What is the approach and management for a patient with urinalysis positive for esterase, white blood cells (WBC), red blood cells (RBC), and rare bacteria after chronic Foley's (indwelling urinary catheter) removal?

From the Guidelines

For a urinalysis showing positive esterase, WBCs, RBCs, and rare bacteria after removal of a chronic Foley catheter, I recommend empiric antibiotic treatment for catheter-associated urinary tract infection (CAUTI) with a 7-day course of an oral antibiotic such as nitrofurantoin 100mg twice daily, trimethoprim-sulfamethoxazole DS twice daily, or ciprofloxacin 500mg twice daily, depending on local resistance patterns and patient factors, as suggested by the Infectious Diseases Society of America guidelines 1.

Key Considerations

• The presence of esterase, WBCs, RBCs, and rare bacteria in the urinalysis indicates a possible infection, which is a common complication after chronic Foley catheter use.
• The guidelines recommend antimicrobial treatment of asymptomatic women with catheter-acquired bacteriuria that persists 48 h after catheter removal may be considered 1.
• However, the most recent and highest quality study suggests that a 7-day course of antibiotic treatment is recommended for most patients with CA-UTI, regardless of whether the patient remains catheterized or not 1.

Management Approach

• Collect a urine culture before starting antibiotics to guide therapy adjustments if needed.
• Ensure adequate hydration with 2-3 liters of fluid daily to help flush the urinary tract.
• Monitor for symptom improvement within 48-72 hours; persistent symptoms warrant reassessment.
• Consider intermittent catheterization instead of indwelling catheters when possible to reduce infection risk for patients requiring long-term catheterization.
• Follow up with repeat urinalysis after completing antibiotics to confirm resolution.

Rationale

• The use of a chronic Foley catheter can cause mucosal irritation and create conditions favorable for bacterial colonization, leading to infection.
• Even after catheter removal, bacteria can remain and cause infection, making empiric antibiotic treatment necessary.
• The choice of antibiotic and duration of treatment should be guided by local resistance patterns, patient factors, and the results of the urine culture.

From the Research

Approach to Urinalysis Results

The approach to managing a patient with urinalysis results positive for esterase, WBC, RBC, and rare bacteria after chronic Foley catheter use involves several steps:

• Identifying the underlying cause of the infection, which could be related to the chronic use of a Foley catheter 2, 3
• Selecting an appropriate antibiotic therapy, taking into account the potential for antibiotic resistance 3, 4
• Considering the use of fluoroquinolones, such as levofloxacin or ciprofloxacin, which have been shown to be effective against a range of bacterial infections, including those caused by ESBL-producing Enterobacteriaceae 2, 4
• Monitoring the patient's response to treatment and adjusting the antibiotic regimen as needed 5, 6

Management of Urinary Tract Infections

The management of urinary tract infections (UTIs) in patients with chronic Foley catheter use requires careful consideration of the following factors:

• The type of bacteria causing the infection, which can be identified through urine culture and sensitivity testing 4, 6
• The potential for antibiotic resistance, which can be addressed through the use of combination therapy or the selection of antibiotics with a broader spectrum of activity 3, 4
• The need for ongoing monitoring and adjustment of the treatment plan to ensure effective management of the infection and prevention of future infections 5, 6
• The use of pharmacodynamic models, such as those using artificial urine, to evaluate the effectiveness of different antibiotics against UTI-causing bacteria 4

Antibiotic Therapy Options

The choice of antibiotic therapy for UTIs in patients with chronic Foley catheter use depends on several factors, including:

• The type of bacteria causing the infection 4, 6
• The potential for antibiotic resistance 3, 4
• The patient's medical history and underlying health conditions 2, 5
• The use of fluoroquinolones, such as levofloxacin or ciprofloxacin, which have been shown to be effective against a range of bacterial infections, including those caused by ESBL-producing Enterobacteriaceae 2, 4