What antibiotic is recommended for a patient with a suprapubic (urinary catheter inserted through the abdomen) catheter to prevent or treat urinary tract infections (UTIs)?

Antibiotic Recommendations for Suprapubic Catheter Patients

Prophylactic antibiotics should NOT be routinely administered to patients with suprapubic catheters to prevent urinary tract infections. 1

Key Principle: Do Not Treat Asymptomatic Bacteriuria

The Infectious Diseases Society of America strongly recommends against screening for or treating asymptomatic bacteriuria in patients with suprapubic catheters, whether short-term or long-term. 1, 2, 3 This applies equally to suprapubic and urethral catheters, as management considerations are identical for both catheter types. 2

Why No Prophylaxis?

• Prophylactic antimicrobials should not be given at catheter placement, removal, or replacement to reduce catheter-associated bacteriuria or UTI (strong recommendation, high-quality evidence). 1

• Treatment of asymptomatic bacteriuria does not improve outcomes and leads to significant harm including antimicrobial resistance, adverse drug effects, and increased costs. 1, 3

• A randomized trial of 35 patients with long-term catheters showed no difference in UTI rates between those treated with cephalexin versus no antibiotics, but the treated group had 47% resistant organisms compared to 26% in controls. 1

• Antimicrobial therapy did not alter mortality in catheterized patients with bacteriuria in multivariate analysis. 1

When Antibiotics ARE Indicated

Symptomatic Catheter-Associated UTI Only

Antibiotics should only be prescribed when patients develop symptomatic infection, not for positive urine cultures alone. 3, 4

Diagnostic Criteria for Symptomatic CAUTI:

• New onset fever without another identified source 3
• Suprapubic tenderness 3
• Costovertebral angle pain or tenderness 3
• Acute hematuria 3
• New onset delirium (particularly in elderly patients) 3

Treatment Algorithm for Symptomatic CAUTI:

1. Obtain urine culture before starting antibiotics to guide targeted therapy. 3

2. Replace the catheter if it has been in place ≥2 weeks at onset of symptoms to hasten resolution and reduce recurrence risk. 1

3. Select empirical antibiotics based on local resistance patterns, then adjust based on culture results. 1, 3

4. Duration of treatment:

   • 7 days for prompt symptom resolution (most patients) 1
   • 10-14 days for delayed response 1
   • 5 days of levofloxacin (750 mg daily) may be considered for patients who are not severely ill 1
   • 3 days may be considered for women ≤65 years with mild symptoms after catheter removal 1

Single Exception: Urologic Procedures

The only situation requiring prophylactic antibiotics is before urologic procedures involving mucosal trauma. 3 In this case, give 1-2 doses of targeted antimicrobial therapy 30-60 minutes before the procedure. 3

Critical Pitfalls to Avoid

• Do not order routine urine cultures in asymptomatic catheterized patients – this leads to unnecessary treatment of colonization. 4

• Do not use bladder irrigation with antimicrobials – this provides no benefit. 1, 3

• Do not add antimicrobials or antiseptics to drainage bags – this is ineffective. 3

• Avoid treating nonspecific symptoms (confusion, weakness) as UTI without meeting diagnostic criteria, as this drives resistance. 1

Prevention Strategies (Non-Antibiotic)

The most effective prevention is removing the catheter as soon as clinically appropriate, as infection risk increases ~5% per day of catheterization. 3

• Maintain closed drainage system at all times 1, 3
• Keep drainage bag below bladder level 1, 3
• Minimize catheter-tubing disconnections 1, 3
• Consider antimicrobial-coated catheters for short-term use only 1, 3