The programme of surveillance of Catheter Associated Urinary Tract Infections (CAUTIs)
commenced in April 2004. Surveillance of CAUTI is a voluntary surveillance programme
which is available to all those acute and primary care divisions who would like
For further information on this programme contact
Sonja Millar in the first instance.
Project Manager: Jane McNeish, Senior Nurse Epidemiologist, Scottish Surveillance HAI Programme
Scientific Lead: Dr Jodie McCoubrey, Epidemiologist, HAI Surveillance
Why do surveillance in CAUTI?
Epidemiology of Healthcare Associated
Urinary Tract Infections
Urinary tract infections (UTI) are the most common infections acquired in hospitals
and long-term care facilities. Early studies estimate the incidence of healthcare
associated UTIs at around 2-3 patients per 100 admissions and this is supported
by the more recently published Plowman Report (Plowman et al, 1999; Kreiger et al,
1983 and Turck and Stamm, 1981). A number of risk factors for healthcare associated
UTI have been suggested and it is now well established that the major predisposing
factor for healthcare associated UTI is the presence of an indwelling urethral catheter.
Several studies have indicated that between 75 and 80% of all healthcare associated
UTIs follow the insertion of a urinary catheter (Bryan and Reynolds 1984 and Turck
and Stamm, 1981) and a study investigating 40 English hospitals estimated that around
26% of all hospitalised patients have a urinary catheter inserted during their stay
in hospital (Glynn et al, 1997).
The problem of CAUTIs in long-term care facilities such as nursing homes is well
recognised, however the full extent of the problem has not been fully established.
Use of catheters is common in long term care facilities and many patients are catheterised
for long periods, thus increasing their risk of acquiring a CAUTI. One study which
investigated male patients in a nursing home illustrates the problem of CAUTI in
long term care of the elderly. During the one-year study period 80% of patients
had at least one CAUTI and 48% of patients had two or more CAUTIs (Ouslander, 1987).
Costs associated with Healthcare Associated UTI
The costs associated with healthcare associated UTIs result from additional diagnostic
testing, treatment regimes and increased hospital stays of on average 5-6 days.
The Plowman report published in 1999 estimated the additional NHS costs of treating
a healthcare associated UTI were £1327 per case and the national burden of healthcare
associated UTI was approximately £125 million per annum. The majority of theses
costs result from extended hospital stays for the large numbers of patients affected
by UTI and this places a significant burden on the healthcare system.
There are also considerable costs to the patient in terms of increased morbidity
and mortality. CAUTI are also associated with bacteraemia, increased mortality and
may lead to complicated infections of the urinary tract (Bryan and Reynolds, 1984
and Platt et al, 1982).
What are the risks for CAUTI?
A number of research studies have demonstrated that there may be associated risk
factors for CAUTI. Factors including a history of previous catheter use, the duration
the catheter is in situ , the length of hospital stay prior to catheter insertion,
the reason for and location of catheter insertion (Leone et al, 2003; Stamm, 1991;
Bryan and Reynolds, 1984 and Garibaldi et al, 1974).
The relationship between the duration the catheter is in situ and the development
of CAUTI is well established. A number of studies have demonstrated an association
between bacteriuria and the duration the catheter is in situ . One study reported
that the risk of developing bacteriuria increased by 5% for each additional day
the catheter is in situ and that after the tenth day, 50% of patients had acquired
bacteruria (Garibaldi et al, 1974). Shapiro et al, (1984) demonstrated that a catheter
in situ for more than seven days was a risk factor for acquiring a CAUTI.
Innate risk factors such as gender, increasing age and general debilitation are
associated with CAUTIs. Females are at increased risk of acquiring UTIs due to the
relative ease with which bacteria colonising the perineum can reach the urethra
and in common with other HAIs it is frequently the elderly and debilitated that
are at risk of acquiring infections (Hussain et al, 1996).
Who can participate in the CAUTI surveillance programme?
Surveillance of CAUTI is a voluntary surveillance programme which is available to
all acute and primary care divisions who wish to participate. Participation for
a minimum of 3 months is required, however it is recommended that sites participate
for six months.
Specialties included in surveillance
As listed in the protocol, surveillance of CAUTI can be carried out in any of the
Geriatric Medicine (Care of the Elderly) *
Haematology (including bone marrow transplantation)
Nephrology (including renal transplantation)
* Geriatric Psychiatric and Geriatric Medicine units have been chosen to include
Trauma & Orthopaedics
Gynaecology & Obstetrics
Which patients can be included in the surveillance?
All patients who have an indwelling urinary catheter inserted in
the specialty chosen for surveillance are included.
Details of the surveillance programme can be found in the Catheter Associated Urinary
Tract Infection Protocol and Resource Pack.
Data Collection for CAUTI Surveillance
Staff collect data at local level, the data can be collected on paper forms or on
electronic forms. All data are returned to SSHAIP for quality checking and reporting
on a quarterly basis.
Paper Data Collection
Paper forms are supplied to sites by HPS and should be returned on a monthly basis
for processing. The data are quality checked at HPS and any anomalous data are returned
to staff for checking locally.
Electronic Data Collection
An innovative electronic data collection tool has been developed for the CAUTI surveillance
project. The data collection tool can be run from a Tablet PC or a laptop. This
data collection tool comprises an "on-screen" data collection form which
is displayed on the Tablet PC/laptop screen. Data is then entered directly to the
"on-screen" form. Once data has been entered to the electronic data collection
form it is automatically stored in the database for transfer to the SSHAIP team
The data are quality checked at HPS and any anomalous data are returned to staff
for checking locally.
How are the data reported?
A standard report is provided on a quarterly basis. In addition, an annual report
for all sites participating in CAUTI Surveillance is published.
Training in the data definitions and data collection process is provided to all
staff who are involved in CAUTI surveillance.
Training resources can also been downloaded for training at local level.
Audit Tool for Urinary Catheterisation and Catheter
In addition to surveillance of CAUTI, the SSHAIP Team have developed an Audit Tool
for urinary catheterisation. The audit tool was developed to audit against the Best
Practice as laid out in the NHS Quality Improvement Scotland Statement for Urinary
Catheterisation and Catheter Care. The Audit Tool can be used in combination with
CAUTI surveillance or it can be used independently.
Audit of Best Practice for Urinary Catheterisation
and Catheter Care
Under guidance from an expert working group a set of audit tools to measure current
practice and policies for urinary catheterisation and catheter care against the
standards set out in the BPS have been developed. The current set of audit tools
focuses on indwelling catheters, audit tools for supra pubic and intermittent catheters
will be developed in the future.
Audit of urinary catheterisation and catheter care practices will act as the basis
to implementation of the best practices and improvements in patient care, including
CAUTI. The audit tool can be used in conjunction with surveillance or it may be
used independently to measure the quality of urinary catheter care.
The Audit Tools
A series of audit tools have been developed to facilitate audit of policy and practice;
observational audit; knowledge and self-reported audit; audit of catheter materials
management and audit of patient care documentation.
Each of the tools can be used alone or in conjunction with one another. The set
of tools will facilitate audit in priority areas at local level.
Auditors could include ICNs, surveillance nurses, ward nurses, theatre nurses, community
nurses or another suitable member of the multidisciplinary team. This would be agreed
at local level.
More information on the audit tool and a copy of the data collection tools can be
found in the CAUTI surveillance protocol.
Bryan CS and Reynolds KL (1984). Hospital-acquired bacteraemic urinary infection:
epidemiology and outcome. Journal of Urology 132:494-8.
Garibaldi RA, Burke JP, Dickman ML and Smith CB (1974). Factors predisposing to
bacteriuria during indwelling urethral catheterisation. The New England Journal
of Medicine 291:213-219.
Hussain M, Oppenheim P, O'Neill C et al (1996). Prospective survey of the incidence,
risk factors and outcome of hospital-acquired infections in the elderly. Journal
of Hospital Infection 32:117-126.
Krieger JN, Kaiser DL and Wenzel RP (1983). Urinary tract aetiology of blood stream
infections in hospitalised patients. Journal of Infectious Diseases 148:57-62.
Leone M, Albanese J, Garnier F, Sapin C, Barrau K, Bimar MC Martin C. Risk factors
of nosocomial catheter-associated urinary tract infection in a polyvalent intensive
care unit (2003). Intensive Care Medicine 29:929-32.
Ouslander JG, Greengold B and Chen S (1987). Complications of chronic indwelling
urinary catheters among male nursing home patients: a prospective study. Journal
of Urology 138:1191-5
Platt R, Polk BF,Murdock B, Rosner B (1982). Mortality associated with nosocomial
urinary tract infection. New England Journal of Medicine 307(11):637-42.
Shapiro M, Simchen E, Izraeli S and Sacks TG (1984). A multivariate analysis of
risk factors for acquiring bacteruria in patients with indwelling urinary catheters
for longer than 24 hours. Infection Control 5:525-532.
Stamm WE (1991). Catheter-associated urinary tract infections, epidemiology, pathogenesis
and prevention. The American Journal of Medicine 91(3B):65S-71S.
Turck A and Stamm W (1981). Nosocomial infection of the urinary tract. American
Journal Medicine 70:651-654.