From the Research
For a patient with obstructive urinary symptoms and ESBL E. coli infection requiring a Foley catheter, a trial of void could reasonably be attempted after 3-5 days of appropriate antibiotic therapy, assuming clinical improvement is observed. One week from antibiotic initiation would be a reasonable timeframe, as this allows sufficient time for the antibiotics to reduce bacterial load and inflammation while not unnecessarily prolonging catheterization. The patient should be on an appropriate antibiotic for ESBL E. coli, such as a carbapenem (meropenem, ertapenem) or potentially fosfomycin, depending on susceptibility testing 1. When conducting the trial of void, the catheter should be removed in the morning to allow for monitoring of urination throughout the day. Success criteria include the ability to void spontaneously with post-void residual volumes less than 100-150 mL, absence of significant pain, and no signs of urinary retention. If the trial fails, the catheter should be reinserted and another attempt could be made a few days later. The rationale for this timing is that while antibiotics begin working quickly, the inflammatory process in the urinary tract takes several days to resolve sufficiently to allow for normal voiding patterns, as suggested by studies on antibiotic prophylaxis for urinary tract infections after removal of urinary catheter 2. Complete resolution of inflammation may take the full 14-day course, but a trial of void need not wait until complete resolution if the patient is clinically improving. It is also important to consider the risks of catheter-associated urinary tract infections (CAUTIs) and take steps to prevent them, such as using aseptic technique for site preparation and supplies, and limiting the use and duration of urinary catheters 3. Additionally, the use of antimicrobial-coated catheters may help reduce the incidence of CAUTIs, although their clinical efficacy is not well established 4. In general, the management of patients with urinary catheters requires careful consideration of the risks and benefits of catheterization, as well as the potential consequences of antibiotic use, such as the development of antimicrobial resistance 5.
Some key points to consider when deciding on the timing of a trial of void include:
- The patient's clinical improvement on antibiotic therapy
- The presence of any signs or symptoms of urinary retention or obstruction
- The results of urine cultures and susceptibility testing
- The patient's overall health status and ability to tolerate a trial of void
- The potential risks and benefits of prolonged catheterization versus early removal of the catheter.
By considering these factors and using the available evidence to guide decision-making, clinicians can make informed decisions about the timing of a trial of void for patients with obstructive urinary symptoms and ESBL E. coli infection requiring a Foley catheter.