How to manage asymptomatic bacteriuria (presence of bacteria in urine) and hematuria (blood in urine) in an elderly patient with a chronic Foley (indwelling urinary) catheter?

Management of Asymptomatic Bacteriuria and Hematuria in Elderly Patients with Chronic Foley Catheters

Do not screen for or treat asymptomatic bacteriuria in patients with long-term indwelling catheters, regardless of the presence of bacteria in urine cultures or pyuria. 1

Asymptomatic Bacteriuria Management

Core Principle: No Treatment Required

• Bacteriuria is universal in patients with chronic indwelling catheters and does not require antimicrobial therapy unless the patient develops systemic signs of infection such as fever, rigors, hypotension, or hemodynamic instability. 1

• The 2019 IDSA guidelines provide a strong recommendation against screening for or treating asymptomatic bacteriuria in patients with long-term indwelling catheters, based on low-quality evidence showing no clinical benefit and high-quality evidence demonstrating harm from unnecessary antibiotic use. 1

• Pyuria accompanying asymptomatic bacteriuria is not an indication for antimicrobial treatment, as it is expected in catheterized patients and does not distinguish between colonization and true infection. 1

When to Treat: Symptomatic Infection Only

• Initiate antimicrobial therapy only when systemic signs of infection are present: fever (temperature >38°C or >100.4°F), new-onset confusion with acute change, rigors, hemodynamic instability, or signs consistent with sepsis syndrome. 1, 2

• In elderly patients with functional or cognitive impairment who have bacteriuria and delirium or falls without fever or hemodynamic instability, assess for other causes and observe carefully rather than treating the bacteriuria, as antimicrobial therapy has not been shown to improve these outcomes and increases risk of Clostridioides difficile infection and antimicrobial resistance. 1

Common Pitfall to Avoid

• Do not obtain urine cultures or initiate antibiotics based solely on positive urine cultures, cloudy urine, or foul-smelling urine in catheterized patients without systemic signs of infection, as this leads to inappropriate antibiotic use in approximately 32-70% of cases. 2, 3, 4

Hematuria Management

Immediate Assessment Required

Remove the indwelling catheter immediately if there is no ongoing clinical indication, as this is the single most important intervention to prevent complications and allow proper evaluation of the hematuria. 2

Diagnostic Evaluation Algorithm

Step 1: Rule Out Symptomatic UTI

• Evaluate for systemic signs of infection (fever, rigors, hypotension, acute delirium) that would indicate symptomatic UTI requiring treatment. 2
• Do not obtain urine cultures for asymptomatic bacteriuria, as bacteriuria is universal in chronic catheterization. 2

Step 2: Mandatory Cystoscopy

• Perform cystoscopy in any patient with hematuria and catheter history to evaluate for bladder lesions, urethral strictures, catheter trauma, false passages, bladder stones, or malignancy. 2
• This is critical because chronically catheterized patients, particularly those with spinal cord injury, have a 25-81% rate of squamous cell carcinoma of the bladder. 2
• Catheter trauma, urethral irritation, and false passages are common causes of hematuria that cannot be diagnosed without direct visualization. 2

Step 3: Upper Tract Imaging

• Obtain CT urogram (preferred) or renal ultrasound to evaluate for renal masses, stones, hydronephrosis, or upper tract transitional cell carcinoma. 2
• CT urogram is superior to intravenous urography for detecting small renal masses. 2

Step 4: Additional Testing

• Obtain urine cytology if risk factors for transitional cell carcinoma exist (smoking history, chemical exposure, age >50) or if cystoscopy shows suspicious findings. 2
• Measure serum creatinine to assess renal function. 2

Critical Pitfall

• Never assume hematuria is "just from the catheter" without complete evaluation, as malignancy must be excluded given the significantly elevated cancer risk in chronically catheterized patients. 2

If Catheter Must Remain

• If the catheter has been in place ≥2 weeks and symptomatic UTI is suspected, replace the catheter before obtaining urine specimens or starting antimicrobials, as this improves clinical outcomes and diagnostic accuracy. 2

Follow-Up Strategy

• Repeat urinalysis 48 hours after catheter removal to confirm persistence of hematuria. 2
• If hematuria resolves after catheter removal and workup is negative, no further evaluation is needed unless hematuria recurs. 2

Long-Term Complications of Chronic Catheterization

• Patients with long-term catheters face risks beyond infection, including catheter obstruction, urinary tract stones, local periurinary infections, chronic renal inflammation, chronic pyelonephritis, and bladder cancer developing over years. 5
• These complications underscore why alternative methods of bladder drainage (intermittent catheterization, suprapubic catheterization, condom catheters) should be considered whenever clinically feasible. 5