Should a suprapubic catheter be replaced in a patient with stage 3 prostate cancer and a history of suprapubic catheter placement, who has a recurring low-grade fever and hematuria despite antibiotic treatment?

Should the Suprapubic Catheter Be Replaced?

Yes, the suprapubic catheter should be replaced if fever persists beyond 72 hours despite appropriate antibiotic therapy, as catheter removal is indicated for recurrent infection or lack of response to antibiotics after 2-3 days of treatment. 1

Indications for Catheter Replacement

Catheter removal is specifically recommended when:

• Infection is recurrent or response to antibiotics is not apparent after 2-3 days of therapy, regardless of the causative organism 1
• Persistent bacteremia or fungemia occurs >72 hours after initiating appropriate antimicrobial therapy 1
• There is evidence of tunnel infection, septic emboli, hypotension associated with catheter use, or a nonpatent catheter 1

Why Fever Persists Despite Antibiotics

The recurring low-grade fever (37.5°C) despite antibiotics suggests several possibilities:

Catheter-related factors:

• The suprapubic catheter itself serves as a biofilm-covered foreign body that can harbor bacteria resistant to systemic antibiotics, preventing complete eradication of infection 1
• Catheter colonization with organisms that respond poorly to antimicrobial treatment alone (such as P. aeruginosa, Stenotrophomonas maltophilia, or Candida species) often requires catheter removal for cure 1

Inadequate source control:

• Persistent fever for 5-7 days despite appropriate antibacterial therapy indicates either inadequate source control, resistant organisms, invasive fungal infection, or non-infectious causes 2, 3
• The catheter may be harboring organisms in biofilm that are inaccessible to systemic antibiotics 1

Why There Is Blood in the Urine (Hematuria)

The hematuria has multiple potential etiologies in this clinical context:

Catheter-related trauma:

• Chronic indwelling suprapubic catheters cause mechanical irritation and trauma to the bladder mucosa, leading to bleeding 3
• Encrustation of the catheter with mineral deposits can cause mucosal injury and bleeding

Infection-related causes:

• Bacterial cystitis commonly causes hematuria due to inflammatory damage to the bladder mucosa 4
• Candiduria is extremely common in patients with indwelling urinary catheters and represents the most frequent isolate in surgical ICU patients, which can cause hemorrhagic cystitis 3

Cancer-related bleeding:

• Stage 3 prostate cancer with local extension can cause hematuria through direct bladder invasion or obstruction 3
• Tumor progression may be contributing to bleeding independent of infection

Fungal infection:

• Ascending candidal infection from the urinary tract can cause pyelonephritis or hemorrhagic cystitis in high-risk patients with indwelling catheters 3

Recommended Management Algorithm

Immediate actions:

1. Replace the suprapubic catheter and culture the removed catheter tip using semiquantitative culture methods 1
2. Obtain two sets of blood cultures (one peripheral, one from catheter if still in place) before catheter removal 1
3. Collect urine culture from the newly placed catheter 3

Empirical therapy adjustments:

• Initiate empirical antifungal therapy immediately with either liposomal amphotericin B or caspofungin, as persistent fever for >5-7 days despite appropriate antibacterial therapy meets the established threshold for empirical antifungal coverage 2, 3
• Continue current antibacterial regimen if the patient is clinically stable, as persistent fever alone in a hemodynamically stable patient is not an indication for undirected antibiotic changes 2

Diagnostic imaging:

• Obtain CT abdomen and pelvis with IV contrast to evaluate for occult abscess, invasive fungal infection, or disease progression 2, 3
• Perform serum galactomannan testing twice weekly to evaluate for invasive aspergillosis 2

Critical Pitfalls to Avoid

• Do not delay catheter replacement beyond 72 hours of persistent fever despite appropriate antibiotics, as this represents treatment failure requiring source control 1
• Do not delay antifungal therapy beyond 5-7 days of persistent fever despite antibiotics, as mortality from invasive fungal infection increases significantly with treatment delays 2, 3
• Do not assume negative blood cultures exclude serious infection, as the majority of persistent fever episodes have no identifiable source despite thorough evaluation 2, 3
• Do not overlook the suprapubic catheter as both a portal for bacterial entry and a common site of fungal colonization that can progress to invasive disease 3

Reassess at 48-72 hours after catheter replacement and antifungal initiation to evaluate clinical response, review culture data, and adjust therapy accordingly. 2, 3