What is the recommended treatment for a male patient with a Urinary Tract Infection (UTI) and a suprapubic catheter?

Treatment of UTI in Male Patients with Suprapubic Catheter

For male patients with a urinary tract infection (UTI) and a suprapubic catheter, a 7-14 day course of antibiotics is recommended, with 14 days being preferred when prostatitis cannot be excluded. 1, 2

Antibiotic Selection

• First-line empirical treatment options include:

  • Amoxicillin plus an aminoglycoside
  • A second-generation cephalosporin plus an aminoglycoside
  • An intravenous third-generation cephalosporin 1

• Fluoroquinolones (e.g., ciprofloxacin) should only be used when:

  • Local resistance rates are <10%
  • The patient can be treated entirely as an outpatient
  • The patient has not used fluoroquinolones in the previous 6 months
  • The patient has anaphylaxis to β-lactam antibiotics 1

• A 5-day regimen with levofloxacin (750 mg once daily) may be considered for patients with mild catheter-associated UTI who respond promptly to therapy 2, 3

Treatment Duration

• 7 days if symptoms resolve promptly 2
• 10-14 days for patients with a delayed response to therapy 2
• 14 days for male patients when prostatitis cannot be excluded 1

Catheter Management

• If the suprapubic catheter has been in place for ≥2 weeks at the onset of UTI, it should be replaced to:

  • Hasten resolution of symptoms
  • Reduce the risk of subsequent catheter-associated bacteriuria and UTI 2

• A urine specimen for culture should be obtained prior to initiating antimicrobial therapy due to:

  • The wide spectrum of potential infecting organisms
  • Increased likelihood of antimicrobial resistance 2

Microbial Considerations

• Catheter-associated UTIs have a broader microbial spectrum than uncomplicated UTIs, with common pathogens including:

  • E. coli
  • Proteus species
  • Klebsiella species
  • Pseudomonas species
  • Serratia species
  • Enterococcus species 1

• Antimicrobial resistance is more likely in catheter-associated UTIs, necessitating culture-guided therapy whenever possible 1, 4

Special Considerations for Male Patients

• UTIs in males are classified as complicated infections, traditionally requiring longer treatment durations than in females 5
• When prostatitis cannot be excluded (common in male UTIs), a 14-day course is recommended 1
• For patients with infections resistant to oral antibiotics, culture-directed parenteral antibiotics should be used for as short a course as reasonable, generally no longer than 7 days 2

Prevention of Recurrence

• Management of any underlying urological abnormality is mandatory for preventing recurrence 1
• Catheterization duration is the most important risk factor for catheter-associated UTI development, so the catheter should be removed as soon as clinically appropriate 1, 4
• For patients requiring long-term catheterization, regular catheter changes at appropriate intervals may help reduce infection risk 2

Pitfalls and Caveats

• Do not treat asymptomatic bacteriuria in patients with indwelling catheters, as this leads to antimicrobial resistance without clinical benefit 1
• Avoid ciprofloxacin and other fluoroquinolones for empirical treatment in patients from urology departments or when patients have used fluoroquinolones in the last 6 months 1
• Recognize that clinical signs and symptoms of UTI in patients with suprapubic catheters may differ from classic symptoms and include:
  • New onset or worsening of fever
  • Altered mental status
  • Malaise or lethargy
  • Flank pain
  • Costovertebral angle tenderness
  • Acute hematuria
  • Pelvic discomfort 1