https://orcid.org/0000-0001-6455-6962
Figures
Abstract
Background
Catheter-associated urinary tract infection (CAUTI) is a common device-associated complication in intensive care units (ICUs).
Objective
To characterize bacterial CAUTI in an ICU cohort and identify independent associations with demographic and clinical characteristics available at or before ICU admission.
Methods
This single-center retrospective cohort included 3326 index ICU admissions from January 2017 through June 2023. After exclusion of 95 fungal-only clinically classified cases, 3231 records remained. Bacterial CAUTI required compatible clinical findings, at least 48 hours of catheter exposure, and ≥10³ CFU/mL of one or two bacterial species. All patients were catheterized throughout the observed ICU stay. The primary logistic model included only admission characteristics; ICU stay/catheter duration was descriptive because exact CAUTI onset dates were unavailable. Skewed biomarkers were summarized with medians, interquartile ranges, and Mann-Whitney tests.
Results
Bacterial CAUTI occurred in 301 patients (9.3%; 95% CI 8.4%−10.4%). Mean ICU stay/catheter duration was 28.3 versus 13.6 days (difference 14.8 days; 95% CI 11.7–17.8), but duration was not interpreted as an independent risk estimate. Mortality was 49.2% versus 45.9% (risk difference 3.2 percentage points; 95% CI −2.7 to 9.1), and bacterial CAUTI was not associated with death after adjustment for admission characteristics (OR 0.95; 95% CI 0.75–1.22). Female sex (OR 1.48; 95% CI 1.15–1.90), obesity (OR 1.62; 95% CI 1.20–2.19), and COVID-19 (OR 2.16; 95% CI 1.55–3.00) were independently associated. At least one resistance phenotype was recorded in 200 patients (66.4%).
Citation: Bartoszewicz M, Krysik M, Czaban SL, Ładny JR (2026) Characteristics and outcomes of ICU patients with bacterial catheter-associated urinary tract infection. PLoS One 21(9): e0358796. https://doi.org/10.1371/journal.pone.0358796
Editor: Arghya Das, AIIMS: All India Institute of Medical Sciences, INDIA
Received: May 28, 2026; Accepted: September 4, 2026; Published: September 25, 2026
Copyright: © 2026 Bartoszewicz et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All de-identified data underlying the findings are provided with this submission as Supporting Information: S1 Microbiology Data (301 bacterial CAUTI records), S2 Screening Summary, S3 Data Dictionary. Direct identifiers, exact dates, hospital numbers, addresses, and free text were removed. Clinical and microbiology files use independent randomized synthetic identifiers and intentionally cannot be linked.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors declare no competing interests.
Abbreviations: BSI, Bacterial bloodstream infection; CAUTI, Catheter-associated urinary tract infection; CFU, Colony-forming units; CI, Confidence interval; COVID-19, Coronavirus disease 2019; CRP, C-reactive protein; ESBL, Extended-spectrum beta-lactamase; HLAR, High-level aminoglycoside resistance; ICU, Intensive Care unit; MBL, Metallo-beta-lactamase; MDR, Multidrug-resistant; NDM, New Delhi metallo-beta-lactamase; OR, Odds ratio; TISS-28, Therapeutic Intervention Scoring System-28; VAP, Ventilator-associated pneumonia; VRE, Vancomycin-resistant Enterococcus; WBC, White blood cell count
Introduction
Healthcare-associated infections remain an important source of morbidity in intensive care units (ICUs), where critical illness, immune dysfunction, antimicrobial exposure, and invasive devices converge [1–4]. Catheter-associated urinary tract infection (CAUTI) is clinically relevant because indwelling bladder catheters are frequently required for hourly urine-output measurement and fluid-balance management. These infections increase diagnostic testing, antimicrobial exposure, and the risk of secondary bloodstream infection [5,6].
An indwelling urethral catheter disrupts normal urinary defenses, promotes ascending microbial migration, and provides a surface for biofilm formation. Risk increases with cumulative device exposure; prevention guidance therefore emphasizes appropriate indications, aseptic insertion, maintenance of a closed drainage system, and prompt removal when continuous monitoring is no longer required [5–7].
The microbiology of catheter-associated infection in the ICU differs from uncomplicated community-acquired urinary infection. Enterococcus, Klebsiella, Pseudomonas, Acinetobacter, Staphylococcus, and other healthcare-associated organisms may predominate after prolonged hospitalization and broad-spectrum antimicrobial treatment. Extended-spectrum beta-lactamase (ESBL), metallo-beta-lactamase (MBL), vancomycin resistance, and high-level aminoglycoside resistance (HLAR) can substantially restrict treatment options [8–12].
The COVID-19 pandemic altered ICU case mix and device exposure. Severe SARS-CoV-2 infection frequently required prolonged mechanical ventilation, deep sedation, prone positioning, corticosteroids, and extended catheterization. A previous publication from our center examined CAUTI in 201 patients with COVID-19 admitted between March 2020 and July 2021 [13]. The broader cohort analyzed here includes that previously reported subset but addresses bacterial CAUTI across all ICU diagnoses over more than six years.
The primary objective was to estimate the proportion of ICU patients who developed bacterial CAUTI and identify independent associations with demographic and clinical characteristics available at or before ICU admission. Secondary objectives were to quantify mortality and co-occurring device-associated infections, describe ICU length of stay/observed catheter exposure without assigning causal direction, compare TISS-28 interventions after normalization to observation time, and describe local bacterial and antimicrobial resistance patterns.
Materials and methods
Study design, setting, and reporting
This single-center retrospective cohort study was conducted in the ICU of the University Clinical Hospital in Bialystok, Poland. The source period extended from January 1, 2017, through June 1, 2023. Reporting follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) recommendations [14].
Study population and index admission
The source cohort comprised 3326 index ICU admissions. Only the first eligible ICU admission for each patient was retained. A secondary ICU hospitalization was defined as any later ICU admission after discharge from the index ICU, whether during the same hospital episode or a subsequent hospitalization; these later admissions were excluded to avoid repeated observations from the same patient.
Relationship to prior publications
The database includes the 201-patient COVID-19 cohort previously reported by Dąbrowska et al. [13], which was restricted to COVID-19 admissions from March 2020 through July 2021. To avoid duplicate reporting, that publication is identified as an overlapping subgroup. The present revised analysis uses a bacterial-only primary outcome across the full source cohort, excludes 95 fungal-only records identified in the broader dataset, includes 301 bacterial CAUTI cases and 2930 comparison records, extends follow-up through June 2023, normalizes TISS-28 interventions to person-time, and evaluates multivariable associations across ICU diagnoses. All COVID-19 diagnoses occurred from March 2020 onward. The cohort flow and bacterial classification are summarized in Fig 1.
The figure shows the source cohort, continuous ICU catheter exposure, the complete clinical and microbiological criteria, exclusion of fungal-only clinically classified cases, and the revised primary bacterial CAUTI groups. The no-bacterial-CAUTI group was not defined by a negative culture. CAUTI, catheter-associated urinary tract infection; CFU, colony-forming units; CI, confidence interval; ICU, intensive care unit.
Primary and secondary outcomes
The primary outcome was bacterial CAUTI during the index ICU admission. Secondary outcomes were in-hospital death, ICU length of stay/observed ICU catheter exposure, bacterial bloodstream infection (BSI), ventilator-associated pneumonia (VAP), normalized TISS-28 intervention rates, and patient-level bacterial organism and resistance-phenotype distributions. BSI and VAP were recorded if documented at any time during the index ICU stay; event dates were unavailable, so temporal ordering relative to CAUTI could not be established.
Clinical and microbiological case definition
All patients had an indwelling bladder catheter continuously throughout the observed ICU stay. Urine cultures were obtained when clinical features suggested urinary tract infection. Bacterial CAUTI required catheter exposure for at least 48 hours before diagnosis; compatible findings such as fever, suprapubic or costovertebral-angle discomfort, altered mental status, hypotension, or systemic inflammatory response without another identified source; and a positive catheter urine culture. The catheter was replaced before sample collection to reduce contamination by established biofilm. A positive bacterial culture was defined as ≥10³ colony-forming units (CFU)/mL of one or two bacterial species in a single catheter specimen; cultures with three or more microorganisms were classified as contaminated. Microbiological specimens were obtained before antimicrobial treatment whenever clinically feasible.
The same quantitative threshold of ≥10³ CFU/mL was applied to yeast growth in the source classification. For the revised primary bacterial analysis, 95 clinically classified cases with fungal growth but no bacterial growth were excluded rather than reclassified as non-CAUTI. Patients with bacterial growth remained in the bacterial CAUTI group when concurrent fungal urine growth was also recorded.
Urine culture, identification, and antimicrobial susceptibility testing
For catheterized patients, approximately 5 mL of urine was aspirated aseptically from the disinfected sampling port of the closed Foley-catheter system after catheter replacement. Specimens were transported to the laboratory within 2 hours. When immediate transport was not possible, specimens were refrigerated at 4°C and cultured within 4 hours. Quantitative culture used a sterile calibrated 1-µL loop (0.001 mL), so one colony represented 10³ CFU/mL. Plates were incubated and read after 18–24 hours; incubation was extended to 48 hours when clinically indicated or after prior antimicrobial exposure, and fungal cultures were incubated for at least 48 hours.
Blood cultures and bacteremic CAUTI
The retrospective extract did not document protocol-mandated blood-culture collection at every CAUTI diagnosis. Blood cultures were therefore treated as clinically indicated rather than systematic. BSI denotes any bacterial bloodstream infection during the ICU stay; bacteremic CAUTI could not be distinguished reliably from coincident or secondary BSI.
Data collection and variables
Demographic characteristics, comorbidities, admission laboratory results, ICU interventions, and outcomes were extracted from electronic records. Covariates for the primary multivariable model were selected on clinical grounds and were restricted to characteristics available at or before ICU admission: age, sex, obesity, COVID-19, diabetes mellitus, heart and/or respiratory failure, atrial fibrillation, and acute myocardial infarction or ischemic stroke. Obesity was classified from BMI-derived or documented obesity fields. Systemic steroid therapy was retained as a descriptive variable but was not included in the primary model because its timing relative to CAUTI was unavailable. Admission biomarkers were not included in the primary model because of substantial missingness.
Catheter exposure and normalized TISS-28 analysis
Because every patient had an indwelling bladder catheter continuously from ICU admission until ICU discharge or death, observed ICU catheter exposure equaled ICU length of stay. Pre-ICU catheter exposure and exact CAUTI onset times were not available for the full cohort. ICU length of stay/catheter duration could therefore include time both before and after CAUTI and was not entered into the primary logistic regression. It was summarized descriptively, and a crude incidence estimate was calculated per 1000 observed ICU catheter-days among records with complete ICU length of stay. A time-dependent or competing-risk analysis could not be performed without reliable CAUTI onset dates. TISS-28 items were expressed as intervention-days per 100 observed TISS days. Rate ratios were estimated with Poisson regression using log(observation days) as an offset and heteroskedasticity-robust standard errors.
Statistical analysis
Continuous variables are reported as mean (standard deviation). Because CRP, procalcitonin, and lactate showed marked right-skew, these biomarkers are also reported as median [interquartile range], with two-sided Mann-Whitney U tests presented alongside Welch t tests. Categorical variables are reported as number (percentage). The bacterial CAUTI proportion was accompanied by a Wilson 95% confidence interval (CI). Key continuous differences used Welch 95% CIs; key categorical outcomes used Newcombe 95% CIs for risk differences. The primary multivariable logistic regression estimated adjusted odds ratios (ORs) for bacterial CAUTI using only admission characteristics and heteroskedasticity-robust standard errors. ICU length of stay/catheter duration, TISS-28 intensity, systemic steroid therapy, BSI, and VAP were excluded from this model because they accrued after admission or lacked reliable temporal ordering relative to CAUTI. A separate admission-characteristic-adjusted logistic model assessed the association between bacterial CAUTI and in-hospital death. Complete-case analysis was used. Biomarker comparisons were exploratory and were not adjusted for multiplicity. Statistical significance was defined as two-sided p < 0.05. Analyses used Python 3.13, pandas 2.2.3, SciPy 1.17.0, statsmodels 0.14.6, and scikit-learn 1.8.0.
Sample size and precision
No a priori sample-size calculation was performed because all eligible index admissions in the source period were included. With 301 bacterial CAUTI and 2930 comparison patients, the available sample had approximately 80% power at a two-sided alpha of 0.05 to detect an absolute mortality difference of about 8.5 percentage points, assuming 45.9% mortality in the comparison group. Interpretation emphasizes effect estimates and 95% CIs rather than post hoc significance alone.
Ethics
The study was conducted in accordance with the Declaration of Helsinki. The Bioethics Committee of the Medical University of Bialystok, Poland, confirmed that this retrospective study did not constitute a medical experiment and did not require prospective ethics committee approval (protocol APK.002.82.2024; February 22, 2024). The requirement for informed consent was waived because routinely collected retrospective data were used.
Results
Cohort and bacterial CAUTI occurrence
The source cohort included 3326 index ICU admissions. After exclusion of 95 fungal-only clinically classified cases, the primary analytic cohort included 3231 records. Bacterial CAUTI occurred in 301 patients (9.3%; 95% CI 8.4%−10.4%); 2930 patients did not meet the complete bacterial CAUTI definition (Fig 1).
Patient characteristics and admission laboratory variables
Patients with bacterial CAUTI were more frequently female or obese and had higher frequencies of COVID-19, atrial fibrillation, and systemic steroid treatment; they were also older on unadjusted comparison. For the right-skewed biomarkers, CRP was lower in the bacterial CAUTI group by both Welch and Mann-Whitney testing (median 99.6 [IQR 53.9–170.4] vs 119.2 [62.4–193.0] mg/L; Mann-Whitney p = 0.010). Procalcitonin means did not differ by Welch testing (p = 0.270), whereas the median was lower in the bacterial CAUTI group (0.73 [0.23–3.04] vs 1.13 [0.26–5.01] ng/mL; Mann-Whitney p = 0.029). Lactate means differed by Welch testing (p < 0.001), but medians were nearly identical (1.89 [1.35–2.54] vs 1.80 [1.27–2.80] mmol/L; Mann-Whitney p = 0.927), indicating that the mean difference was driven by upper-tail values rather than a general shift in the distribution. WBC did not differ by Welch testing, and glucose was higher in the bacterial CAUTI group (Table 1). BMI and admission biomarkers had substantial variable-specific missingness (Table C in S1 File).
Clinical outcomes and catheter exposure
Mean observed ICU stay/catheter duration was 28.3 days in the bacterial CAUTI group and 13.6 days in the comparison group (difference 14.8 days; 95% CI 11.7–17.8; p < 0.001). Corresponding medians were 21 days (IQR 11–38) and 8 days (IQR 3–18). Among 3187 records with complete exposure data, 47713 observed ICU catheter-days and 301 bacterial CAUTI events yielded a crude incidence of 6.31 per 1000 observed ICU catheter-days. Because duration included time after CAUTI onset for affected patients and exact onset dates were unavailable, these comparisons are descriptive and do not estimate a causal effect of catheter duration.
In-hospital mortality was 49.2% with bacterial CAUTI and 45.9% without bacterial CAUTI (risk difference 3.2 percentage points; 95% CI −2.7 to 9.1; p = 0.284). In the admission-characteristic-adjusted mortality model, bacterial CAUTI was not associated with death (adjusted OR 0.95; 95% CI 0.75–1.22; p = 0.708). BSI and VAP were substantially more frequent among bacterial CAUTI patients, although temporal ordering could not be determined (Table 2).
Multivariable associations based on admission characteristics
The revised primary complete-case model included 3170 patients and all 301 bacterial CAUTI events. Female sex, obesity, and COVID-19 were independently associated with bacterial CAUTI. Age, diabetes, heart and/or respiratory failure, atrial fibrillation, and acute myocardial infarction or ischemic stroke were not independently associated (Table 3). ICU length of stay/catheter duration and other post-admission variables were not included. The model area under the receiver-operating characteristic curve was 0.620; the maximum non-intercept variance inflation factor was 1.18.
TISS-28 person-time results
Cumulative TISS intervention-days were higher among bacterial CAUTI patients because their observation time was substantially longer. After normalization, overall daily TISS intensity differed by 0.17 item-days per observed day (95% CI 0.05–0.28). Respiratory physiotherapy and enteral nutrition remained more frequent per observed day, whereas several other large cumulative differences attenuated or reversed. Selected normalized rates are shown in Table 4; all TISS-28 items are reported in Table A in S1 File.
COVID-19 sensitivity analysis
All COVID-19 diagnoses occurred from March 2020 onward. Bacterial CAUTI occurred in 55/351 patients with COVID-19 (15.7%) and 246/2880 patients without COVID-19 (8.5%), an absolute difference of 7.1 percentage points (95% CI 3.5–11.4) and a risk ratio of 1.83 (95% CI 1.40–2.40). COVID-19 remained associated in the multivariable model. A calendar-era comparison of pre-pandemic versus pandemic non-COVID admissions could not be reconstructed because exact dates were not retained in the source analytical data.
Microbiology and resistance
The detailed UTI microbiology analysis was restricted to 301 bacterial CAUTI records. Concurrent fungal urine growth was recorded in 54 patients (17.9%), who remained in the bacterial analysis because bacterial growth was also present. Organism-group variables were patient-level and non-mutually exclusive. Enterococcus, Klebsiella, Staphylococcus, Escherichia, and Acinetobacter were the most frequent recorded bacterial groups (Table 5).
At least one resistance phenotype was recorded in 200 patients (66.4%); 90 (29.9%) had at least two, 28 (9.3%) at least three, and 8 (2.7%) at least four. The most frequent pairwise co-occurrences were NDM with MBL (23), MBL with MDR/W-OPOR (16), ESBL with HLAR (15), ESBL with MDR/W-OPOR (14), and VRE with MDR/W-OPOR (11). NDM is an MBL subtype, so NDM-MBL co-recording partly reflects hierarchical coding.
Discussion
After exclusion of fungal-only clinically classified cases, bacterial CAUTI occurred in 9.3% of the revised cohort. Bacterial CAUTI identified a population with substantially longer observed ICU stay/catheter exposure and a high burden of VAP and BSI. In the model restricted to admission characteristics, female sex, obesity, and COVID-19 remained independently associated. The unadjusted mortality difference was imprecise and crossed the null, and bacterial CAUTI was not associated with death after adjustment for admission characteristics.
The large difference in ICU length of stay/observed catheter duration is clinically relevant but cannot be interpreted as an independent risk estimate. Duration accrued after ICU admission and, for patients with CAUTI, could include both pre-infection time at risk and post-infection prolongation of care. Entering log2(days+1) into a standard logistic model would therefore condition on a post-admission variable that may partly be a consequence of CAUTI, creating reverse-causation and overadjustment bias. We removed ICU length of stay/catheter duration and daily TISS intensity from the primary multivariable model rather than interpreting the previous adjusted OR of 1.92. Exact CAUTI onset dates were unavailable, precluding a time-dependent Cox or competing-risk analysis. Duration is retained only as a descriptive time-at-risk measure, and the direction and magnitude of any causal relationship remain unresolved.
The incidence estimate of 6.31 bacterial CAUTI events per 1000 observed ICU catheter-days is lower than the previously reported 15.8 per 1000 catheter-days in the overlapping COVID-19 cohort [13]. The estimates are not directly interchangeable because the earlier study was restricted to severe COVID-19, whereas the present analysis covers all ICU diagnoses and applies a bacterial-only primary outcome after excluding fungal-only records from the broader source dataset. Explicit disclosure of the overlap prevents presentation of the earlier disease-specific result as if it were newly derived.
Person-time normalization materially changed interpretation of the TISS-28 findings. Cumulative intervention-days were much higher among bacterial CAUTI patients, but much of that difference reflected approximately twice as many observed days. Overall daily TISS intensity differed only modestly. Respiratory physiotherapy and enteral nutrition remained more frequent per observed day, while several other cumulative differences attenuated or reversed. This analysis avoids treating longer hospitalization as equivalent to uniformly greater daily care intensity.
The high frequency of Enterococcus is plausible in a prolonged, catheterized, and antibiotic-exposed ICU population. Enterococci adhere to catheter-associated biofilm, tolerate environmental stress, and may be selected by broad-spectrum antibacterial treatment [6,15,16]. Local colonization pressure and repeated sampling may also contribute. Because organism variables were non-mutually exclusive patient-level indicators and genomic typing was not performed, the data cannot distinguish independent episodes, persistent colonization, repeated isolation, or clonal transmission.
The revised analysis applies a bacterial case definition. The ≥ 10³ CFU/mL threshold was applied to yeasts in the source classification, but 95 fungal-only clinically classified cases were excluded to avoid combining candiduria or fungal CAUTI with bacterial CAUTI in one primary outcome. Concurrent fungal urine growth in patients who also had bacterial CAUTI was retained and reported separately. This approach improves interpretability without reclassifying fungal-only cases as uninfected.
The resistance profile reinforces the need for institution-specific treatment guidance. HLAR, ESBL, MDR/W-OPOR, MBL, VRE, and NDM were common, and 29.9% of bacterial CAUTI patients had at least two recorded resistance phenotypes. Co-occurrence may represent a single multidrug-resistant organism, multiple organisms in the same patient, or hierarchical coding of one mechanism. OXA-48 and MDR coding were harmonized. The unresolved MRR field was not converted into a MarR molecular finding because the data did not document such testing.
COVID-19 remained independently associated with bacterial CAUTI. Severe SARS-CoV-2 infection often required prolonged ventilation, sedation, immobility, systemic steroids, and complex nursing care [13,17–19]. The present analysis is broader than the prior COVID-specific report and explicitly discloses the overlapping cohort and the revised bacterial-only definition.
This study has several limitations. It was retrospective and single-center; event timing was incomplete; pre-ICU catheter exposure and exact CAUTI onset were unavailable; and residual confounding by illness severity and treatment exposure is likely. Removing ICU length of stay/catheter duration from the primary model avoids conditioning on a potential consequence of CAUTI, but the cumulative-incidence logistic model still cannot account fully for differential time at risk; reliable onset dates would be required for a time-to-event or competing-risk analysis. All patients were catheterized, so the study cannot compare catheterized with non-catheterized patients. ICU length of stay was missing in 44 records, and BMI and admission biomarkers had substantial missingness. A complete APACHE II or SOFA score was unavailable for the full cohort. Blood cultures were not documented as systematic at CAUTI diagnosis, so bacteremic CAUTI could not be classified. Microbiology fields were non-mutually exclusive patient-level indicators rather than a relational isolate-level database. Finally, the observed mortality difference was smaller than the approximate 80% detectable difference and remained compatible with no difference.
Strengths include the large consecutive source cohort, explicit bacterial case definition, complete reanalysis after exclusion of fungal-only cases, detailed laboratory procedures, direct descriptive characterization of observed ICU catheter exposure, person-time normalization of TISS-28, an admission-characteristic model that avoids conditioning on post-admission duration, distribution-sensitive biomarker reporting, resistance co-occurrence analysis, and provision of aggregate microbiology summaries and an accompanying data dictionary.
Conclusions
Bacterial CAUTI occurred in 9.3% of the revised ICU cohort. Female sex, obesity, and COVID-19 were independently associated in the model restricted to admission characteristics. Patients with bacterial CAUTI had substantially longer observed ICU stay/catheter exposure, but the direction of this relationship could not be determined and no causal effect of duration was estimated. Bacterial CAUTI was not associated with in-hospital death after adjustment for admission characteristics. Person-time normalization showed that much of the apparent intervention burden reflected longer observation rather than uniformly higher daily intensity. Strict catheter stewardship, clear separation of bacterial infection from fungal-only disease or colonization, reproducible microbiological methods, and treatment guided by local resistance patterns remain central to prevention and management.
Supporting information
S1 File. Supporting tables.
Table A: All TISS-28 intervention rates normalized to observed ICU days. Table B: Admission-characteristic-adjusted logistic regression for in-hospital death. Table C: Missing data for key variables in the revised primary cohort. Table D: Rare bacterial groups and common resistance-phenotype co-occurrences.
https://doi.org/10.1371/journal.pone.0358796.s001
(DOCX)
S1 Data. Aggregate microbiology frequencies (301 bacterial CAUTI records).
Counts of 1–4 are withheld.
https://doi.org/10.1371/journal.pone.0358796.s002
(CSV)
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