What is the appropriate antibiotic regimen for treating cystitis in a patient with a Foley catheter (indwelling urinary catheter) in place?

Treatment of Cystitis in Patients with Indwelling Foley Catheters

Replace the Foley catheter immediately before starting antibiotics if it has been in place for ≥2 weeks, then initiate empiric antibiotic therapy with levofloxacin 750 mg orally once daily for 7 days (or 14 days in males when prostatitis cannot be excluded), adjusting based on culture results. 1, 2

Critical First Step: Catheter Replacement

• The Infectious Diseases Society of America mandates replacing the indwelling catheter before initiating antimicrobial therapy if it has been in place for ≥2 weeks, as this significantly decreases polymicrobial bacteriuria, shortens time to clinical improvement, and reduces CA-UTI recurrence rates within 28 days (25 versus 11 patients showed improved clinical status with replacement, p <0.001). 1, 2

• Obtain the urine culture specimen from the freshly placed catheter after allowing urine to accumulate, as biofilm on old catheters does not accurately reflect bladder infection status. 1

• Do not delay catheter replacement—this must be done before starting antibiotics, as it is crucial for treatment success. 1, 2

Diagnostic Requirements

• Always obtain urine culture prior to initiating antibiotics due to the wide spectrum of potential organisms and high likelihood of antimicrobial resistance in catheter-associated UTI. 1

• Treat only symptomatic catheter-associated UTI (fever, rigors, altered mental status, flank pain, costovertebral angle tenderness, acute hematuria, pelvic discomfort, dysuria, suprapubic pain)—do not treat asymptomatic bacteriuria, as this increases antimicrobial resistance without preventing CA-UTI. 2

Empiric Antibiotic Selection

For Mild to Moderate CA-UTI:

• Levofloxacin 750 mg orally once daily is the first-line treatment, demonstrating superior microbiologic eradication rates and specifically validated for catheter-associated UTI. 1

• Avoid fluoroquinolones if the patient has used them in the last 6 months or is from a urology department, as resistance rates may exceed 10%. 1

For Moderate to Severe CA-UTI or Septic Patients:

• Intravenous options include:

  • Fluoroquinolones: ciprofloxacin 400 mg IV twice daily or levofloxacin 750 mg IV daily 1
  • Extended-spectrum cephalosporins: ceftriaxone 1-2 g IV daily or cefepime 1-2 g IV twice daily 1, 2
  • Broad-spectrum penicillins: piperacillin-tazobactam 2.5-4.5 g IV three times daily 1
  • Alternative combinations: amoxicillin plus an aminoglycoside, or second-generation cephalosporin plus an aminoglycoside 2

• Reserve carbapenems only for patients with early culture results showing multidrug-resistant organisms. 1

Treatment Duration

• Standard treatment duration is 7 days for patients with prompt symptom resolution. 1, 2

• Extend to 10-14 days for patients with delayed response, regardless of whether the catheter remains in place. 1, 2

• For males specifically, use 14 days when prostatitis cannot be excluded, as prostatic involvement is common. 1

• Treatment duration should be closely related to the treatment of any underlying urological abnormality, and 7 days is recommended when the patient is hemodynamically stable and has been afebrile for at least 48 hours. 2

Critical Pitfalls to Avoid

• Do not give prophylactic antimicrobials routinely at the time of catheter replacement alone (without symptoms), as this promotes antimicrobial resistance without reducing CA-UTI. 2

• Avoid concomitant use of Foley catheters with other urinary devices (PCNT, ureteral stents) when feasible. 3

• Do not perform surveillance urinary cultures or treat asymptomatic patients, except in pregnant women or patients undergoing urologic procedures with anticipated mucosal bleeding. 3, 2

• The guidelines for uncomplicated cystitis (nitrofurantoin, fosfomycin, trimethoprim-sulfamethoxazole) do not apply to catheter-associated UTI, which requires different management. 3