What is the most likely diagnosis for a paraplegic male patient with a permanent Foley catheter, facial fractures, cloudy urine, elevated WBC count, and positive urine culture: catheter-associated asymptomatic bacteriuria or urinary tract infection?

Diagnosis: Catheter-Associated Asymptomatic Bacteriuria

This patient has catheter-associated asymptomatic bacteriuria (CAABU), not a urinary tract infection, because he lacks any signs or symptoms referable to the urinary tract or systemic infection. 1, 2, 3

Clinical Reasoning

Why This is Asymptomatic Bacteriuria

• Patients with chronic indwelling Foley catheters are virtually always bacteriuric due to universal biofilm formation along the catheter surface, with bacteriuria acquisition occurring at 3-5% per catheter day. 1, 2

• This patient has NO symptoms of UTI: He has no fever, shaking chills, hypotension, delirium, or other systemic signs of infection—his presentation is entirely related to trauma from the fall. 3

• Cloudy urine alone is meaningless in catheterized patients and is extremely common without representing infection. 4, 2

• The elevated WBC count (13,000) and pyuria (30 WBC) are non-specific: Pyuria has no predictive value in differentiating symptomatic UTI from asymptomatic bacteriuria in catheterized patients. 4, 3

• The bacterial colony count of 100,000 CFU/mL does not distinguish infection from colonization in patients with indwelling catheters. 2

Evidence Supporting Non-Treatment

• The IDSA provides a strong recommendation against screening for or treating asymptomatic bacteriuria in patients with indwelling catheters, regardless of short-term or long-term catheterization. 1, 2

• Only 7.7% of catheterized patients with bacteriuria develop any subjective symptoms, and bacteremia directly attributable to catheter-associated bacteriuria occurs in only 0.5-0.7% of cases. 1, 2, 5

• Short-term catheter-associated bacteriuria does not increase risk for sepsis or death. 1, 2

• Antimicrobial therapy only temporarily suppresses bacteriuria; recurrence with the same or different (often more resistant) organisms occurs universally. 1, 2

Critical Pitfall to Avoid

Do NOT treat this patient's bacteriuria with antibiotics before surgery. 1, 2

• Treating cloudy urine or positive cultures without symptoms leads to unnecessary antibiotic use, promotes resistance, and provides no clinical benefit. 4, 6

• In one study, 32% of catheter-associated asymptomatic bacteriuria cases were inappropriately treated with antibiotics despite clear guidelines against this practice. 6

• The presence of facial fractures requiring operative management does NOT change this recommendation—asymptomatic bacteriuria should not be treated even in the perioperative setting for most patients. 1

When Treatment WOULD Be Indicated

Treatment of asymptomatic bacteriuria in catheterized patients is warranted only in these specific circumstances: 2

• Planned urologic procedure with anticipated mucosal bleeding
• Pregnancy
• High-risk neutropenia

None of these apply to this patient undergoing facial fracture repair. 2

Proper Management

• Replace the catheter if it has been in place ≥2 weeks before any planned procedure. 3

• Monitor for development of systemic signs (fever >38°C, shaking chills, hypotension, new delirium) that would indicate progression to symptomatic UTI. 3

• Proceed with facial fracture surgery without antibiotic treatment for the bacteriuria. 1, 2