
infections and asymptomatic bacteriuria in pregnancy", section on 'Asymptomatic bacteriuria'
and "Approach to the adult with asymptomatic bacteriuria", section on 'Urologic intervention'.)

PREVENTION

In general, the most important aspects of prevention of catheter-associated urinary tract

infections (UTI) are avoidance of unnecessary catheterization, use of sterile technique when
placing the catheter, and removal of the catheter as soon as possible. As an example, in a
nationwide prospective study in the United States, implementing initiatives to reinforce these
concepts was associated with a decline in the baseline rate of catheter-associated UTIs in non-
intensive care units [41]. Similarly, in a Canadian study, there was a modest but sustained
reduction in post-operative UTI with a standardized approach to perioperative bladder
catheterization that followed these principles [42].

There is no clear benefit to using either antibiotic-coated urinary catheters or prophylactic

antibiotics to reduce the risk of catheter associated urinary tract infection. These and other
issues related to catheter care for prevention of UTI are discussed in detail separately. (See
"Placement and management of urinary bladder catheters in adults", section on 'Catheter care'
and "Placement and management of urinary bladder catheters in adults", section on 'To prevent
urinary tract infection' and "Placement and management of urinary bladder catheters in adults",
section on 'Catheter removal' and "Placement and management of urinary bladder catheters in
adults", section on 'Prophylactic antibiotics'.)

RECOMMENDATIONS OF OTHERS

Several expert and governmental groups have released guidelines or recommendations on the
identification, management, and prevention of catheter associated urinary tract infections (UTIs)
[1,12,37,43]. All of them stress restricting the use of indwelling catheters and those that address
treatment recommend avoidance of unnecessary antimicrobial use for asymptomatic bacteriuria.

The Infectious Diseases Society of America (IDSA), in collaboration with other international
expert groups, released practice guidelines on the diagnosis, prevention, and treatment of
catheter-associated UTI in 2009 [1]. The discussion in this topic is generally consistent with
those guidelines.

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In 2014, a collaborative panel sponsored by the Society for Healthcare Epidemiology of America
(SHEA) released recommendations on the prevention of catheter-associated UTI [12]. This
publication highlighted the importance of the judicious use of urethral catheters only for
appropriate indications, adequate expertise and sterile technique for insertion, continued
assessment of the necessity of catheterization, and maintenance of a sterile, continuously
closed drainage system that allows unobstructed urine flow.

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Urinary tract infections in
adults".)

SUMMARY AND RECOMMENDATIONS

● Catheter-associated urinary tract infections (UTIs) are a common health care-associated

infection. 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,
approximately 10 to 25 percent develop UTI. The most important risk factor is the duration
of catheterization. Other risk factors include errors in catheter care. (See 'Epidemiology'
above.)

● Fever is the most common symptom of catheter-associated UTI. Pyuria is usually present.
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, these
symptoms are not specific to UTI and may be seen in catheterized patients without
bacteriuria. Pyuria is also common in catheterized patients with bacteriuria without UTI.
(See 'Clinical features' above.)

● The diagnosis of a catheter-associated UTI is made by the finding of bacteriuria in a

catheterized patient who has signs and symptoms that are consistent with UTI or systemic
infection and are otherwise unexplained. Consistent findings may be specific to the urinary
tract or may be more general, such as fever, leukocytosis, malaise, or signs of sepsis. If the
diagnosis is based on such nonspecific findings, the evaluation should rule out the
possibility of other systemic infections (eg, bacteremia, pneumonia, skin or soft tissue
infection) prior to attributing them to a catheter-associated UTI. (See 'Diagnosis' above.)

● Ideally, urine samples for culture should be obtained by removing the indwelling catheter
and obtaining a midstream specimen or, if ongoing catheterization is warranted, a specimen

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through a new catheter. When this is not possible, the culture should be obtained through
the catheter port, not the drainage bag. (See 'Specimen collection' above.)

● Antimicrobial selection should be based upon the culture results when available. However,
in some cases, 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. Depending on the clinical response, the infecting organism, and the agent used for
treatment, 7 to 14 days of therapy is generally appropriate. (See 'Antimicrobial therapy'
above.)

● In general, patients with infection who no longer require catheterization should have the
catheter removed and receive appropriate antimicrobial therapy. Patients who require
extended catheterization should be managed with intermittent catheterization, if possible. If
long term catheterization is needed and intermittent catheterization is not feasible, the
catheter should be replaced at the initiation of antimicrobial therapy. (See 'Catheter
management' above.)

● Evaluating for asymptomatic bacteriuria in patients with indwelling catheters is warranted

only in the setting of pregnancy or prior to urologic procedures for which mucosal bleeding is
anticipated. For other asymptomatic patients with indwelling catheters, routine urine cultures
and urinalyses are not warranted and treatment of incidentally discovered asymptomatic
bacteriuria is not indicated. (See 'Asymptomatic bacteriuria' above.)

● Avoidance of unnecessary catheterization, use of sterile technique for insertion, and

removal as soon as possible are essential to the prevention of catheter-associated UTI.
Antimicrobial agents have no role in prevention of infection for the majority of patients with
urinary catheters. (See 'Prevention' above and "Placement and management of urinary
bladder catheters in adults".)

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Tema 8054 Versión 21.0

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