Management of Urinary Retention and UTI in Patients with Long-Term Foley Catheters
For patients with urinary retention and UTI with a long-term Foley catheter in place, the catheter should be replaced before starting appropriate antimicrobial therapy, followed by a trial of void after completing the full antibiotic course if the underlying cause of retention has resolved. 1, 2
Initial Assessment and Management
- Obtain a urine culture specimen after changing the catheter and allowing for urine accumulation while plugging the catheter (do not collect from extension tubing or collection bag) 1
- Replace the catheter before starting antimicrobial therapy if it has been in place for ≥2 weeks, as this improves clinical outcomes, decreases polymicrobial bacteriuria, shortens time to clinical improvement, and lowers rates of UTI recurrence 1, 3, 2
- Select antimicrobial therapy based on culture results and local resistance patterns, considering drugs with good urinary penetration 3
Antimicrobial Treatment Duration
- For patients with catheter-associated UTI (CAUTI) who have prompt resolution of symptoms, treat for 7 days 3
- For patients with delayed response to treatment, extend therapy to 10-14 days 3
- A 5-day regimen of levofloxacin may be considered for patients who are not severely ill 3
- A 3-day antimicrobial regimen may be considered for women aged ≤65 years who develop CAUTI without upper urinary tract symptoms after catheter removal 3
Catheter Management During and After Treatment
- Continue catheter drainage until the UTI has been adequately treated 2
- Remove the catheter as soon as clinically appropriate to reduce the risk of recurrent infection 3, 2
- For patients with short-term urinary retention, consider transitioning to intermittent catheterization after catheter removal, performing catheterization every 6 hours initially 2
- Consider a trial of void successful if residual volumes are consistently less than 30 ml on the majority of catheterizations for 3 consecutive days 2
Special Considerations
- For patients with recurrent UTIs and an indwelling catheter, urodynamic evaluation may be appropriate to identify risk factors such as elevated post-void residual or vesicoureteral reflux 1
- Do not use daily antibiotic prophylaxis in patients with long-term indwelling catheters, as this does not prevent UTI and increases bacterial resistance 1, 3
- For patients with febrile UTI who do not respond appropriately to antibiotic therapy, obtain upper tract imaging to evaluate for complications such as stones or hydronephrosis 1
- Monitor for signs of UTI recurrence (fever, dysuria, frequency, urgency) after catheter removal 2
Common Pitfalls to Avoid
- Treating asymptomatic bacteriuria in catheterized patients is not recommended as it does not reduce subsequent CAUTI and increases antimicrobial resistance 1, 3
- Failing to obtain cultures before initiating antibiotics may lead to inappropriate antibiotic selection given the high likelihood of resistant organisms 3, 2
- Not replacing catheters that have been in place for ≥2 weeks prior to antibiotic treatment reduces treatment efficacy due to biofilm formation 3, 4
- Removing the catheter before completing appropriate antibiotic treatment may lead to persistent infection 2
- Catheter flushing or daily perineal care do not prevent infection and may increase infection risk 4
Long-Term Management Strategies
- For patients with recurrent catheter blockage due to encrustation, consider increasing fluid intake with citrated drinks until definitive management can be arranged 5
- The elimination of Proteus mirabilis (a common cause of catheter encrustation) by appropriate antibiotic therapy when it first appears may improve quality of life for patients with long-term catheters 5
- Regular assessment of whether the catheter is still necessary should be performed, as catheters are associated with various complications including healthcare-associated infection 6