What is the recommended duration of antibiotic therapy for an adult with catheter‑associated urinary tract infection, both uncomplicated and complicated?

Management of Catheter-Associated UTI: Antibiotic Duration

For symptomatic catheter-associated UTI, treat for 7 days in patients with prompt symptom resolution, or 10-14 days for those with delayed response or bacteremia. 1

Treatment Duration Based on Clinical Presentation

Uncomplicated Symptomatic CA-UTI

• Standard duration is 7 days when the patient is hemodynamically stable and has been afebrile for at least 48 hours 1
• This 7-day course applies to patients with prompt symptom resolution 1

Complicated or Bacteremic CA-UTI

• Treat for 10-14 days in patients with delayed clinical response or bacteremia 2, 1
• Extend to 14 days in men when prostatitis cannot be excluded, as prostate involvement requires longer therapy 2
• For tunneled or permanent catheters that cannot be removed in hemodynamically stable patients, treat for 14 days with systemic therapy 2

Special Circumstances Requiring Extended Therapy

• If S. aureus is isolated, perform transesophageal echocardiography to rule out endocarditis; treat for 14 days without endocarditis, but 4-6 weeks if endocarditis is present 2
• Treatment duration should be closely related to any underlying urological abnormality 1

Critical Pre-Treatment Step: Catheter Replacement

Replace the indwelling catheter before initiating antimicrobial therapy if it has been in place for ≥2 weeks, as this significantly decreases polymicrobial bacteriuria, shortens time to clinical improvement, and lowers CA-UTI recurrence rates 2, 1

• Obtain urine culture from the new catheter before starting antibiotics to guide appropriate antimicrobial selection 2
• Failing to replace catheters in place ≥2 weeks before starting antibiotics significantly reduces treatment efficacy due to established biofilms 2

IV-to-Oral Transition Strategy

Transition from IV to oral antibiotics when the patient is hemodynamically stable, has been afebrile for at least 48 hours, and the oral route is functioning 2

• Fluoroquinolones are preferred oral agents for step-down when the catheter remains in place 2
• Only use ciprofloxacin if local resistance is <10% and the patient has not used fluoroquinolones in the last 6 months 2

Common Pitfalls to Avoid

Do Not Treat Asymptomatic Bacteriuria

• Never treat asymptomatic bacteriuria in patients with retained catheters, as this promotes antimicrobial resistance without reducing subsequent CA-UTI 2, 1, 3
• The only exceptions are pregnant women or patients undergoing urologic procedures with anticipated mucosal bleeding 1, 3

Do Not Use Prophylactic Antibiotics

• Do not administer prophylactic antimicrobials at catheter replacement, as this promotes resistance without benefit 2, 1, 3
• Prophylactic antimicrobials should not be given routinely at catheter placement, removal, or replacement 3

Obtain Cultures Before Starting Antibiotics

• Not obtaining cultures before initiating antibiotics leads to inappropriate antibiotic selection given high rates of multidrug-resistant organisms in CAUTI 2

Consider Catheter Removal for Specific Organisms

• Strongly consider catheter removal for Pseudomonas species, Burkholderia cepacia, Stenotrophomonas, Agrobacterium, and Acinetobacter baumannii, especially if bacteremia persists despite appropriate antimicrobials 2