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

Treatment of Foley Catheter-Related UTI

For catheter-associated UTI, initiate empirical therapy with intravenous third-generation cephalosporin, amoxicillin plus aminoglycoside, or second-generation cephalosporin plus aminoglycoside, and replace the catheter if it has been in place for ≥2 weeks. 1, 2

Immediate Diagnostic Steps

Obtain urine culture before starting antibiotics due to the broad spectrum of potential pathogens (E. coli, Proteus, Klebsiella, Pseudomonas, Serratia, Enterococcus) and high likelihood of antimicrobial resistance in catheter-associated infections. 3, 1, 2

• If the catheter has been in place ≥2 weeks, replace it before initiating antimicrobials to obtain accurate culture from fresh catheter and improve treatment outcomes. 3, 1, 2
• Collect the urine specimen from the freshly placed catheter when feasible, as biofilm on old catheters may not reflect true bladder infection status. 3

First-Line Empirical Antibiotic Regimens

The European Association of Urology strongly recommends these options for empirical treatment: 1, 2

• Intravenous third-generation cephalosporin (preferred first-line option) 1, 2
• Amoxicillin plus aminoglycoside 1, 2
• Second-generation cephalosporin plus aminoglycoside 1, 2

Fluoroquinolone Considerations

Fluoroquinolones may be used only if ALL of the following criteria are met: 1, 2

• Local resistance rates <10% 1, 2
• Patient has not used fluoroquinolones in the last 6 months 1, 2
• Patient does not require hospitalization 2
• Patient has anaphylaxis to β-lactam antimicrobials 2

Avoid fluoroquinolones in patients from urology departments or with recent fluoroquinolone exposure due to emerging resistance, particularly in older patients. 1, 2

Treatment Duration

The duration depends on clinical response: 3, 1, 4, 2

• 7 days for patients with prompt symptom resolution (fever, dysuria, flank pain resolve quickly) 3, 1, 4, 2
• 10-14 days for patients with delayed response to therapy 3, 1, 4, 2
• 14 days for male patients where prostatitis cannot be excluded 1, 4, 2

Alternative Shorter Regimens

• 5-day levofloxacin (750 mg once daily) may be considered in patients who are not severely ill 3, 4
• 3-day regimen may be considered for women aged ≤65 years without upper urinary tract symptoms after catheter removal 3

Catheter Management Strategy

Replace the catheter if it has been in place ≥2 weeks at UTI onset to hasten symptom resolution and reduce risk of recurrent infection. 3, 1, 4, 2

• Remove the catheter as soon as clinically appropriate, as catheterization duration is the most important risk factor for CA-UTI development. 4, 5
• For patients with urinary retention and UTI, ensure appropriate antibiotic treatment before removing the Foley catheter. 2

Pathogen-Specific Management

Staphylococcus aureus CA-UTI

Remove the catheter immediately and treat with appropriate antibiotics for 4-6 weeks unless specific exceptions apply. 2

Coagulase-Negative Staphylococci

Remove the catheter and treat with appropriate antibiotics based on susceptibility. 2

Carbapenem-Resistant Enterobacterales (CRE)

Use plazomicin, ceftazidime-avibactam, or polymyxin-based combination therapy. 1

Oral Step-Down Therapy Options

After clinical improvement with parenteral therapy, consider: 1

• Nitrofurantoin for susceptible organisms 1
• Fosfomycin for susceptible organisms 1
• Culture-directed oral antibiotics for as short a course as reasonable (generally ≤7 days) for resistant organisms 1, 4

Critical Pitfalls to Avoid

Do not treat asymptomatic bacteriuria in catheterized patients unless specific indications exist (e.g., immediately prior to invasive urological procedures). 1, 2, 6

• Do not rely solely on urine dipstick tests in elderly patients, as specificity ranges from 20-70%. 1
• Antimicrobial treatment of asymptomatic CA-UTI does not decrease symptomatic episodes but leads to emergence of resistant organisms. 6
• Do not use moxifloxacin for UTI treatment due to uncertainty regarding effective urinary concentrations. 3

Monitoring and Follow-Up

Monitor for resolution of symptoms (fever, dysuria, flank pain) within 48 hours of appropriate therapy. 2

• Consider complications or resistant organisms if symptoms persist beyond 48 hours. 2
• Monitor for signs of UTI recurrence after catheter removal. 2
• Be aware that CA-UTIs are the leading cause of secondary healthcare-associated bacteremia (approximately 20% of hospital-acquired bacteremias) with mortality rate of approximately 10%. 1, 2

Prevention Considerations

Use local antimicrobial resistance patterns to guide empirical therapy choices. 1, 2

• Limit catheter use and discontinue when no longer needed—the most effective prevention strategy. 5, 7
• Maintain closed drainage system and adhere to appropriate catheter care techniques. 6
• Avoid catheter flushing or daily perineal care, as these do not prevent infection and may increase risk. 6