Antibiotic Treatment for Catheter-Associated Cystitis
For patients with indwelling urinary catheters who develop acute cystitis, levofloxacin 750 mg orally once daily for 7 days is the first-line treatment, but you must replace the catheter before starting antibiotics if it has been in place for ≥2 weeks. 1
Critical First Step: Catheter Management
Replace the indwelling catheter before initiating antimicrobial therapy if it has been in place for ≥2 weeks. 1 This is not optional—catheter replacement significantly decreases polymicrobial bacteriuria, shortens time to clinical improvement, and reduces recurrence rates within 28 days. 1
- 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
Diagnostic Requirements Before Treatment
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). 1
- Do not treat asymptomatic bacteriuria, as this increases antimicrobial resistance without preventing catheter-associated UTI. 1
Empiric Antibiotic Selection
Levofloxacin 750 mg orally once daily is the first-line treatment, demonstrating superior microbiologic eradication rates and specifically validated for catheter-associated UTI. 1
When to Avoid Fluoroquinolones:
- Do not use 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
Intravenous Options (if oral therapy not feasible):
- 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
- Carbapenems: Reserve 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
- Extend to 10-14 days for patients with delayed response, regardless of whether the catheter remains in place. 1
- For males specifically, use 14 days when prostatitis cannot be excluded, as prostatic involvement is common. 1
Critical Pitfalls to Avoid
The guidelines for uncomplicated cystitis (nitrofurantoin, fosfomycin, trimethoprim-sulfamethoxazole) do not apply to catheter-associated UTI, which requires different management. 1 These agents are first-line for uncomplicated cystitis 2, but catheter-associated infections demand fluoroquinolones or broader-spectrum agents due to different microbiology and resistance patterns.
- Do not give prophylactic antimicrobials routinely at the time of catheter replacement alone (without symptoms), as this promotes antimicrobial resistance without reducing catheter-associated UTI. 1
- Do not perform surveillance urinary cultures or treat asymptomatic patients, except in pregnant women or patients undergoing urologic procedures with anticipated mucosal bleeding. 1
- Avoid concomitant use of Foley catheters with other urinary devices (PCNT, ureteral stents) when feasible. 1