What is the recommended treatment for a patient with a stroke or seizure and a urinary tract infection (UTI) without sepsis?

Treatment of UTI in Stroke or Seizure Patients Without Sepsis

For patients with stroke or seizure and urinary tract infection without sepsis, appropriate antibiotics should be prescribed promptly based on suspected pathogens, with removal of indwelling catheters as soon as medically feasible to improve outcomes.

Diagnosis and Assessment

• UTIs are common in stroke patients, occurring in 15-60% of cases 1
• UTIs independently predict worse outcomes after stroke 1
• Risk factors for UTI in stroke patients include:
  • Severe stroke (NIHSS score ≥15) 2
  • Indwelling urinary catheters 2, 3
  • Increased age 3
  • Post-stroke disability 3
  • Admission from another hospital 4

Management Recommendations

Catheter Management

1. Remove indwelling catheters within 48 hours to reduce UTI risk 1

   • If used, remove as soon as the patient is medically and neurologically stable 1
   • Consider alternatives such as:
     • Intermittent catheterization
     • External catheters
     • Incontinence pants 1

2. If catheterization is necessary:

   • Use silver alloy-coated urinary catheters 1
   • Implement excellent pericare and infection prevention strategies 1

Antibiotic Treatment

1. For uncomplicated UTI in stroke/seizure patients:

   • First-line options include:
     • Oral fluoroquinolones (if susceptible)
     • Oral trimethoprim-sulfamethoxazole (for simple cystitis) 1
     • Amoxicillin/clavulanic acid 1

2. For complicated UTI in stroke/seizure patients:

   • Consider parenteral therapy with:
     • Ceftriaxone 5
     • Single-dose aminoglycoside (for simple cystitis) 1
     • IV fosfomycin (for complicated UTI) 1

3. For UTI caused by multidrug-resistant organisms:

   • For carbapenem-resistant Enterobacterales (CRE):
     • Ceftazidime-avibactam 2.5g IV q8h 1
     • Meropenem-vaborbactam 4g IV q8h 1
     • Imipenem-cilastatin-relebactam 1.25g IV q6h 1
     • Plazomicin 15 mg/kg IV q12h 1

Additional Management Considerations

1. Temperature monitoring:

   • Monitor temperature every 4 hours for the first 48 hours 1
   • For temperature >37.5°C, increase monitoring frequency and investigate for UTI 1

2. Bladder training program:

   • Implement for patients with urinary incontinence 1
   • Include timed and prompted toileting on a consistent schedule 1
   • Consider acidification of urine to lessen infection risk 1
   • Anticholinergic agents may help in recovery of bladder function 1

3. Early mobilization:

   • Begin mobilization between 24-48 hours after stroke onset if no contraindications 1
   • Avoid frequent, intense, out-of-bed activity within first 24 hours of stroke 1

Special Considerations

• Community-acquired vs. hospital-acquired UTI:

  • Most UTIs in stroke patients (65%) are present on admission 4
  • Hospital-acquired UTIs are more common in patients transferred from other facilities 4

• Impact on outcomes:

  • UTIs are associated with longer hospital stays (median 12 days vs. 3 days) 2
  • UTIs are linked to worse 3-month functional outcomes 2
  • The association between UTI and poor outcomes may be attenuated when controlling for stroke severity 3

• Common pathogens:

  • Escherichia coli is the most common pathogen (41.9%) 2
  • Consider local resistance patterns when selecting empiric therapy

Pitfalls and Caveats

1. Avoid prophylactic antibiotics - Not recommended for prevention of UTI in stroke patients 1

2. Do not delay treatment - Prompt antibiotic therapy is essential once UTI is diagnosed 1

3. Recognize that UTI can worsen neurological status - Assess for UTI if there is a change in level of consciousness with no other identified cause 1

4. Consider hospital-level variations - UTI rates vary between hospitals (3-11%), which may reflect differences in staffing and resources 6

5. Do not overlook the impact of systemic inflammation - The fever and inflammatory response associated with UTI may impair stroke recovery 7

By following these recommendations, clinicians can effectively manage UTIs in stroke or seizure patients without sepsis, potentially improving neurological outcomes and reducing hospital length of stay.