Does a patient with a suprapubic (urinary catheter inserted through the abdomen) catheter, especially those with underlying neurological conditions or impaired renal function, require a urinalysis and urine culture before undergoing surgery or invasive procedures?

Preoperative Urinalysis and Urine Culture for Patients with Suprapubic Catheters

For patients with suprapubic catheters undergoing non-urologic surgery or procedures, urinalysis and urine culture are NOT recommended, as asymptomatic bacteriuria should not be screened for or treated in this population. 1

Key Distinction: Type of Surgery Determines Testing Requirements

Non-Urologic Surgery (Most Procedures)

• Do not obtain urinalysis or urine culture for patients with suprapubic catheters undergoing elective non-urologic surgery 1
• The 2019 IDSA guidelines provide a strong recommendation against screening for or treating asymptomatic bacteriuria (ASB) in patients undergoing elective non-urologic surgery 1
• Patients with suprapubic catheters should be managed identically to those with indwelling urethral catheters—both short-term (<30 days) and long-term catheterization warrant no screening 1
• Standard perioperative antimicrobial prophylaxis (when indicated for the surgical procedure itself) is sufficient without targeting urinary pathogens 1

Endoscopic Urologic Procedures with Mucosal Trauma

• Obtain preoperative urine culture if the patient will undergo endoscopic urologic procedures associated with mucosal trauma (e.g., TURP, ureteroscopy with lithotripsy, percutaneous stone surgery) 1
• This represents the only scenario where screening is strongly recommended (strong recommendation, moderate-quality evidence) 1
• Use targeted antimicrobial therapy based on culture results rather than empiric therapy 1
• Administer 1-2 doses of antimicrobials 30-60 minutes before the procedure 1
• The rationale: these procedures carry substantial risk of sepsis when performed in the presence of bacteriuria, as they involve heavily contaminated surgical fields 1

Clinical Reasoning Behind These Recommendations

Why Not Screen for Non-Urologic Surgery?

• Asymptomatic bacteriuria is nearly universal in patients with long-term indwelling catheters (including suprapubic) 1
• No evidence demonstrates that treating ASB reduces postoperative complications in non-urologic surgery 1
• Screening and treating ASB increases antimicrobial resistance, Clostridioides difficile infection risk, adverse drug effects, and healthcare costs without proven benefit 1
• Device infections (e.g., orthopedic implants) are typically caused by skin flora, not urinary pathogens 1

Postoperative Fever Considerations

• During the first 72 hours postoperatively, urinalysis and culture are not mandatory if fever is the only indication 1
• For febrile patients with indwelling catheters (including suprapubic) present for ≥72 hours, urinalysis and culture should be performed 1
• However, this applies to symptomatic UTI evaluation, not preoperative screening 1

Important Caveats and Pitfalls

Common Overdiagnosis Problem

• Neurosurgical ICU data shows that only 4.76% of febrile catheterized patients had true UTI as the fever source, with most having alternative causes (sputum, blood, CSF) 2
• Avoid reflexive urine testing in catheterized patients with fever—evaluate other sources first unless clinical suspicion for UTI is high 2

Catheter Management Considerations

• If urine culture is obtained for any reason in a patient with a chronic indwelling catheter, consider replacing the catheter before specimen collection to reduce multidrug-resistant organism isolation and improve culture accuracy 3
• This practice decreased antimicrobial costs by $15.64 per patient and reduced identification of colonizing organisms versus true pathogens 3

Special Populations

• Spinal cord injury patients: Do not screen for or treat ASB (strong recommendation) 1
• Patients with neurological conditions: Clinical signs of UTI may differ from classic symptoms; consider atypical presentations when deciding whether bacteriuria represents infection versus colonization 1, 4
• Neutropenic patients (absolute neutrophil count <100 cells/mm³, ≥7 days): No clear recommendation exists (knowledge gap) 1

Practical Algorithm

1. Identify procedure type:

   • Endoscopic urologic with mucosal trauma → Obtain preoperative urine culture 1
   • All other surgeries/procedures → Do not obtain urinalysis or culture 1

2. If urologic procedure requiring culture:

   • Obtain culture 1-2 days before procedure 1
   • Prescribe targeted antimicrobials based on sensitivities 1
   • Give 1-2 doses starting 30-60 minutes preoperatively 1

3. If non-urologic surgery:

   • Proceed with standard perioperative prophylaxis per surgical protocol 1
   • Do not adjust prophylaxis based on presumed urinary flora 1