What is the treatment for a catheter-related Urinary Tract Infection (UTI)?

Treatment of Catheter-Related Urinary Tract Infection

For catheter-associated urinary tract infections (CAUTIs), the first-line empirical treatment should be an intravenous third-generation cephalosporin, or a combination of amoxicillin plus an aminoglycoside, or a second-generation cephalosporin plus an aminoglycoside. 1

Diagnosis and Initial Management

• Obtain urine culture and susceptibility testing before initiating antimicrobial therapy due to the wide spectrum of potential infecting organisms and increased likelihood of antimicrobial resistance 1, 2
• If the catheter has been in place for ≥2 weeks at the onset of UTI, replace it before starting antibiotics to hasten symptom resolution and reduce the risk of subsequent infection 1, 3
• Signs and symptoms compatible with CAUTI include new onset or worsening of fever, rigor, altered mental status, malaise, flank pain, costovertebral angle tenderness, acute hematuria, pelvic discomfort, and in patients whose catheter has been removed: dysuria, urgency, frequency, and suprapubic pain 4

First-Line Empirical Treatment Options

• Intravenous third-generation cephalosporin is strongly recommended as first-line empirical treatment 1
• Alternative first-line options include:
  • Amoxicillin plus an aminoglycoside 1
  • Second-generation cephalosporin plus an aminoglycoside 1

Treatment Duration

• 7 days of antimicrobial therapy for patients who show prompt clinical response 1, 2
• 10-14 days for patients with delayed response 1, 2
• 14 days for male patients where prostatitis cannot be excluded 4, 2

Pathogen-Specific Considerations

• CAUTIs have a broader microbial spectrum than uncomplicated UTIs, with common pathogens including E. coli, Proteus spp., Klebsiella spp., Pseudomonas spp., Serratia spp., and Enterococcus spp. 4, 1
• For S. aureus CAUTI, remove the catheter immediately and treat with appropriate antibiotics for 4-6 weeks unless specific exceptions apply 4
• For coagulase-negative staphylococci, remove the catheter and treat with appropriate antibiotics 4

Alternative Treatment Options

• Fluoroquinolones (e.g., ciprofloxacin) can be used only if:
  • Local resistance rates are <10% 4, 1
  • The patient has not used fluoroquinolones in the last 6 months 4, 1
  • The patient does not require hospitalization 1
  • The patient has anaphylaxis to β-lactam antimicrobials 1
• Trimethoprim-sulfamethoxazole can be used for susceptible strains of E. coli, Klebsiella species, Enterobacter species, Morganella morganii, Proteus mirabilis, and Proteus vulgaris 5

Catheter Management

• Remove or replace the catheter before starting antibiotic therapy whenever possible 1, 3
• For patients with urinary retention and UTI, ensure appropriate antibiotic treatment before removing the Foley catheter 3
• After completing appropriate antibiotic treatment, consider a trial of void protocol for patients with short-term urinary retention 3

Common Pitfalls and Caveats

• Do not use fluoroquinolones for empirical treatment in patients from urology departments or when patients have used fluoroquinolones in the last 6 months due to increased risk of resistance 4, 1
• Avoid treating asymptomatic bacteriuria in catheterized patients unless specific indications exist 1
• Do not rely solely on urine dipstick tests in elderly patients, as specificity ranges from 20% to 70% 1
• CAUTIs are the leading cause of secondary healthcare-associated bacteremia, with approximately 20% of hospital-acquired bacteremias arising from the urinary tract and a mortality rate of approximately 10% 4, 6
• Failing to obtain cultures before initiating antibiotics may lead to inappropriate antibiotic selection given the high likelihood of resistant organisms 3

Monitoring and Follow-up

• Monitor for resolution of symptoms, such as fever, dysuria, and flank pain 2
• Consider complications or resistant organisms if symptoms persist beyond 48 hours of appropriate therapy 2
• Monitor for signs of UTI recurrence (fever, dysuria, frequency, urgency) after catheter removal 3