What are the treatment guidelines for a urinary tract infection (UTI) in patients with an indwelling catheter, based on the McGeer criteria?

McGeer Criteria for UTI Diagnosis and Treatment in Patients with Indwelling Catheters

For patients with indwelling urinary catheters, the Infectious Diseases Society of America strongly recommends against screening for or treating asymptomatic bacteriuria, as treatment does not improve outcomes and may lead to adverse effects and antimicrobial resistance. 1

Diagnostic Criteria for Catheter-Associated UTI

• Catheter-associated urinary tract infection (CAUTI) should be diagnosed based on clinical symptoms rather than bacteriuria alone, as asymptomatic bacteriuria is common in catheterized patients 1
• In patients with indwelling catheters, symptoms that may indicate CAUTI include:
  • New onset fever without another identified cause
  • Suprapubic tenderness
  • Costovertebral angle pain or tenderness
  • Acute hematuria
  • New onset delirium (especially in elderly patients) 1, 2
• It's important to note that patients with spinal cord injury may present with atypical symptoms of UTI due to altered sensation 1

Prevention Strategies

• Use indwelling catheters only when absolutely necessary and remove them as soon as possible 2, 3
• Consider alternative methods when appropriate:
  • External condom catheters for men (shown to have lower bacteriuria rates than indwelling catheters) 1, 2
  • Intermittent catheterization when feasible 2
  • Suprapubic catheterization for long-term use (may have advantages over urethral catheterization) 1, 2
• Always maintain a closed catheter drainage system to reduce CA-bacteriuria and CA-UTI 1
• Ensure the drainage bag and connecting tube remain below the level of the bladder at all times 1
• Minimize disconnection of the catheter junction 1
• Consider using a preconnected system (catheter preattached to drainage bag tubing) to reduce CA-bacteriuria 1
• For short-term catheterization, antimicrobial-coated catheters (silver alloy or antibiotic) may be considered to delay onset of bacteriuria 1

Treatment Recommendations

• For asymptomatic bacteriuria in catheterized patients:

  • Do not screen for or treat asymptomatic bacteriuria in patients with short-term (<30 days) or long-term indwelling catheters 1
  • The only exception is before urologic procedures involving mucosal trauma, where screening and treating asymptomatic bacteriuria is recommended 1

• For symptomatic CAUTI:

  • Obtain urine culture prior to initiating antimicrobial therapy to guide targeted treatment 1, 3
  • When treating symptomatic CAUTI, consider removing or changing the catheter if it has been in place for >2 weeks 3, 4
  • Select antimicrobials based on local resistance patterns and culture results 3

Important Considerations

• Duration of catheterization is the most important modifiable risk factor for developing CAUTI, with risk increasing approximately 5% per day 2, 3
• Routine catheter irrigation with normal saline or antimicrobials is not recommended to prevent CAUTI 5
• Do not add antimicrobials or antiseptics to drainage bags 5
• Daily meatal cleansing with antiseptic solutions is not recommended for routine use 5
• Avoid raising the drainage bag above the level of the bladder as this can facilitate bacterial entry 5

Special Situations

• For patients undergoing elective non-urologic surgery, screening for or treating asymptomatic bacteriuria is not recommended 1
• For patients undergoing urologic procedures with mucosal trauma, a short course (1-2 doses) of targeted antimicrobial therapy is suggested 30-60 minutes before the procedure 1
• No recommendation can be made for or against screening/treating asymptomatic bacteriuria at the time of catheter removal due to insufficient evidence 1