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Figure.  Catheter-Associated Urinary Tract Infections During 2015 to 2019
Catheter-Associated Urinary Tract Infections During 2015 to 2019
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    Research Letter
    April 22, 2020

    Incidence of Catheter-Associated Urinary Tract Infections With Compliance With Preventive Guidelines

    Author Affiliations
    • 1Baylor College of Medicine, Surgery, Houston, Texas
    • 2Michael E. DeBakey, Veterans Affairs Medical Center, Surgery, Houston, Texas
    JAMA Surg. 2020;155(7):661-662. doi:10.1001/jamasurg.2020.0428

    The term never event, first introduced in 2001 by Ken Kizer and the National Quality Forum, has been adopted by the US Center for Medicare and Medicaid Services (CMS) to describe preventable hospital-acquired conditions, such as catheter-associated urinary tract infections (CAUTI).1 Between 60% and 75% of CAUTIs are avoidable when appropriate preventive strategies are used.2,3 Guidelines were introduced in 2005 through the Surgical Care Improvement Project by the US Centers for Disease Control and Prevention in attempt to prevent CAUTIs. In 2008, CMS stopped reimbursing hospitals for treatment of CAUTI as part of what it now known as the Hospital-Acquired Condition Reduction Program, with the goal of making CAUTIs a never event.1 However, despite these guidelines and payment penalties, CAUTIs continue to occur and cause significant morbidity for patients. We describe the incidence of CAUTI in a large academic medical center and show that even with prevention guideline adherence, CAUTI cannot truly be a never event.


    This retrospective study was conducted on patients admitted to surgical units in the Michael E. DeBakey Veterans Affairs Medical Center, a tertiary care academic medical center, from October 1, 2015, to July 30, 2019. Institutional review board approval was obtained, without need for consent owing to the use of deidentified data. We examined CAUTI rates (defined as number of CAUTIs per catheter days) and assessed each episode of CAUTI to determine whether the foley was removed within 48 hours as per Surgical Care Improvement Project guidelines. Catheter-associated urinary tract infections are captured by TheraDoc, a program that tracks all hospital-acquired infections based on culture results. For catheters not removed within 48 hours, we examined whether there was a US Centers for Disease Control and Prevention–appropriate indication for continued indwelling urinary catheter use (urinary retention or bladder outlet obstruction, need for accurate measurements of urinary output, genitourinary tract surgery, receiving large volume infusions or diuretics, sacral or perineal wounds in incontinent patients, prolonged immobilization, comfort for end-of-life care, or other appropriate indication such as prolonged effect of epidural anesthesia).4 For each infection, the microbiology was collected. Yearly CAUTI rates were collected.


    A total of 20 467 surgical patients were analyzed. Within this population, 16 CAUTIs were identified. The most common microorganism causing UTI was Escherichia coli, followed by Pseudomonas aeruginosa. In all patients who developed CAUTIs, there was documentation of removal of the foley catheter within 48 hours or an appropriate indication for continued use. Specifically, 6 of 16 CAUTIs (37.5%) had urinary catheter removal within 48 hours, and the other 10 cases (62.5%) had an appropriate indication for continued catheter use, including chronic neurogenic bladder, need for strict urinary output measurements, hematuria, urinary retention, or epidural. An overall decrease in CAUTI rates (2015, 0.7; 2019, 0) was observed from 2015 to 2019 (Figure).


    There is clear evidence that in-dwelling catheter placement lasting longer than 48 hours is associated with an increased risk of developing a UTI, with long-term catheter exposure being linked to an increase in polybacteriuric culturing UTI.3,5,6 Efforts to reduce unnecessary catheter use are critically important in reducing CAUTIs. However, we demonstrate that although labeled as a never event, CAUTIs are not truly a never event. There are limitations with this study, as this is retrospective data examined at a single institution.

    Despite strict adherence to prevention guidelines, this study shows that CAUTIs still occur. This suggests that risk factors exist that may make certain patients more susceptible to CAUTI that are not currently addressed. Future studies are warranted in patient groups that develop CAUTIs despite guideline adherence to determine other risk factors for CAUTIs that should be addressed during patient treatment. Risk determination would also allow for a risk-adjusted rate of CAUTIs to be developed and reported rather than an absolute rate, which would better represent the occurrence of CAUTIs within specific patient subpopulations.

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    Article Information

    Corresponding Author: SreyRam Kuy, MD, MHS, Veterans Integrated Service Network 16, United States Department of Veterans Affairs, 2002 Holcombe Blvd, Houston, TX 77030 (

    Accepted for Publication: February 4, 2020.

    Published Online: April 22, 2020. doi:10.1001/jamasurg.2020.0428

    Author Contributions: Dr Kuy had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Kuy, Awad.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: All authors.

    Critical revision of the manuscript for important intellectual content: Kuy, Gupta, Awad.

    Statistical analysis: Kuy, Gupta, Awad.

    Administrative, technical, or material support: Kuy.

    Supervision: Kuy, Awad.

    Conflict of Interest Disclosures: None reported.

    Author Contributions: We thank Lissy Joseph MSN, RN, CNL, and Stacie Henson (Michael E DeBakey Veterans Affairs Medical Center) for their important contributions in data collection for this study. No compensation was received from a funding sponsor for such contributions.

    Meeting Presentation: This study was presented at the 2020 Academic Surgical Congress National Conference; February 5, 2020; Houston, Texas.

    Austin  JM, Pronovost  PJ.  “Never events” and the quest to reduce preventable harm.   Jt Comm J Qual Patient Saf. 2015;41(6):279-288. doi:10.1016/S1553-7250(15)41038-4PubMedGoogle Scholar
    Umscheid  CA, Mitchell  MD, Doshi  JA, Agarwal  R, Williams  K, Brennan  PJ.  Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs.   Infect Control Hosp Epidemiol. 2011;32(2):101-114. doi:10.1086/657912PubMedGoogle ScholarCrossref
    Wald  HL, Ma  A, Bratzler  DW, Kramer  AM.  Indwelling urinary catheter use in the postoperative period: analysis of the national surgical infection prevention project data.   Arch Surg. 2008;143(6):551-557. doi:10.1001/archsurg.143.6.551PubMedGoogle ScholarCrossref
    Gould  C, Umscheid  C, Agarwal  R, Kuntz  G, Pegues  D; Healthcare Infection Control Practices Advisory Committee (HICPAC). Guidelines for prevention of catheter associated urinary tract infections 2009 (updated June 6, 2019). Accessed December 23, 2019.
    Catheter Associated Urinary Tract Infections. Atlanta: Centers for Disease Control and Prevention. Published 2018. Accessed December 23, 2019.
    Elvy  J, Colville  A.  Catheter associated urinary tract infection: what is it, what causes it, and how can we prevent it?   J Infect Prev. 2009;10(2):36-41. doi:10.1177/1757177408094852Google ScholarCrossref