Should Sodium-Glucose Linked Transporter 2 (SGLT2) inhibitors be held in patients with an indwelling Foley catheter to reduce the risk of urinary tract infection?

SGLT2 Inhibitors and Indwelling Foley Catheters

SGLT2 inhibitors should NOT be routinely held in patients with indwelling Foley catheters, as there is no evidence that these medications increase urinary tract infection risk in catheterized patients, and the cardiovascular and renal benefits of continuing therapy outweigh theoretical concerns.

Evidence-Based Rationale

Catheter-Associated UTI Risk is Independent of SGLT2 Inhibitors

The primary risk factor for catheter-associated urinary tract infections (CAUTI) is the duration of catheterization itself, not concurrent medications. The risk of UTI from an indwelling catheter increases approximately 5% per day of catheterization 1. The most effective strategy to reduce CAUTI is early catheter removal—ideally within 24-48 hours—rather than withholding beneficial medications 1, 2, 3.

Guidelines from the Infectious Diseases Society of America strongly recommend against screening for or treating asymptomatic bacteriuria in catheterized patients, as antimicrobial interventions provide no benefit and increase antimicrobial resistance 1. This underscores that the presence of bacteriuria in catheterized patients is expected and does not warrant intervention—a principle that extends to medication management decisions.

SGLT2 Inhibitors Do Not Increase UTI Risk

While early concerns suggested SGLT2 inhibitors might increase UTI risk due to glycosuria, large randomized controlled trials and real-world studies have consistently failed to demonstrate a significantly increased risk of UTI with SGLT2 inhibitor use 4.

Recent evidence is particularly reassuring:

• A 2024 cross-sectional study of 328 patients found no statistical difference in UTI rates between patients taking SGLT2 inhibitors versus other glucose-lowering medications 5
• A 2023 analysis of a nationwide Japanese claims database found that SGLT2 inhibitor prescription was actually negatively associated with UTI likelihood in male patients with diabetes (OR 0.74,95% CI 0.72-0.75), and showed no increased risk in female patients (OR 0.99,95% CI 0.96-1.01) 6
• A 2022 review concluded that data from large randomized clinical trials and real-world studies have not shown significantly increased UTI risk with SGLT2 inhibitors 4

Cardiovascular and Renal Benefits Outweigh Theoretical Risks

SGLT2 inhibitors provide substantial mortality and morbidity benefits that should not be interrupted without compelling evidence of harm. The ACC Expert Consensus documents that empagliflozin and canagliflozin demonstrate:

• Significant cardiovascular risk reduction in patients with type 2 diabetes and atherosclerotic cardiovascular disease 1
• Favorable effects on kidney function, with empagliflozin reducing progression to macroalbuminuria (HR 0.61,95% CI 0.53-0.70) 1
• Canagliflozin showing 40% improvement in renal composite outcomes (HR 0.60,95% CI 0.47-0.77) 1

Interrupting these medications based on theoretical UTI concerns in catheterized patients would sacrifice proven cardiovascular and renal protection without evidence of benefit.

Practical Management Approach

Focus on Catheter Management, Not Medication Adjustment

The evidence-based strategy to reduce CAUTI risk involves:

• Remove Foley catheters as soon as clinically feasible, ideally within 48 hours 1, 2, 3
• Consider silver alloy-coated catheters if prolonged catheterization is necessary, as they reduce infection risk 1, 2
• Ensure appropriate indications for catheter placement exist and are documented 1
• Implement daily catheter rounds to prompt continued use assessment or removal 1

Continue SGLT2 Inhibitors Unless Contraindicated

The only situations warranting SGLT2 inhibitor discontinuation are established contraindications from the ACC guidelines 1:

• Signs or symptoms of ketoacidosis (dyspnea, nausea, vomiting, abdominal pain)
• Severe renal impairment (eGFR thresholds vary by agent)
• History of lower limb amputation, peripheral arterial disease, neuropathy, or diabetic foot ulcers (particularly with canagliflozin due to black box warning)

The presence of an indwelling Foley catheter is NOT a contraindication to SGLT2 inhibitor therapy.

Common Pitfalls to Avoid

• Do not routinely prescribe prophylactic antibiotics for catheterized patients on SGLT2 inhibitors, as this provides no benefit and increases antimicrobial resistance 1, 2
• Do not obtain urine cultures or treat asymptomatic bacteriuria in catheterized patients, as this is explicitly discouraged by IDSA guidelines 1
• Do not confuse genital mycotic infections with UTIs—SGLT2 inhibitors do increase risk of candida vaginitis and balanitis, but these are typically mild, easily treated, and rarely recur 1
• Do not delay catheter removal based on SGLT2 inhibitor use, as prolonged catheterization is the primary modifiable risk factor for CAUTI 1, 2