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uro.cauti.v1

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

urologyacuteadultgeriatric
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Frame

Detailed

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)

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Patient inputs (23)

Retention vs perioperative vs comfort-only — HOUDINI mnemonic drives removal decision; comfort-only is NOT an indication (IDSA 2019)

Geriatric / nursing home — atypical presentation (altered mental status, delirium, sepsis without dysuria) (IDSA 2019)

Recent broad → MDR risk; recent FQ → avoid empiric FQ (Tamma 2019)

Prior ESBL → empiric ertapenem; prior CRE / KPC → ID consult + carbapenem-sparing alternative (Tamma 2019/2020)

Long-dwell + healthcare exposure → empiric antipseudomonal (cefepime / pip-tazo) (IDSA 2019)

SOT, hematologic malignancy, chronic steroid — broader empirics + ID consult low threshold (IDSA 2019)

Dysuria, urgency, suprapubic pain emerging within 48 h after catheter removal — qualifies as CAUTI per IDSA 2019

Atypical CAUTI presentation in geriatric / IC — fever may be absent (IDSA 2019)

Indwelling urethral / suprapubic / intermittent / external (condom) drive different management; biofilm bias greatest with indwelling (IDSA 2019 PMID 20175247)

>30 d → long-dwell, polymicrobial / biofilm-resistant; ≤7 d → typical empiric coverage suffices (IDSA 2019)

Pregnancy — treat ASB even in catheter context (USPSTF 2019)

Pyuria + symptoms — diagnosis support; pyuria alone in catheterised patient is NOT diagnostic (IDSA 2019)

Culture ≥10^3 CFU/mL from FRESH catheter sample (replace before culture to minimise biofilm bias); pre-replacement sample is biofilm-biased (IDSA 2019)

Leukocytosis → severity; thrombocytopenia → sepsis (SCC 2026)

AKI staging + dose adjustment (KDIGO AKI 2026)

Flank / costovertebral angle tenderness → pyelo overlap; route to uro.pyelonephritis.v1 alongside source control (IDSA 2019)

Fever ≥38.0°C in catheterised patient without alternative source — strongly suggests CAUTI (IDSA 2019)

Hypotension + fever → urosepsis ICU (SCC 2026)

Anticoagulant + cephalosporin / FQ interaction; warfarin + sulfa INR rise; methotrexate + sulfa toxicity (FDA)

Pre-instrumentation with mucosal trauma — treat ASB single-course before procedure (USPSTF 2019)

Bacteremia in CAUTI prolongs course to 10–14 d; STAT if febrile / septic (IDSA 2019; SCC 2026)

CRP/PCT for bacterial vs viral / severity adjunct (panel.inflammation)

Renal US if obstruction concern (IDSA 2019; AUA 2016)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (14)

14 need judgement
  • informationallife_threateningCAUTI_with_sepsis
    CAUTI + qSOFA ≥2 OR hypotension → urosepsis; route to id.sepsis.core.v1 sepsis bundle (1-hour antibiotic + crystalloid + lactate-guided) (SCC 2026)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepseudomonal_cauti_long_term
    Long-term catheterised + Pseudomonas aeruginosa culture — antipseudomonal cefepime / pip-tazo / meropenem per susceptibility (IDSA 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereESBL_KPC_resistant_cauti
    Prior or current ESBL E. coli / Klebsiella → ertapenem; KPC / CRE → ID consult + novel agents (Tamma IDSA 2019/2020 PMID 33106864)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereCAUTI_with_pyelonephritis
    CAUTI + fever + flank pain → upper-tract overlap; route to uro.pyelonephritis.v1 alongside source control + extend duration (IDSA 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatesymptomatic_cauti_remove_replace_catheter
    Catheterised (or recently de-catheterised <48 h) patient with pyuria + symptoms + culture ≥10^3 CFU/mL — symptomatic CAUTI; remove or replace catheter and treat (IDSA 2019 PMID 20175247)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepolymicrobial_cauti_long_dwell
    Long-dwell catheter (>30 d) + polymicrobial culture — biofilm-driven; broader empirics; narrow per dominant susceptibility (IDSA 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatebiofilm_resistant_cauti
    Persistent symptoms / persistent positive cultures despite culture-directed therapy — biofilm-resistant; catheter replacement mandatory + ID consult (IDSA 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecandiduria_symptomatic
    Catheterised + symptomatic candiduria OR immunocompromised OR pre-procedure — fluconazole 200 mg PO daily × 14 d (or 400 mg if severe); remove catheter (IDSA candiduria 2009)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateintermittent_cath_recurrent_uti
    Intermittent self-catheterisation + recurrent breakthrough UTI — distinct phenotype; counsel sterile vs clean technique, hydration; consider prophylaxis with caution (IDSA 2019; AUA 2022)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatesupra_pubic_catheter_associated
    Suprapubic catheter + new symptoms — similar management to indwelling urethral; replace before culture; abx + source control (IDSA 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatenursing_home_cauti
    Nursing home resident with catheter — atypical presentation (delirium / sepsis without classic urinary symptoms); high MDR exposure; lower threshold for empiric broader coverage; rule out alternative source (IDSA 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildasymptomatic_bacteriuria_DO_NOT_TREAT
    Positive culture WITHOUT urinary symptoms in catheterised patient — DO NOT TREAT except in pregnancy or pre-urologic procedure with mucosal trauma (IDSA 2019; USPSTF 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildcandiduria_asymptomatic_DO_NOT_TREAT
    Yeast in urine in catheterised patient WITHOUT symptoms — DO NOT TREAT; remove or replace catheter; over-treatment drives resistance (IDSA candiduria 2009)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildcatheter_removal_after_treatment_replacement_protocol
    Replace catheter BEFORE culture and abx; remove catheter ASAP after treatment if HOUDINI permits — explicit IDSA 2019 protocol; minimises biofilm bias and recurrence
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

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Recommended regimen

CAUTI — source control (remove / replace catheter) + empiric ceftriaxone / cefepime / pip-tazo / ertapenem (per risk) + candiduria fluconazole + ASB DO-NOT-TREAT doctrine
axis: cauti_source_control_and_targetedstep 1 - STEP 1 — Source control (HOUDINI mnemonic; remove or replace catheter)
Selected step "STEP 1 — Source control (HOUDINI mnemonic; remove or replace catheter)" — All CAUTI episodes
  • Remove indwelling catheter when feasible (HOUDINI: Haematuria, Obstruction, Urinary retention, Decubitus ulcer healing, Input/output strict monitoring required, Not for incontinence alone, Immobility severe, end-of-life)
    first line
    procedure
    triggers: catheter_in_place, no_hard_indication_per_HOUDINI
    IDSA 2019 — primary intervention; biofilm cannot be cleared with abx alone (PMID 20175247)
  • Replace catheter BEFORE culture and treatment (if retained)
    first line
    procedure
    triggers: catheter_must_remain
    IDSA 2019 — minimises biofilm bias in culture and exposes new mucosa to abx; replacement is bundled with treatment initiation
  • Convert to intermittent self-cath when feasible
    second line
    procedure
    triggers: recurrent_cauti_chronic_indwelling
    IDSA 2019 / AUA 2022 — fewer biofilm episodes than indwelling; education + supplies

outpatient playbook — drug actions (4)

  1. 1. replace catheter before culture (or remove per HOUDINI)
    procedure • procedure • once
    trigger: Symptomatic CAUTI
    IDSA 2019 source control + minimise biofilm bias
  2. 2. cefpodoxime (empiric PO)
    100 mg PO BID × 7 d • PO • BID
    trigger: No prior MDR / Pseudomonas risk; PO-tolerant
    IDSA 2019 outpatient empiric
  3. 3. TMP-SMX (alternative if susceptible)
    160/800 mg PO BID × 7 d • PO • BID
    trigger: Local resistance <20%; culture susceptible
    IDSA 2019 alternative
  4. 4. fluconazole (candiduria symptomatic)
    200 mg PO daily × 14 d • PO • once daily
    trigger: Symptomatic candiduria + catheter
    IDSA candiduria 2009

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Patient with indwelling catheter develops fever, suprapubic pain, CVA tenderness, dysuria after removal, or new altered mental status (IDSA 2009/2019 CAUTI); Positive culture ≥10^3 CFU/mL in catheterised patient — ASYMPTOMATIC bacteriuria is the default; treat only if symptomatic (IDSA 2019); Long-dwell catheter (>30 d) — polymicrobial / biofilm-resistant pattern (IDSA 2019).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Catheter-Associated UTI (CAUTI) — indwelling / suprapubic / intermittent / long-term** (uro.cauti.v1).
Phenotype framing: 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)
Scope: 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)

No severity triggers fired against current inputs.

Plan

Regimen axis: **CAUTI — source control (remove / replace catheter) + empiric ceftriaxone / cefepime / pip-tazo / ertapenem (per risk) + candiduria fluconazole + ASB DO-NOT-TREAT doctrine** — step "STEP 1 — Source control (HOUDINI mnemonic; remove or replace catheter)".
1. Remove indwelling catheter when feasible (HOUDINI: Haematuria, Obstruction, Urinary retention, Decubitus ulcer healing, Input/output strict monitoring required, Not for incontinence alone, Immobility severe, end-of-life) (procedure, first line) — IDSA 2019 — primary intervention; biofilm cannot be cleared with abx alone (PMID 20175247)
2. Replace catheter BEFORE culture and treatment (if retained) (procedure, first line) — IDSA 2019 — minimises biofilm bias in culture and exposes new mucosa to abx; replacement is bundled with treatment initiation
3. Convert to intermittent self-cath when feasible (procedure, second line) — IDSA 2019 / AUA 2022 — fewer biofilm episodes than indwelling; education + supplies

Setting playbook (outpatient) — Symptomatic CAUTI in stable, PO-tolerant outpatient — replace catheter (or remove if HOUDINI permits) + obtain culture from FRESH sample + empiric cefpodoxime 100 mg PO BID × 7 d; tailor by culture (IDSA 2019)
4. replace catheter before culture (or remove per HOUDINI) procedure procedure once — Symptomatic CAUTI (IDSA 2019 source control + minimise biofilm bias)
5. cefpodoxime (empiric PO) 100 mg PO BID × 7 d PO BID — No prior MDR / Pseudomonas risk; PO-tolerant (IDSA 2019 outpatient empiric)
6. TMP-SMX (alternative if susceptible) 160/800 mg PO BID × 7 d PO BID — Local resistance <20%; culture susceptible (IDSA 2019 alternative)
7. fluconazole (candiduria symptomatic) 200 mg PO daily × 14 d PO once daily — Symptomatic candiduria + catheter (IDSA candiduria 2009)

Non-pharmacologic actions:
- Patient + caregiver education — return precautions (worsening, fever, no improvement at 48–72 h)
- 48–72 h follow-up call; culture at 24–48 h → narrow / broaden per susceptibility
- HOUDINI prompt for ongoing catheter need
- Discuss conversion to intermittent self-cath if recurrent

AVOID / contraindication checks:
- Asymptomatic_bacteriuria_DO_NOT_TREAT_except_pregnancy_or_pre_procedure (USPSTF / IDSA 2019)
- CAUTI_remove_catheter_when_possible_HOUDINI (IDSA 2019 PMID 20175247)
- CAUTI_replace_catheter_before_culture_if_retained_to_minimise_biofilm_bias (IDSA 2019)
- CAUTI_do_NOT_treat_ASB_in_catheterised_patients_drives_resistance (IDSA 2019)
- Nitrofurantoin_avoid_in_CAUTI_pyelonephritis_overlap_no_renal_tissue_penetration (IDSA 2019)
- Fluoroquinolones_FDA_black_box_tendinopathy_aortic_CNS_dysglycemia (FDA 2016)
- Fluoroquinolones_avoid_throughout_pregnancy_cartilage (FDA)
- Carbapenem_CNS_lowered_seizure_threshold_renal_dose_adjust (FDA)
- ESBL_use_ertapenem_first_meropenem_sparing (Tamma 2019/2020)
- CRE_KPC_MDR_ID_consult_mandatory_tailored_per_susceptibility (Tamma 2020)
- Fluconazole_hepatotoxicity_QTc_drug_interactions (FDA)
- Fluconazole_avoid_asymptomatic_candiduria_drives_resistance (IDSA candiduria 2009)
- Amphotericin_B_systemic_nephrotoxicity_use_bladder_irrigation_only_for_localised (IDSA)
- Cefepime_neurotoxicity_in_renal_impairment_monitor (FDA)
- Pip_tazo_AKI_risk_with_vancomycin_combination (FDA)
- Catheter_culture_pre_replacement_biofilm_bias_use_post_replacement_sample (IDSA 2019)

Monitoring

Regimen monitoring:
- symptom resolution by 48 to 72h (IDSA 2019)
- urine culture results at 24 to 48h adjust per susceptibility (IDSA 2019)
- reassess for pyelonephritis if fever or flank pain develops (IDSA 2019)
- recheck after catheter removal or replacement (IDSA 2019)
- blood culture clearance if bacteremic total 10 to 14d (IDSA 2019)
- daily HOUDINI catheter indication prompt (IDSA 2019)
- fluconazole LFTs QTc during extended courses (FDA)
- recurrent cauti consider conversion to intermittent self cath (AUA 2022)
- cefepime mental status in renal impairment (FDA)

Setting (outpatient) monitoring:
- Symptom resolution at 48–72 h (IDSA 2019)
- Culture results at 24–48 h (IDSA 2019)
- Treatment failure → admit

Follow-up plan: 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)
- Close-out criterion: follow-up + catheter-care plan documented

Monitoring phase: 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)

Disposition

Current setting: outpatient — Symptomatic CAUTI in stable, PO-tolerant outpatient — replace catheter (or remove if HOUDINI permits) + obtain culture from FRESH sample + empiric cefpodoxime 100 mg PO BID × 7 d; tailor by culture (IDSA 2019)

Disposition criteria:
- Discharge with oral abx + 48–72 h follow-up + return precautions (IDSA 2019)
- Admit if fever / sepsis / non-PO / pregnancy with new symptoms

Escalation triggers (move to higher acuity):
- Treatment failure at 48–72 h → admit
- Fever + flank pain → ED (pyelo overlap)
- Sepsis screen positive → ED
- Pregnancy + new symptoms → STAT OB / ED

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] CAUTI + qSOFA ≥2 OR hypotension → urosepsis; route to id.sepsis.core.v1 sepsis bundle (1-hour antibiotic + crystalloid + lactate-guided) (SCC 2026)
- [SEVERE] Long-term catheterised + Pseudomonas aeruginosa culture — antipseudomonal cefepime / pip-tazo / meropenem per susceptibility (IDSA 2019)
- [SEVERE] Prior or current ESBL E. coli / Klebsiella → ertapenem; KPC / CRE → ID consult + novel agents (Tamma IDSA 2019/2020 PMID 33106864)

Citations

- IDSA 2010 Hooton CAUTI guideline + IDSA Asymptomatic Bacteriuria 2019 (Nicolle) + IDSA 2020 MDR-GNB (Tamma — ESBL/CRE/DTR) + IDSA acute uncomplicated cystitis/pyelonephritis 2011 (Gupta) + IDSA Candidiasis 2016 (Pappas — candiduria) [PMID:20175247](https://pubmed.ncbi.nlm.nih.gov/20175247/)
- Cited evidence (PMID 30895288) [PMID:30895288](https://pubmed.ncbi.nlm.nih.gov/30895288/)
- Cited evidence (PMID 33106864) [PMID:33106864](https://pubmed.ncbi.nlm.nih.gov/33106864/)
- Cited evidence (PMID 21292654) [PMID:21292654](https://pubmed.ncbi.nlm.nih.gov/21292654/)
- Cited evidence (PMID 26679628) [PMID:26679628](https://pubmed.ncbi.nlm.nih.gov/26679628/)

Last reconciled with current guidelines: 2026-05-22.
References
  • IDSA 2010 Hooton CAUTI guideline + IDSA Asymptomatic Bacteriuria 2019 (Nicolle) + IDSA 2020 MDR-GNB (Tamma — ESBL/CRE/DTR) + IDSA acute uncomplicated cystitis/pyelonephritis 2011 (Gupta) + IDSA Candidiasis 2016 (Pappas — candiduria) — PMID:20175247
  • Cited evidence (PMID 30895288) — PMID:30895288
  • Cited evidence (PMID 33106864) — PMID:33106864
  • Cited evidence (PMID 21292654) — PMID:21292654
  • Cited evidence (PMID 26679628) — PMID:26679628