Should Pseudomonas aeruginosa in the urine of an asymptomatic patient with a chronic indwelling urinary catheter be treated?

From the Guidelines

No, Pseudomonas aeruginosa in the urine of an asymptomatic patient with a chronic indwelling urinary catheter should not be treated. Asymptomatic bacteriuria, including Pseudomonas, is common in patients with long-term catheters and does not require antibiotic treatment, as stated in the 2019 clinical practice guideline for the management of asymptomatic bacteriuria by the Infectious Diseases Society of America 1. Treating in this scenario can lead to unnecessary antibiotic use, increased risk of side effects, and development of antibiotic resistance, with high-quality evidence showing harm and very low certainty of any benefit 1. Instead, focus on proper catheter care and hygiene:

• Ensure good hand hygiene before and after catheter handling
• Keep the catheter and collection bag below the level of the bladder
• Empty the collection bag regularly
• Perform routine catheter changes as recommended by the healthcare provider Only treat with antibiotics if the patient develops symptoms of a urinary tract infection, such as fever, pain, or changes in urine appearance. In such cases, obtain a urine culture before starting antibiotics and choose therapy based on culture results, as the presence of bacteria in catheterized patients without symptoms is a result of biofilm formation on the catheter surface, which protects the bacteria from the immune system and antibiotics 1. Treating this colonization does not improve outcomes and can lead to selection of more resistant organisms, with studies consistently reporting rapid emergence of antimicrobial resistance in urinary strains after treatment of asymptomatic bacteriuria in patients with chronic catheters 1.

From the Research

Treatment of Pseudomonas aeruginosa in Asymptomatic Patients

• The presence of Pseudomonas aeruginosa in the urine of an asymptomatic patient with a chronic indwelling urinary catheter is a common occurrence, and the decision to treat it is a topic of debate 2, 3, 4, 5, 6.
• Studies have shown that asymptomatic catheter-associated bacteriuria, including Pseudomonas aeruginosa, is not typically treated with antibiotics, as it may lead to the development of resistant flora 2, 3, 4, 6.
• The use of antibiotics in asymptomatic patients may result in infection of the bladder with resistant organisms, including Candida, and can have negative consequences for the patient and the medical unit 2.
• The general consensus is that asymptomatic catheter-associated bacteriuria should not be treated with antibiotics, and that treatment should be reserved for symptomatic patients, usually with fever or signs of sepsis 2, 3, 4, 6.
• Education and awareness of the guidelines for the management of catheter-associated urinary tract infections are essential to reduce unnecessary antibiotic usage and prevent the development of resistant organisms 3, 4, 6.

Complications and Risks

• The presence of an indwelling urinary catheter can lead to a range of complications, including catheter-associated urinary tract infections, catheter obstruction, urinary tract stones, local periurinary infections, chronic renal inflammation, chronic pyelonephritis, and bladder cancer 2, 5.
• The risk of these complications can be minimized by using alternative methods for urine drainage, such as condom, intermittent, suprapubic, and intraurethral catheterization, whenever possible 2.
• The use of a closed catheter system and adherence to proper catheter care and maintenance can also help to reduce the risk of complications 2.

Management and Prevention

• The management of catheter-associated urinary tract infections, including asymptomatic bacteriuria, requires a multifaceted approach that includes education, awareness, and adherence to guidelines and protocols 3, 4, 6.
• The use of antimicrobial stewardship programs can help to reduce the overuse of antibiotics and prevent the development of resistant organisms 4.
• Technological innovations in catheter materials and design may also play a role in preventing catheter-associated urinary tract infections and reducing the risk of complications 5.