What is the treatment for catheter-associated urinary tract infection (CAUTI)?

Treatment of Catheter-Associated Urinary Tract Infection (CAUTI)

For patients with catheter-associated urinary tract infection (CAUTI), the urinary catheter should be removed or replaced if it has been in place for ≥2 weeks, and antimicrobial therapy should be initiated for 7 days in patients with prompt symptom resolution or 10-14 days for those with delayed response. 1

Initial Management Steps

1. Obtain urine culture before starting antibiotics

   • Essential due to wide spectrum of potential pathogens and high likelihood of antimicrobial resistance 1
   • Collect specimen from freshly placed catheter if replacement is performed 1

2. Catheter management

   • Remove the catheter if no longer needed (highest priority intervention)
   • Replace the catheter if it has been in place for ≥2 weeks and continued catheterization is necessary 1
   • Catheter replacement significantly improves clinical outcomes:
     • Decreases polymicrobial bacteriuria
     • Shortens time to clinical improvement
     • Reduces risk of subsequent CAUTI 1

Antimicrobial Therapy

Duration of Treatment

• 7 days for patients with prompt symptom resolution 1
• 10-14 days for patients with delayed response 1
• These recommendations apply regardless of whether the patient remains catheterized

Special Considerations for Duration

• 5-day regimen of levofloxacin (750 mg daily) may be considered for non-severely ill patients 1
• 3-day regimen may be considered for women <65 years who develop CAUTI without upper tract symptoms after catheter removal 1

Antimicrobial Selection

For empiric treatment of CAUTI with systemic symptoms, the EAU guidelines recommend: 1

• First-line options:

  • Amoxicillin plus an aminoglycoside
  • Second-generation cephalosporin plus an aminoglycoside
  • IV third-generation cephalosporin

• Fluoroquinolones (e.g., ciprofloxacin):

  • Only use if local resistance rates are <10%
  • Only appropriate when:
    • Entire treatment can be given orally
    • Patient doesn't require hospitalization
    • Patient has anaphylaxis to β-lactam antibiotics
  • Avoid in patients from urology departments or who have used fluoroquinolones in the last 6 months 1

• Adjust therapy based on culture results and antimicrobial susceptibility testing

Clinical Pearls and Pitfalls

Common Pitfalls

1. Failing to replace long-term catheters before treatment

   • Biofilms on catheters can harbor bacteria and reduce treatment efficacy
   • Catheter urine culture results may not accurately reflect bladder infection in the presence of biofilm 1

2. Overtreatment of asymptomatic bacteriuria

   • Asymptomatic bacteriuria in catheterized patients should generally not be treated
   • Exception: Consider treatment for women with asymptomatic bacteriuria persisting 48 hours after short-term catheter removal 1

3. Inadequate antimicrobial coverage

   • CAUTIs are often polymicrobial and caused by multidrug-resistant organisms
   • Local resistance patterns should guide empiric therapy 1

Signs and Symptoms of CAUTI

• New onset or worsening fever
• Rigors
• Altered mental status
• Malaise or lethargy without other identified cause
• Flank pain or costovertebral angle tenderness
• Acute hematuria
• Pelvic discomfort
• Dysuria, urgency, or frequency after catheter removal 1

Prevention Strategies

• Limit urinary catheter use to appropriate indications
• Remove catheters as soon as possible
• Maintain closed drainage systems
• Use proper aseptic technique for catheter insertion and maintenance
• Consider alternatives to indwelling catheters when appropriate 2

By following these evidence-based recommendations for CAUTI management, clinicians can optimize patient outcomes while practicing good antimicrobial stewardship.