Should Empagliflozin Be Discontinued in Catheter-Associated UTI?
No, empagliflozin does not need to be discontinued in patients with catheter-associated urinary tract infection (CAUTI). The primary management of CAUTI focuses on catheter replacement and appropriate antimicrobial therapy, not discontinuation of SGLT2 inhibitors 1, 2.
Primary Management of CAUTI
The cornerstone of CAUTI treatment involves catheter management, not medication discontinuation:
Replace the catheter before starting antibiotics if it has been in place for ≥2 weeks, as this improves clinical outcomes, decreases polymicrobial bacteriuria, shortens time to clinical improvement, and lowers rates of UTI recurrence 2, 3.
Obtain urine culture after changing the catheter and allowing for urine accumulation while plugging the catheter 2.
Treat with antimicrobials for 7 days for patients with prompt symptom resolution, or extend to 10-14 days for delayed response 1, 2.
Remove the catheter as soon as clinically appropriate to reduce risk of recurrent infection 1, 2.
Evidence Regarding SGLT2 Inhibitors and UTI Risk
The concern about continuing empagliflozin during CAUTI is understandable given the increased UTI risk with SGLT2 inhibitors, but the evidence does not support routine discontinuation:
Empagliflozin increases UTI risk modestly in general populations (urinary tract infections occurred in 7.6% with empagliflozin 10 mg, 9.3% with empagliflozin 25 mg, versus 7.6% with placebo in pooled trials), but most infections are mild to moderate and respond to standard antimicrobial treatment 4.
In catheterized patients specifically, a retrospective study of 25 veterans using catheters found no statistically significant difference in UTI rates when comparing catheters alone (0.09 UTIs/month) versus concurrent catheter and empagliflozin use (0.07 UTIs/month, P=0.61) 5.
UTI discontinuation rates are very low with empagliflozin (0.1-0.2% in clinical trials), indicating that most infections are manageable without stopping the drug 4.
Cardiovascular and Renal Benefits Outweigh UTI Risk
The decision to continue empagliflozin should prioritize mortality and morbidity outcomes:
SGLT2 inhibitors reduce cardiovascular death and heart failure hospitalization in patients with type 2 diabetes and established cardiovascular disease 1.
Empagliflozin provides kidney protection and is effective even in patients with moderate kidney dysfunction (eGFR ≥30 mL/min/1.73 m²) 1.
Benefits occur rapidly (within weeks) and are maintained regardless of age, sex, or background medical therapy 1.
The favorable safety profile includes low risk of hypoglycemia, no blood pressure or heart rate effects, and no dose titration requirements 1.
When to Consider Temporary Discontinuation
There are specific clinical scenarios where temporary discontinuation may be warranted, but these relate to acute illness complications rather than the UTI itself:
Discontinue 3 days before elective surgery to prevent postoperative ketoacidosis 1.
Consider temporary discontinuation if severe sepsis or urosepsis develops with hemodynamic instability requiring aggressive fluid resuscitation, as volume depletion risk may be enhanced 4.
Hold if diabetic ketoacidosis occurs (a rare complication that can be triggered by intercurrent illness, reduced food/fluid intake, or reduced insulin doses) 1, 4.
Common Pitfalls to Avoid
Do not treat asymptomatic bacteriuria in catheterized patients, as this does not reduce subsequent CAUTI and increases antimicrobial resistance 2, 3.
Do not use prophylactic antimicrobials routinely at catheter placement, removal, or replacement, as this promotes resistance without reducing CAUTI 3.
Do not assume all UTIs require SGLT2 inhibitor discontinuation – most are mild to moderate and respond to standard treatment while continuing the medication 4, 6.
Be cautious in patients with bladder outlet obstruction or significant urinary retention, as urinary stasis combined with glucosuria may increase infection risk 7.