Management of Catheter-Associated UTI in Skilled Nursing Facility Residents
Replace the catheter before starting antibiotics if it has been in place ≥2 weeks, then initiate oral antimicrobial therapy based on culture results and clinical severity. 1
Critical First Step: Catheter Replacement
If the indwelling catheter has been in place for ≥2 weeks at symptom onset, replace it before initiating antimicrobial therapy. 1, 2
Catheter replacement significantly improves outcomes:
Collect the urine culture specimen from the newly placed catheter before starting antibiotics to ensure accurate pathogen identification. 1, 3
Biofilms develop on both internal and external catheter surfaces, protecting uropathogens from antimicrobials and the host immune response, making treatment through an old catheter substantially less effective. 4, 5
Confirm Symptomatic Infection Before Treatment
Only treat symptomatic CA-UTI; do not treat asymptomatic bacteriuria. 1, 6
Symptomatic CA-UTI requires presence of: fever, rigors, altered mental status, flank pain, costovertebral angle tenderness, acute hematuria, pelvic discomfort, dysuria, or suprapubic pain. 1
Asymptomatic bacteriuria in catheterized patients should never be treated (except in pregnancy or before traumatic urologic procedures), as treatment promotes antimicrobial resistance without preventing symptomatic infection. 7, 1, 6
Oral Antibiotic Selection for Mild-to-Moderate CA-UTI
First-Line Oral Agent
Levofloxacin 750 mg orally once daily is the preferred oral agent for mild-to-moderate CA-UTI in SNF residents who can tolerate oral therapy. 1
Levofloxacin demonstrates superior microbiologic eradication rates (79% versus 53% for ciprofloxacin, 95% CI 3.6%–47.7%). 1
Avoid fluoroquinolones if:
Alternative Oral Options
For patients who cannot receive fluoroquinolones, consider oral cephalosporins or amoxicillin-clavulanate based on local susceptibility patterns and culture results. 1
Avoid moxifloxacin as urinary concentrations are insufficient for CA-UTI treatment. 1
Dose Adjustments
- Fluoroquinolones require dose reduction when creatinine clearance is <50 mL/min. 1
When to Use IV Antibiotics
For moderate-to-severe CA-UTI with systemic symptoms (hypotension, altered mental status, severe sepsis), initiate IV therapy: 1, 3
Third-generation cephalosporin: ceftriaxone 1–2 g daily or cefepime 1–2 g twice daily 1
Combination therapy: amoxicillin plus aminoglycoside, or second-generation cephalosporin plus aminoglycoside 1, 3
SNF residents have increased risk of multidrug-resistant organisms due to healthcare exposure and prior antibiotic use, warranting broader empirical coverage pending cultures. 1
Treatment Duration
Standard duration is 7 days for patients with prompt symptom resolution. 1, 3
- Patients must be hemodynamically stable and afebrile for ≥48 hours to qualify for 7-day treatment. 1, 3
Extend treatment to 10–14 days for delayed responders: 1, 3
- Persistent fever beyond 72 hours despite appropriate therapy 1, 3
- Delayed clinical improvement 1, 3
- Men when prostatitis cannot be excluded (14 days recommended) 3
Shortened 5-day course of levofloxacin 750 mg may be considered in non-severely ill patients when susceptibility is confirmed. 1
Culture-Directed Therapy
De-escalate to the narrowest effective antimicrobial once culture and susceptibility results are available. 1
- This approach reduces unnecessary broad-spectrum exposure and limits resistance development in the SNF setting. 1
Management of Persistent Fever (>72 Hours)
If fever persists >72 hours despite appropriate therapy for a susceptible organism, investigate alternative infection sources: 1
- Obtain blood cultures if not already done, as catheterized patients have increased bacteremia risk. 1
- Consider imaging (renal ultrasound or CT) to identify abscess, obstruction, or complicated infection. 1
- Evaluate for prostatitis in men, bloodstream infection, or non-infectious causes (drug fever, underlying malignancy). 1
Post-Treatment Catheter Management
Remove the Foley catheter after completing the appropriate antibiotic treatment (7–14 days), not before. 3
Removing the catheter before completing antibiotics leads to persistent infection. 3
Evaluate whether the catheter remains clinically necessary. Duration of catheterization is the principal determinant of infection risk, so removal is the most effective prevention strategy. 4, 5
Critical Pitfalls to Avoid
Do not administer prophylactic antimicrobials at the time of catheter placement, removal, or replacement—this promotes resistance without reducing CA-UTI. 7, 6
Do not delay catheter replacement if it has been in place ≥2 weeks; biofilm formation markedly diminishes treatment efficacy. 1, 6
Do not treat asymptomatic bacteriuria in catheterized SNF residents (except pregnant women or before traumatic urologic procedures); this increases resistance without clinical benefit. 7, 1, 6
Do not use routine periodic catheter changes (e.g., monthly) to prevent infection—this practice is not evidence-based and lacks clinical trial support. 7, 6
Do not obtain urine cultures in the absence of symptoms—this leads to unnecessary treatment of colonization rather than infection. 7