How to manage recurrent urinary tract infections (UTIs) in a patient with a cystostomy due to stage IV prostate cancer in remission?

Management of Recurrent UTIs in a 90-Year-Old Patient with Cystostomy Due to Prostate Cancer

For a 90-year-old patient with a cystostomy due to stage IV prostate cancer in remission who suffers from frequent UTIs sometimes leading to sepsis, the management should focus on optimizing catheter care, obtaining appropriate cultures, and implementing targeted antibiotic therapy based on culture results while avoiding prophylactic antibiotics.

Diagnostic Approach

• Obtain urine culture with sensitivity testing before initiating treatment for each symptomatic episode to guide appropriate antibiotic selection 1
• For patients with cystostomy or indwelling catheters, any detectable concentration of bacteria in properly collected specimens is significant 2
• When collecting urine samples from patients with indwelling catheters, obtain the specimen after changing the catheter and allowing for urine accumulation while plugging the catheter - do not collect from extension tubing or collection bag 2
• Document positive cultures and types of microorganisms to establish patterns and identify persistent organisms 1
• For recurrent infections with the same organism, consider imaging to rule out structural abnormalities such as stones or foreign bodies 2

Catheter Management

• Implement proper catheter hygiene including daily cleaning of the perineal region and proximal catheter with soap and water 2
• Ensure proper hand hygiene before and after catheter manipulation or drainage system changes 2
• Consider regular scheduled catheter changes to prevent biofilm formation, which serves as a reservoir for bacteria 3
• Maintain adequate hydration (2-3L per day unless contraindicated) to promote frequent bladder flushing 2
• Avoid disconnecting the closed drainage system whenever possible 4

Antibiotic Treatment Approach

• For acute symptomatic episodes, select antibiotics based on culture and sensitivity results 1
• Use targeted narrow-spectrum antibiotics when possible to reduce risk of resistance 1
• For sepsis episodes, consider broader coverage initially while awaiting culture results, then narrow therapy based on sensitivities 2
• Treat for appropriate duration (7-14 days for complicated UTIs) based on severity and clinical response 2
• Consider trimethoprim-sulfamethoxazole for susceptible organisms, as it is FDA-approved for urinary tract infections due to susceptible strains of E. coli, Klebsiella, Enterobacter, Morganella morganii, and Proteus species 5

Antibiotic Prophylaxis

• Daily antibiotic prophylaxis should not be used in patients who manage their bladder with an indwelling catheter to prevent UTIs 2
• Prophylactic antibiotics have been shown to increase bacterial resistance approximately 2-fold without significantly decreasing symptomatic UTI rates 2
• For patients with recurrent sepsis episodes despite optimal catheter care, consider consultation with infectious disease specialists for individualized management 1

Non-Antibiotic Prevention Strategies

• Consider cranberry products (juice or tablets) as a supplement to other preventive measures, though evidence is limited 2
• For diabetic patients, be cautious with cranberry juice due to high sugar content 2
• Methenamine salts and urinary acidification products have insufficient evidence to recommend their routine use 2
• Ensure adequate hydration to promote urinary flow and bacterial clearance 2

Monitoring and Follow-up

• Repeat urine cultures when UTI symptoms persist following antimicrobial therapy 2
• Do not routinely perform microbiological reassessment after successful treatment (symptom clearance is sufficient) 2
• For patients with rapid recurrence with the same organism, consider evaluation on and off therapy to identify those who warrant further urologic evaluation 2
• Consider upper tract imaging (ultrasound or CT) to evaluate for diagnoses such as stones and hydronephrosis in patients with recurrent infections 2

Common Pitfalls to Avoid

• Treating asymptomatic bacteriuria, which increases antimicrobial resistance without clinical benefit 2
• Using broad-spectrum antibiotics when narrower options are available based on culture results 1
• Failing to obtain cultures before initiating treatment in recurrent cases 1
• Not considering structural abnormalities in patients with relapsing infections 1
• Collecting urine samples from the extension tubing or collection bag rather than after changing the catheter 2