What is the management for a patient with green drainage from a suprapubic (urinary catheter inserted through the abdomen) tube site, indicating a potential urinary tract infection (UTI)?

Management of Green Drainage from Suprapubic Tube Site

Obtain urine culture with microscopy immediately to guide targeted antimicrobial therapy, and assess the patient for systemic signs of infection requiring urgent treatment. 1

Initial Assessment and Diagnostic Approach

Green drainage from a suprapubic catheter site strongly suggests catheter-associated urinary tract infection (CA-UTI), likely with purulent material tracking along the catheter tract. The clinical evaluation must distinguish between:

• Local site infection (cellulitis around insertion site)
• CA-UTI with or without systemic symptoms (fever, hypotension, altered mental status)
• Asymptomatic bacteriuria (colonization without true infection) 1

Critical first steps:

• Obtain urine culture with microscopy before initiating antibiotics - this is essential as urine culture should not be performed without accompanying microscopy due to common sample contamination and bacterial colonization 1
• Assess for systemic symptoms including fever, rigors, hypotension, or altered mental status that would indicate urosepsis or pyelonephritis 1, 2
• Examine the insertion site for erythema, induration, purulent drainage, or tracking cellulitis 1

Antimicrobial Management

When Systemic Symptoms Are Present

If the patient has fever, hemodynamic instability, or signs of tissue invasion, this is NOT prophylaxis but active treatment requiring immediate empiric antibiotics while awaiting culture results. 1

For empiric therapy in symptomatic CA-UTI:

• First-line options include fluoroquinolones (ciprofloxacin 500-750 mg twice daily or levofloxacin 750 mg once daily) if local resistance rates are below 10% 3
• Alternative agents include trimethoprim-sulfamethoxazole 160/800 mg twice daily, third-generation cephalosporins (cefpodoxime 200 mg twice daily), or aminoglycosides for multidrug-resistant organisms 3, 4
• Treatment duration should be 7-14 days depending on clinical response, with assessment at 72 hours to determine if therapy adjustment is needed 3

When Only Local Drainage Without Systemic Symptoms

Prophylactic antimicrobials should NOT be administered routinely to catheterized patients to reduce CA-bacteriuria or CA-UTI. 1 This is a strong recommendation (A-I evidence) from the Infectious Diseases Society of America guidelines.

However, if there is purulent drainage suggesting local infection at the insertion site, local wound care and consideration of catheter replacement may be warranted while awaiting culture results. 1

Catheter Management

Replace the suprapubic catheter if it has been in place for ≥2 weeks, and obtain a fresh urine culture from the newly placed catheter. 3 This is critical because:

• Established biofilms on catheters protect uropathogens from antimicrobials and host immune response 1
• Many bacterial species decrease substantially when comparing cultures from old versus replacement catheters 1
• Green drainage suggests significant bacterial burden, likely with biofilm formation 1

Important caveats:

• There is insufficient evidence to recommend routine catheter changes every 2-4 weeks for prevention, but in the setting of active infection with purulent drainage, replacement is appropriate 1
• Maintain closed drainage system integrity during replacement to minimize contamination risk 1

Interventions NOT Recommended

Do not add antimicrobials or antiseptics to the drainage bag - randomized trials show no benefit in reducing CA-bacteriuria or CA-UTI rates (A-I evidence). 1

Do not perform bladder irrigation with antimicrobials or antiseptics routinely - this does not reduce infection risk and is not evidence-based. 1

Follow-Up and Monitoring

• Reassess clinical response within 72 hours of treatment initiation if antibiotics were started 3
• Adjust therapy based on culture and sensitivity results once available, as empiric treatment may not cover the actual pathogen 3, 5
• Consider extending treatment to 10-14 days if symptoms persist beyond 72 hours or if there is delayed clinical response 3
• Evaluate for underlying urological abnormalities that may predispose to recurrent infections, particularly in male patients where UTI is always considered complicated 3, 2

Common Pitfalls to Avoid

• Treating asymptomatic bacteriuria: If the patient has no systemic symptoms and only colonization, antimicrobials are not indicated and may promote resistance 1
• Obtaining cultures without microscopy: This leads to overtreatment of contamination rather than true infection 1
• Delaying catheter replacement in established infection: Old catheters with biofilms will not clear infection despite appropriate antibiotics 1
• Using prophylactic antibiotics at catheter changes: This is not recommended and promotes antimicrobial resistance (A-III evidence) 1