Catheter-Associated Urinary Tract Infections

Publication ID: 8923476198
Published on: February 2022
Major Revision: May 1, 2024


The annual death rate from catheter-associated urinary tract infections (CAUTI) in the US is estimated to be 9,000–13,000, costing the healthcare system approximately $450 million. Complications with CAUTIs are the leading cause of sepsis in adults over 65, which itself is the tenth leading cause of death in the US. Because 17%–69% of CAUTIs are preventable, heightened precautions should be taken in the monitoring and prevention of cases. Translating best practices into reliable frontline processes may be challenging due to human factors in an ever-changing environment; however, many healthcare organizations have successfully implemented and sustained improvements to mitigate the impacts of CAUTI by incorporating our blueprints.
Frontline staff

This blueprint outlines the steps that frontline staff can follow to prevent CAUTI:


  1. If an indwelling urinary catheter is present on admission, assess
  2. Check for signs of infection and assess for necessity and
  3. Consider the possibility of varied symptoms that may be somewhat
  4. Determine need for removal, insertion of new indwelling catheter, or use of alternative collection device.
  5. Adhere to aseptic

Routine Care

  1. Catheters should only be inserted if appropriate.
  2. Justify insertion of the catheter based on evidence-based recommendations, as the best way to prevent CAUTI is to avoid insertion in general.
  3. Appropriate indications for catheter use include:
    1. Urinary retention or bladder obstruction
    2. Voiding difficulties
    3. The need for measurements of output
    4. Use for long surgical procedures
    5. The need for intraoperative monitoring or urinary output
    6. Immobilization for a long period of time
    7. Comfort for end-of-life care
  4. Do not use indwelling catheters in place of nursing care or to obtain a urine culture when the patient is able to perform voluntarily.
    1. Consider alternatives to an indwelling catheter, such as intermittent catheterization or suprapubic catheters.
    2. Ask patients if they have a preference for which staff member (male or female) inserts the catheter and maintain the patient’s privacy (e.g., curtains, etc.).
  5. Minimize duration of catheter use.
    1. If inserted perioperatively, remove as soon as possible post-op.
    2. Consider the use of a bladder scanner to assist in determination of urine volumes.
  6. Certain steps should be included in day-to-day care to avoid and monitor for presence of infection.
    1. Ensure hand hygiene with soap and water is performed routinely by providers, patients, and visitors.
    2. Assess for catheter necessity and document. Ensure clarity of this assessment in the hand-off.
      1. Include patients and family members in the hand-off whenever possible. As the clinical hand-off is being conducted by a frontline clinician, watch the nonverbal communication of the patients and family members to try to understand unspoken needs.
    3. Select the best catheter size for the patient.
    4. Assess if an alternative/external urine collection device can be implemented.
    5. Conduct assessment of urine output.
    6. Adhere to aseptic technique.
    7. Perform meatal hygiene with unscented wash.
    8. Use sterile supplies/equipment.
      1. Catheter insertion kit (sterile gloves, drape, sponges)
      2. Antiseptic or sterile solution to clean meatal area
  • Lubricant jelly
  1. Maintain unobstructed urine flow.
  2. Keep the catheter and collecting tube free from kinking.
  3. Verify catheter securement device is in place.
  4. Ensure closed drainage system.
  5. Always keep the collecting bag below the level of the bladder. Do not rest the bag on the floor.
  6. Assess skin.
  7. Empty drain bag using a clean container and safe emptying practices. Do not hold the bag upside down while emptying, and empty the bag every eight hours (or when 2/3 full).
  8. Verify unobstructed flow.
  9. Unless contraindications exist, do not use antimicrobials routinely to prevent CAUTI.
  10. Encourage fluid intake of at least 2 liters if there isn’t a contraindication for fluids (e.g., CHF patients).


  1. Upon discharge, communicate with patient and patient family members the guidelines for catheter use and infection prevention.
  2. Assess necessity and promptly remove indwelling urinary catheters if no longer necessary.
  3. Assess for signs/symptoms of infection.
  4. If the patient is going home with an indwelling catheter in place, begin preparation for discharge as soon as possible while the patient is still in the hospital to allow for thorough education on maintenance, need, and next steps.
  5. Educate patients and family on CAUTI prevention, including maintenance information and expectations of catheter use based on the patient’s circumstance.
  6. If patient is being transferred, include indwelling urinary catheter information in report/hand-off. Anticipate gaps in the receiving clinician’s understanding of the hand-off report and work to mitigate these potential gaps early on.
  7. Anticipate the patient’s journey after they leave your direct care and screen for patient needs for future safety. Connect the patient with these resources, whether clinical resources or community-based resources.
  8. Remain sensitive to the patient’s spoken and unspoken needs (e.g., socioeconomic challenges that may compromise patient’s recovery). If resources don’t exist based on the needs of the patient, elevate this gap to leadership.

Education for Patients and Family Members

The following outlines information that should be conveyed to the patient and family members by someone on the care team in a consistent and understandable manner. In all communication with patients and family members, start by trying to understand their level of health literacy without making any implicit assumptions of their literacy level. Once this literacy level is established, work to communicate in this way in all discussions.

  1. Equip patients and family members with tools and knowledge needed to be involved in their loved one’s care (e.g., provide them with a copy of the care plan, ask to see their notes on their care plan, help them to maintain a log of assessments that should be and were conducted, etc.).
  2. Before providing information, ask how the patients and family members prefer to learn (e.g., verbal discussion, writing, etc.) and accommodate as much as possible (e.g., with pamphlets, etc.).
  3. Explain why a catheter is needed and what is involved in insertion. Ensure the patients do not misinterpret catheter insertion as a sexual procedure.
  4. Discuss what the care team is doing to prevent infection and how the patient and family members can get involved in prevention with tangible examples (e.g., wash hands, don’t touch the urine collection bag, etc.).
  5. Explain how long the catheter is expected to remain in place, provide the anticipated date of removal, and share any updates in the days leading up to removal. Make the information specific to their circumstance (e.g., “Based on your scheduled procedure, the catheter use may be increased by day(s)”).
  6. Explain the importance of removing the catheter as soon as possible and the implications of leaving the catheter in for extended periods of time, whether in the hospital or upon discharge.
  7. Indicate what patients and family members can watch out for. Patients and family members may be able to detect and raise a concern if:
    1. The catheter has been in for a long time. (Ensure patients and family members are clear about how long is long).
    2. They witness a lack of hand hygiene before manipulating the catheter (e.g., touching the door handle with gloves already on before manipulating the catheter).
    3. The position of the urine bag is not below the level of the bladder.
    4. The catheter tubing is twisted.
    5. The bag needs to be emptied or if the bag is about to overflow.
    6. There’s blood in the urine.
    7. A sterile pack is not used before catheterization. (Explain what a sterile pack looks like before making this recommendation.)
    8. There’s a lack of daily care from the care team.
  8. Instead of taking place, leaving capacity for questions and repeat-back strategies. When patients and family members understand the signs and symptoms that could be indicative of a problem, they are able to serve as an extra set of eyes in order to elevate this concern as early as possible.
  9. Questions patients and family members might ask:
    1. “Is this catheter necessary?”
    2. “How long will this catheter remain in place?”
    3. “Are there alternative methods?”
    4. “Why do I have a urinary catheter in place?”
Unit Managers

This guide outlines the steps that unit managers can follow to prevent CAUTI:

Use this checklist as a guide to determine whether current evidence-based guidelines are being followed in your organization:

  1. Ensure that the indications to place a catheter are correct and that an order has been placed for it.
  2. Ensure that the nurses that place the urinary catheter are properly trained in infection control.
  3. Measure and report CAUTI incidence monthly (CAUTI based on CDC NHSN definitions for all inpatient united [CDC, 2015]/total number of urinary catheter days for all patients with a urinary catheter in all tracked units). Note trends in areas with high incidence and prevalence. Routinely reassess outcomes.
  4. If CAUTI rates indicate room for improvement, initiate a PI (performance improvement) project. If a problem is not indicated, routinely reassess to identify gaps and ensure integrity of the data collected.
  5. Ensure that the staff are involved in the improvement effort.
    1. Ensure frontline involvement in CAUTI improvement activities. Maintain their engagement and remove barriers to progress.
  6. Understand how policies and procedures are helping staff champion the removal of the catheters when indicated.
  7. Assess whether the inappropriate insertion is due to a lack of knowledge about evidence-based indications for insertion or if it is due to other reasons.
  8. Ensure that CAUTI protocols are embedded into clinical workflows, whether electronic or paper. Involve all stakeholders as early as possible when making or planning a change that will impact their workflow.
  9. Ensure there are enough trained staff to effectively manage necessary preventive care.
  10. Ensure adequate training and documentation of CAUTI competencies and skills for all involved (e.g., train admitting staff properly to maintain a heightened sense of awareness for signs of CAUTI).
  11. Debrief on a regular basis to solicit team feedback about barriers to sustained compliance. Adjust the plan quickly and nimbly as needed. Create a standardized process for evaluation of fallouts.
  12. Acknowledge those doing the work for their successes using direct data tied to their behaviors.
  13. Engage with providers to obtain buy-in and compliance.
  14. Prioritize person-centeredness in the CAUTI initiative.
    1. Establish the expectation that each patient with a catheter will have a multidisciplinary team assessment and will be involved in decision making and hand-offs at every possible opportunity.
  15. Educate frontline clinicians about the impact of the invasive catheter insertion beyond the immediate point of care.
  16. Establish systems to help those on the frontline coordinate resources for patients when a need is identified. See Care Coordination AEBP.
  17. Establish a mechanism for those on the frontline to elevate patient needs identified that do not have an appropriate resource/solution (e.g., lack of transportation will compromise the patient’s ability to visit an outpatient provider after discharge).
  18. Ensure that leaders have a simple process to oversee CAUTI improvement work while also considering how it aligns with other initiatives across the organization.
    1. Establish an oversight committee to ensure alignment between all specific HAI committees.
    2. Standardize communication upon any changes (e.g., equipment, process, etc.).
  19. Assess vendor shortage mitigation plan and compare plans across multiple vendors.
    1. Determine the capacity for sourcing equipment from multiple areas in the case of an emergency.
  20. Ensure a performance improvement plan is put in place and reviewed regularly. The action plan should include the following steps:
    1. Assess the ability of the culture to change and adopt appropriate
    2. Revise policies and
    3. Redesign forms and electronic record
    4. Clarify patient and family education sources and
    5. Create a plan for changing documentation forms and
    6. Develop the communication
    7. Design the education
    8. Clarify how and when people will be held
  21. Consistently review, celebrate, and adjust strategies based on performance metrics. Discuss results with teams, address obstacles, and refine plans as necessary. Stay agile to maintain momentum while coordinating efforts with similar projects to maximize efficiency. 

CAUTI processes to consider assessing:

  1. Hand hygiene
  2. Environmental cleaning/equipment disinfection
  3. Teamwork and decision making:
    1. Routine CAUTI debrief and evaluation
    2. Documentation and justification of catheter insertion
    3. Evaluation of alternative methods aside from catheter use
    4. Routine evaluation of catheter necessity
    5. Diagnosing infection
Hospital Executives

This protocol outlines the steps that executives can follow to prevent CAUTI: 

The Problem

Urinary tract infections (UTIs) are infections involving any part of the urinary system, including urethra, bladder, ureters, and kidneys. UTIs are among the most common healthcare-associated infections (HAIs), accounting for up to 40% of infections reported in acute care hospitals.

Catheter-associated urinary tract infections (CAUTIs) are a frequent cause of harm and death in US hospitalized patients. Of all reported UTIs acquired in hospitals, up to 80% are associated with a urinary catheter—a thin, flexible tube put in a patient’s body to drain the urine from their bladder.

Because 17%–69% of CAUTIs are preventable, including 380,000 cases and 9,000 deaths annually, and because the Centers for Medicare and Medicaid (CMS) defined CAUTI as a non-payment infection, heightened precautions should be allocated to the monitoring and prevention of cases. Yet, translating the best practices into reliable frontline processes is immensely challenging due to human factors in an ever-changing environment.

The Cost

It is estimated that CAUTI is directly associated with an annual death rate of between 9,000 to 13,000 in the US. Annually, CAUTI alone costs the healthcare system $450 million, with significant capacity for an increase in cost upon acquisition of directly related complications, including urosepsis and septicemia. Complications with CAUTIs are the leading cause of sepsis in adults over 65, which itself is the 10th leading cause of death in the US.

Clinical Implications

There are an estimated 560,000 diagnosed UTIs in US hospitals each year, with a projected cost of $450 million. Healthcare-associated UTI frequency among all other HAIs is 12.9%, 19.6%, and 24% in the US, Europe, and developing countries, respectively. In the UK specifically, CAUTIs are associated with 45,717 additional bed days and 1,467 deaths.

CAUTI represents nearly 9% of all hospital-acquired infections, and 65% –70% of CAUTIs are believed to be completely preventable.

Financial Implication

Each CAUTI incident is associated with a cost of approximately $758, and cumulatively, a total of between $340 and $450 million is spent annually to treat CAUTI incidents in the US alone. Furthermore, CAUTIs are considered to be a preventable complication of hospitalization by the Centers for Medicare and Medicaid Services. As such, no additional payment is provided to hospitals for CAUTI treatment-related costs. Internationally, in the UK for example, total CAUTI-related direct hospital costs were estimated at £54.4 million.

Patient & Families

The following guide outlines the steps that patients and patient families can follow to prevent CAUTI:

As a patient or family member, it is vital that you understand the signs and symptoms of a catheter-related problem or infection. Family members can serve as an extra set of eyes to catch and bring attention to any concern as early as possible.

Questions patients or family members should ask about catheters:

  1. Is this catheter necessary?
  2. Are there alternative methods?
  3. Why do I have a urinary catheter in place?
  4. How long will this catheter remain in place?
  5. Am I going to be discharged with a catheter? If so, what do I need to do to avoid an infection at home?
  6. What are the signs and symptoms of a possible catheter-related infection?
  7. What should I do, who should I call, if I think there might be a problem with my catheter? 

To learn more about catheters, visit:


AHRQ. Toolkit To Reduce CAUTI and Other HAIs in Long-Term Care Facilities. (2019)

Clarke, K. et al. Catheter-Associated Urinary Tract Infections in Adults: Diagnosis, Treatment, and Prevention. (2020)

Meddings, J. et al. A Tiered Approach for Preventing Catheter-Associated Urinary Tract Infection. (2019)

NHS Southern Health. Urinary Catheter Care Guidelines (2020)

Patel, P., et al. Review of Strategies to Reduce Central Line-Associated Bloodstream Infection (CLABSI) and Catheter-Associated Urinary Tract Infection (CAUTI) in Adult ICUs (2017)

SGVD Catheter-associated urinary tract infection reduction in critical care units: a bundled care model. (2021)

Smith. D.R.M.  Epidemiology and health-economic burden of urinary-catheter-associated infection in English NHS hospitals: a probabilistic modelling study. (2019)

Urinary Retention Protocol Algorithm. (2013)