What is the recommended empiric antibiotic treatment for a patient with a Foley catheter and End-Stage Renal Disease (ESRD) suspected of having a Urinary Tract Infection (UTI)?

Empiric Antibiotic Treatment for Suspected UTI in Patients with Foley Catheter and ESRD

For patients with a Foley catheter and ESRD suspected of having a UTI, empiric broad-spectrum antibiotic therapy against Enterobacteriaceae and Enterococci should be initiated, with cefepime 1g IV every 24 hours (for CrCl 30-60 mL/min) or 500 mg IV every 24 hours (for CrCl 11-29 mL/min) as the recommended first-line treatment. 1, 2

Diagnostic Approach

Before initiating antibiotics:

• Collect urine sample for culture and sensitivity
• Change indwelling catheter prior to collection 1
• Ensure diagnosis is based on symptoms, not just bacteriuria
• Note that pyuria is common in catheterized patients and has no predictive value in differentiating symptomatic UTI from asymptomatic bacteriuria 1

Treatment Algorithm

First-line Empiric Therapy:

• Cefepime with dose adjusted for renal function: 2
  • CrCl 30-60 mL/min: 1g IV every 24 hours
  • CrCl 11-29 mL/min: 500 mg IV every 24 hours
  • CrCl <11 mL/min: 250 mg IV every 24 hours
  • Hemodialysis: 1g on day 1, then 500 mg every 24 hours thereafter (administer after dialysis)

Alternative Options:

• Piperacillin-tazobactam (dose adjusted for ESRD)
• Ertapenem (dose adjusted for ESRD)
• Meropenem (dose adjusted for ESRD)

Duration of Treatment

• Short-course therapy (3-5 days) with early re-evaluation according to clinical course and laboratory parameters 1
• For severe infections, consider extending to 7-10 days 3

Important Considerations

Asymptomatic Bacteriuria

• Do not treat asymptomatic bacteriuria in catheterized patients 1
• Treatment of asymptomatic bacteriuria does not decrease symptomatic episodes but leads to emergence of resistant organisms 4

Antibiotic Stewardship

• Once culture results are available, narrow therapy based on susceptibility patterns 1
• Reassess need for continued antibiotics after 48-72 hours based on clinical response and culture results

Catheter Management

• Consider catheter removal or replacement if clinically feasible 5
• Maintaining a closed drainage system and proper catheter care are essential to limit infection and complications 4

Special Considerations for ESRD Patients

• Renal dosing of antibiotics is crucial to prevent toxicity
• Higher risk of resistant organisms due to frequent healthcare exposure
• Consider previous culture results and antibiotic exposure when selecting empiric therapy
• Monitor for drug accumulation and toxicity

Common Pitfalls to Avoid

1. Treating asymptomatic bacteriuria in catheterized patients
2. Not adjusting antibiotic doses for renal function
3. Not changing the catheter before collecting urine for culture
4. Prolonged antibiotic courses when shorter durations are effective
5. Not narrowing therapy once culture results are available

The World Society of Emergency Surgery guidelines strongly recommend empiric broad-spectrum antibiotic therapy against Enterobacteriaceae and Enterococci for patients with signs of infection, with dose and timing adapted to the patient's renal function 1. This recommendation aligns with evidence showing that catheterized patients are at high risk for resistant organisms, with E. coli remaining the most common infecting organism but with increasing prevalence of other pathogens including resistant strains 4, 6.