Delayed urine sample collection, transportation, leading to Catheter Associated Urinary Tract infection (CAUTI): a case report.

Introduction: Catheter-Associated Urinary Tract Infections (CAUTIs) are among the most prevalent healthcare-associated infections. This case describes a CAUTI in an ICU with a previously 18-month infection-free record, emphasizing the impact of delays in urine sample processing and catheter management on patient outcomes. Patient Concerns and Clinical Findings: An elderly patient with multiple comorbidities, including diabetes, dementia, and bilateral amputation, developed fever and had a positive urine culture for E. coli following Foley catheter placement during surgery. Initial culture showed 60,000 CFU/mL, and a subsequent culture showed >100,000 CFU/mL, with a fever spike to 39.1°C on day four. Diagnosis: Interventions and Outcomes: The diagnosis was catheter-associated UTI based on CDC criteria. Delay in sample transport (up to 9 hours), lack of timely catheter removal, and delayed antibiotic administration contributed to infection progression. The patient’s fever resolved after antibiotic initiation, but the incident highlighted systemic lapses. Conclusion: This case underscores the critical role of timely urine specimen handling, proper catheter maintenance, and adherence to infection control protocols in preventing CAUTIs. Even in high-performing ICUs, minor lapses can lead to significant patient morbidity.