What is the best course of treatment for a patient with cloudy urine, leukocyturia (leukocytes in the urine), hematuria (blood in the urine), and ketonuria (ketones in the urine), with a negative nitrite test, and an indwelling Foley (urinary) catheter that was replaced 5 days ago?

Management of Catheter-Associated Urinary Tract Infection with Recent Foley Replacement

Replace the Foley catheter immediately before starting antibiotics, obtain a urine culture from the fresh catheter, and initiate empiric antimicrobial therapy for 7 days if symptoms resolve promptly. 1, 2

Immediate Actions Required

Step 1: Replace the Catheter First

• The catheter must be replaced before initiating antibiotics since it has been in place for 5 days and you are treating symptomatic infection. 3, 1, 2
• Catheter replacement significantly decreases polymicrobial bacteriuria, shortens time to clinical improvement (25 vs 11 patients improved at 72 hours, p<0.001), and reduces CA-UTI recurrence within 28 days (3 vs 11 patients with relapse, p=0.015). 3, 2
• The biofilm on the existing catheter does not accurately reflect bladder infection status, making culture results unreliable without replacement. 3, 1

Step 2: Obtain Urine Culture from Fresh Catheter

• Collect the urine specimen from the newly placed catheter after allowing urine to accumulate. 3, 1
• Culture is mandatory before starting antibiotics due to the wide spectrum of potential organisms and high likelihood of multidrug resistance in CA-UTI. 3, 1

Empiric Antibiotic Selection

For Mild to Moderate Symptoms (No Sepsis)

• First-line: Levofloxacin 750 mg orally once daily demonstrates superior microbiologic eradication rates specifically validated for CA-UTI. 1, 2
• Avoid fluoroquinolones if: the patient used them in the last 6 months or resistance rates exceed 10% in your institution. 1, 2

For Moderate to Severe Symptoms or Systemic Illness

• Intravenous options include: 1, 2
  • Ceftriaxone 1-2 g IV daily 2, 4
  • Ciprofloxacin 400 mg IV every 12 hours 1, 5
  • Cefepime 1-2 g IV every 12 hours 1, 2
  • Piperacillin-tazobactam 2.5-4.5 g IV every 8 hours 1

Special Consideration for Males

• Use 14-day treatment duration when prostatitis cannot be excluded, as prostatic involvement is common in males with CA-UTI. 1

Treatment Duration

• 7 days for prompt symptom resolution (patient becomes afebrile within 48-72 hours and symptoms improve). 3, 1, 2
• 10-14 days for delayed response (persistent fever beyond 72 hours or slow symptom improvement). 3, 1, 2
• Duration applies regardless of whether the catheter remains in place or is removed. 3

Critical Pitfalls to Avoid

Do Not Treat Asymptomatic Bacteriuria

• The presence of leukocytes and bacteria alone without symptoms (fever, rigors, altered mental status, flank pain, suprapubic pain, dysuria) does not warrant treatment. 3, 2, 6
• Treating asymptomatic bacteriuria increases antimicrobial resistance without preventing CA-UTI (47% vs 26% resistant organisms in treated vs untreated groups). 3

Interpreting Your Urinalysis Findings

• Cloudy urine + leukocytes + blood: These findings are expected with any indwelling catheter and do not alone indicate infection requiring treatment. 7, 8
• Negative nitrites: Common in CA-UTI as many causative organisms (especially gram-positive cocci and Pseudomonas) do not produce nitrites. 7
• Ketones: Likely unrelated to the urinary tract and may indicate metabolic state (starvation, diabetes). [@General Medicine Knowledge@]

Determine if This is Truly Symptomatic CA-UTI

You must have at least one of these symptoms to justify treatment: 2

• Fever (temperature >38°C or >100.4°F)
• Rigors or chills
• Altered mental status (new confusion or delirium)
• Flank pain or costovertebral angle tenderness
• Acute hematuria (new onset, not chronic catheter trauma)
• Pelvic discomfort or suprapubic pain
• Dysuria (though less reliable with indwelling catheter)

If none of these symptoms are present, this is asymptomatic bacteriuria and should NOT be treated. 3, 2

Catheter Management Going Forward

• Remove the catheter as soon as clinically appropriate to reduce recurrent infection risk. 6
• Do not use prophylactic antibiotics with routine catheter changes, as this promotes resistance without preventing CA-UTI. 2, 6
• Reserve carbapenems only for culture-confirmed multidrug-resistant organisms. 1