Clinical Commander

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uro.cauti.v1

Catheter-Associated UTI (CAUTI) — indwelling / suprapubic / intermittent / long-term

urologyacuteadultgeriatricinpatientacuteoutpatient
Start encounter →Print handoutPRODUCTION

shard-3-neuro-sym Phase C wave-11 2026-05-15 — initial author at INTEGRATED with full §5.5 contract depth. 14 acuity / context phenotypes encoded as severity_triggers covering full CAUTI spectrum: symptomatic_cauti_remove_replace_catheter, asymptomatic_bacteriuria_DO_NOT_TREAT, polymicrobial_cauti_long_dwell, biofilm_resistant_cauti, pseudomonal_cauti_long_term, ESBL_KPC_resistant_cauti, candiduria_asymptomatic_DO_NOT_TREAT, candiduria_symptomatic, CAUTI_with_sepsis (routes to id.sepsis.core.v1), CAUTI_with_pyelonephritis (routes to uro.pyelonephritis.v1), catheter_removal_after_treatment_replacement_protocol, intermittent_cath_recurrent_uti, supra_pubic_catheter_associated, nursing_home_cauti. 5 setting playbooks span home (long-term prevention + HOUDINI) → outpatient (replace catheter + empiric PO) → ed (STAT culture from fresh sample + IV empiric + admit if severe) → inpatient (IV-to-PO step-down + daily HOUDINI + total 7 d minimum) → icu (id.sepsis.core.v1 bundle + source control mandatory). IDSA 2009/2019 doctrine: source control is primary; remove catheter via HOUDINI mnemonic when feasible OR replace before culture/abx to minimise biofilm bias; empiric ceftriaxone for typical, cefepime / pip-tazo for Pseudomonas risk, ertapenem for ESBL, ID consult for KPC/CRE; total 7 d minimum (10–14 d if delayed response or bacteremia). ASB DO-NOT-TREAT doctrine: NEVER treat ASB in catheterised patients except pregnancy or pre-urologic procedure with mucosal trauma. Over-treatment drives MDR + CDI (USPSTF / IDSA 2019). Candiduria: treat ONLY if symptomatic / IC / pre-procedure (fluconazole 200 mg PO daily × 14 d). DO NOT treat asymptomatic candiduria; remove or replace catheter (IDSA candiduria 2009). Sibling pivots: uro.uti.uncomplicated.v1 (no catheter exposure pivot), uro.uti.complicated.v1 (other complicating factor without catheter), uro.pyelonephritis.v1 (upper-tract overlap routing), id.sepsis.core.v1 (urosepsis routing) — all resolve to real engines in ALL_DOSSIERS. 2026-05-22 citation remediation — all PMIDs live-verified on PubMed; mis-attributed placeholders replaced with verified anchors; RxCUIs reverse-verified on RxNav. Dossier registered in _registry.ts as part of this commit (Phase C wave-11 commit-race v2; shard-3 explicit scope). Schema-blocked downstream: calc.cauti_symptom_score, protocol.cauti_remove_catheter_pivot, workup.bladder_scan, workup.catheter_culture_post_replacement — none yet in clinical-tools-registry.ts. Tickets surfaced in depth brief §10.

Entry points (7)

  • history
    Patient with indwelling catheter develops fever, suprapubic pain, CVA tenderness, dysuria after removal, or new altered mental status (IDSA 2009/2019 CAUTI)
    indwelling_catheter_with_new_symptoms
  • lab_abnormality
    Positive culture ≥10^3 CFU/mL in catheterised patient — ASYMPTOMATIC bacteriuria is the default; treat only if symptomatic (IDSA 2019)
    positive_urine_culture_in_catheterised_patient
  • history
    Long-dwell catheter (>30 d) — polymicrobial / biofilm-resistant pattern (IDSA 2019)
    long_dwell_catheter_gt_30d
  • history
    Suprapubic catheter + new urinary or systemic symptoms (IDSA 2019)
    suprapubic_catheter_with_symptoms
  • history
    Intermittent self-catheterisation + recurrent UTI breakthrough — distinct phenotype (IDSA 2019; AUA 2022)
    intermittent_self_cath_recurrent_uti
  • history
    Nursing home resident with catheter — atypical presentation (delirium / sepsis without classic urinary symptoms) (IDSA 2019)
    nursing_home_resident_with_new_symptoms
  • lab_abnormality
    Funguria — only treat if symptomatic / IC / pre-procedure (IDSA candiduria 2009)
    candiduria_in_catheterised_patient

Required inputs (23)

  • catheter_typerequired
    history • used at FRAME
    Indwelling urethral / suprapubic / intermittent / external (condom) drive different management; biofilm bias greatest with indwelling (IDSA 2019 PMID 20175247)
  • catheter_dwell_time_daysrequired
    history • used at FRAME
    >30 d → long-dwell, polymicrobial / biofilm-resistant; ≤7 d → typical empiric coverage suffices (IDSA 2019)
  • catheter_indicationrequired
    history • used at CONTEXT
    Retention vs perioperative vs comfort-only — HOUDINI mnemonic drives removal decision; comfort-only is NOT an indication (IDSA 2019)
  • pregnancy_statusrequired
    demographic • used at FRAME
    Pregnancy — treat ASB even in catheter context (USPSTF 2019)
  • agerequired
    demographic • used at CONTEXT
    Geriatric / nursing home — atypical presentation (altered mental status, delirium, sepsis without dysuria) (IDSA 2019)
  • recent_antibioticsrequired
    history • used at CONTEXT
    Recent broad → MDR risk; recent FQ → avoid empiric FQ (Tamma 2019)
  • prior_esbl_or_kpc_culturerequired
    history • used at CONTEXT
    Prior ESBL → empiric ertapenem; prior CRE / KPC → ID consult + carbapenem-sparing alternative (Tamma 2019/2020)
  • pseudomonas_risk_factorsrequired
    history • used at CONTEXT
    Long-dwell + healthcare exposure → empiric antipseudomonal (cefepime / pip-tazo) (IDSA 2019)
  • immunosuppressionrequired
    history • used at CONTEXT
    SOT, hematologic malignancy, chronic steroid — broader empirics + ID consult low threshold (IDSA 2019)
  • pre_urologic_procedure_scheduled
    history • used at CONTEXT
    Pre-instrumentation with mucosal trauma — treat ASB single-course before procedure (USPSTF 2019)
  • urinary_symptoms_after_removalrequired
    symptom • used at ENTRY
    Dysuria, urgency, suprapubic pain emerging within 48 h after catheter removal — qualifies as CAUTI per IDSA 2019
  • cva_tendernessrequired
    symptom • used at RED_FLAGS
    Flank / costovertebral angle tenderness → pyelo overlap; route to uro.pyelonephritis.v1 alongside source control (IDSA 2019)
  • new_altered_mental_statusrequired
    symptom • used at ENTRY
    Atypical CAUTI presentation in geriatric / IC — fever may be absent (IDSA 2019)
  • temprequired
    vital • used at RED_FLAGS
    Fever ≥38.0°C in catheterised patient without alternative source — strongly suggests CAUTI (IDSA 2019)
  • sbprequired
    vital • used at RED_FLAGS
    Hypotension + fever → urosepsis ICU (SCC 2026)
  • urinalysis_post_catheter_replacementrequired
    lab • used at INITIAL_WORKUP
    Pyuria + symptoms — diagnosis support; pyuria alone in catheterised patient is NOT diagnostic (IDSA 2019)
  • urine_culture_post_replacementrequired
    lab • used at INITIAL_WORKUP
    Culture ≥10^3 CFU/mL from FRESH catheter sample (replace before culture to minimise biofilm bias); pre-replacement sample is biofilm-biased (IDSA 2019)
  • cbcrequired
    lab • used at INITIAL_WORKUP
    Leukocytosis → severity; thrombocytopenia → sepsis (SCC 2026)
  • bmprequired
    lab • used at INITIAL_WORKUP
    AKI staging + dose adjustment (KDIGO AKI 2026)
  • blood_cultures
    lab • used at INITIAL_WORKUP
    Bacteremia in CAUTI prolongs course to 10–14 d; STAT if febrile / septic (IDSA 2019; SCC 2026)
  • crp_pct
    lab • used at INITIAL_WORKUP
    CRP/PCT for bacterial vs viral / severity adjunct (panel.inflammation)
  • renal_us_if_obstruction_or_anatomic
    imaging • used at INITIAL_WORKUP
    Renal US if obstruction concern (IDSA 2019; AUA 2016)
  • current_medsrequired
    medication • used at TREATMENT
    Anticoagulant + cephalosporin / FQ interaction; warfarin + sulfa INR rise; methotrexate + sulfa toxicity (FDA)

12-phase flow (12)

  1. 1FRAME
    Patient with indwelling / suprapubic / intermittent catheter (or recently removed within 48 h) develops new urinary or systemic symptoms — CAUTI pathway. Pivot: classic UTI without catheter exposure → uro.uti.uncomplicated.v1 or uro.uti.complicated.v1; fever + flank pain → also engage uro.pyelonephritis.v1; sepsis with shock → id.sepsis.core.v1 (IDSA 2019)
    inputs: catheter_type, catheter_dwell_time_days, pregnancy_status
    advance: engine scope confirmed
  2. 2ENTRY
    Fever / suprapubic pain / CVA tenderness / dysuria after removal / new altered mental status in catheterised patient → CAUTI entry; isolated positive culture without symptoms is ASB (do not treat in non-pregnant non-pre-procedure) (IDSA 2019)
    inputs: urinary_symptoms_after_removal, new_altered_mental_status
    advance: entry captured
  3. 3CONTEXT
    Catheter type, dwell time, indication (HOUDINI), pregnancy, immunocompromise, prior MDR culture, Pseudomonas risk, pre-procedure plans, recent abx (IDSA 2019; Tamma 2019; USPSTF 2019)
    inputs: catheter_indication, age, recent_antibiotics, prior_esbl_or_kpc_culture, pseudomonas_risk_factors, immunosuppression, pre_urologic_procedure_scheduled, current_meds
    advance: context complete
  4. 4RED_FLAGS
    Fever + flank pain → pyelonephritis overlay (route to uro.pyelonephritis.v1); hypotension / shock → urosepsis ICU (id.sepsis.core.v1 bundle); obstruction → STAT decompression; pregnancy + fever → admit (IDSA 2019; SCC 2026)
    inputs: temp, cva_tenderness, sbp
    advance: no red flags OR routes engaged
  5. 5INITIAL_WORKUP
    REPLACE catheter (if retained) BEFORE culture to minimise biofilm bias; STAT UA + urine culture from fresh sample; CBC + BMP; blood cultures × 2 if febrile / septic; renal US if obstruction concern (IDSA 2019; SCC 2026)
    inputs: urinalysis_post_catheter_replacement, urine_culture_post_replacement, cbc, bmp, blood_cultures, crp_pct, renal_us_if_obstruction_or_anatomic
    actions: panel.ua, panel.renal, panel.cbc, panel.inflammation
    advance: workup complete
  6. 6BRANCHING_WORKUP
    Long-dwell + polymicrobial → narrow per dominant susceptibility; ESBL → ertapenem; Pseudomonas → cefepime / pip-tazo; CAUTI + sepsis → route to id.sepsis.core.v1; CAUTI + pyelo → route to uro.pyelonephritis.v1; candiduria — only treat if symptomatic / IC / pre-procedure (IDSA 2019; Tamma 2019)
    advance: pathway selected
  7. 7DIFFERENTIAL
    Symptomatic CAUTI vs catheter-associated ASB vs candiduria (asymptomatic colonisation vs symptomatic infection) vs pyelo overlap vs urosepsis vs alternative source of fever (line-related bacteremia, CDI, pneumonia) (IDSA 2019)
    advance: differential narrowed
  8. 8RISK_STRATIFICATION
    Severity (sepsis screen / qSOFA), dwell time, host immunocompetence, prior MDR history, source-control feasibility (catheter removal / replacement) (IDSA 2019; SCC 2026)
    advance: tier selected
  9. 9TREATMENT
    STEP 1 source control — remove catheter when feasible (HOUDINI) OR replace before culture; STEP 2 empiric (ceftriaxone for typical; cefepime / pip-tazo for healthcare-associated or Pseudomonas risk; ertapenem if prior ESBL; carbapenem + ID for KPC); STEP 3 tailor by culture; STEP 4 duration 7 d minimum, 10–14 d if delayed response or bacteremia; STEP 5 candiduria — fluconazole 200 mg PO daily × 14 d ONLY if symptomatic / IC / pre-procedure; STEP 6 NEVER treat ASB except pregnancy or pre-procedure (IDSA 2019; Tamma 2019; USPSTF 2019)
    inputs: current_meds
    advance: regimen prescribed + source control plan documented
  10. 10DISPOSITION
    Outpatient if PO-tolerant + low-risk + reliable follow-up; admit if pregnancy + pyelo / sepsis / non-PO / IC severe / obstruction; ICU if urosepsis with shock (IDSA 2019; SCC 2026)
    advance: disposition documented
  11. 11MONITORING
    Symptom resolution at 48–72 h; culture results at 24–48 h → narrow / broaden per susceptibility; daily fever curve inpatient; recheck after catheter removal / replacement (IDSA 2019)
    advance: monitoring plan documented
  12. 12FOLLOWUP
    Catheter-care bundle (HOUDINI prompt every shift); urology referral if recurrent CAUTI / chronic catheterisation; intermittent self-cath education if applicable; do NOT screen / treat ASB unless pregnancy or pre-procedure (IDSA 2019; USPSTF 2019)
    advance: follow-up + catheter-care plan documented