What is the treatment for a catheter-related urinary tract infection (UTI) caused by Extended-Spectrum Beta-Lactamase (ESBL)-producing bacteria?

Treatment of Catheter-Related UTI Caused by ESBL-Producing Bacteria

For catheter-related UTI caused by ESBL-producing bacteria, replace the catheter if it has been in place for ≥2 weeks before starting antimicrobial therapy, and use a carbapenem (such as imipenem) as the first-line treatment option. 1, 2

Initial Management Steps

• Replace the indwelling catheter before starting antimicrobial therapy if the catheter has been in place for ≥2 weeks and continued catheterization is necessary 1
• Catheter replacement has been shown to decrease polymicrobial bacteriuria, shorten time to clinical improvement, and lower rates of CA-UTI recurrence within 28 days after therapy 1
• Obtain urine cultures from the freshly placed catheter prior to initiating antimicrobial therapy to ensure appropriate coverage 2

Antimicrobial Treatment Options

First-line Treatment:

• Carbapenems (such as imipenem) are the most reliable treatment option for ESBL-producing organisms 3, 4
• Imipenem is FDA-approved for complicated and uncomplicated urinary tract infections caused by various pathogens including Enterobacteriaceae 3

Alternative Options (based on susceptibility testing):

• For mild-moderate infections with confirmed susceptibility, consider:
  • Fosfomycin (particularly effective against E. coli) 4, 5
  • Nitrofurantoin (effective against E. coli but less so against Klebsiella) 4, 5
  • Pivmecillinam (if available and susceptible) 5
  • Aminoglycosides (if susceptible) 4

Treatment Duration

• Treatment for 7-14 days is generally recommended for catheter-associated UTIs 2
• For men, consider 14 days when prostatitis cannot be excluded 2
• A shorter treatment duration (7 days) may be appropriate when the patient has been afebrile for at least 48 hours and is hemodynamically stable 2

Special Considerations

• ESBL-producing organisms are considered a complicating factor in UTIs, requiring more aggressive management 2
• These infections are often multidrug-resistant, limiting therapeutic options 4, 5
• Risk factors for ESBL-producing organisms include:
  • Recent hospitalization (within 3 months) 6
  • Residency in long-term care facilities 6
  • Presence of a permanent urinary catheter 6
  • Previous antibiotic exposure 4

Pitfalls to Avoid

• Do not treat asymptomatic bacteriuria in catheterized patients, as this does not reduce subsequent symptomatic infections but increases antimicrobial resistance 2
• Avoid fluoroquinolones for empiric treatment due to high resistance rates among ESBL-producing organisms 4, 5
• Do not administer prophylactic antimicrobials routinely at catheter placement or removal, as this promotes antimicrobial resistance 1
• Do not delay catheter replacement in patients with long-term catheters who develop symptomatic infection, as biofilms protect bacteria from antimicrobials 7, 8

Prevention Strategies

• Limit indwelling catheter use and duration whenever possible 8
• Discontinue the catheter as soon as clinically feasible 8
• Maintain a closed drainage system and adhere to appropriate catheter care techniques 8
• Consider alternative drainage methods when appropriate 2