Urinary Tract Infections

Management Approach

• For a complicated UTI in a male with a Foley catheter, the most effective management approach is to remove the catheter if possible, obtain urine culture from a newly inserted device if catheterization remains necessary, and initiate empiric intravenous antimicrobial therapy with a fluoroquinolone, an aminoglycoside (with or without ampicillin), or an extended-spectrum cephalosporin or penicillin while awaiting culture results, as recommended by the European Association of Urology 1
• The European Association of Urology recommends reserving carbapenems and newer broad-spectrum agents for patients with early culture results indicating multidrug resistance, with a strength of evidence level not specified 1

Treatment Duration

• The treatment duration for complicated UTIs is 7-14 days, with 14 days recommended for men when prostatitis cannot be excluded, as recommended by the European Association of Urology 1

Microbial Spectrum and Antimicrobial Resistance

• The microbial spectrum in complicated UTIs is broader than uncomplicated UTIs, with a higher likelihood of antimicrobial resistance, as stated by the European Association of Urology 1
• Inappropriate antimicrobial therapy may select for resistant organisms, according to the Infectious Diseases Society of America (IDSA) 2
• The following table summarizes the recommended treatment for common pathogens:

Prevention and Catheter Management

• Daily assessment should be performed to determine if the patient still requires the urinary catheter, as recommended by the World Journal of Emergency Surgery and supported by the Centers for Disease Control and Prevention and the Clinical Infectious Diseases guidelines 3, 6, 7
• Remove Foley catheters within 48 hours to minimize infection risk, and consider using silver alloy-coated catheters if extended catheterization is required, with a strength of evidence level of moderate 8
• Implementing comprehensive prevention strategies has been shown to decrease both urinary catheter use and CAUTI rates, ultimately improving patient outcomes and reducing healthcare costs, with each CAUTI case costing approximately $1006 in the United States, as reported by the Clinical Infectious Diseases journal and the Infectious Diseases Society of America 6
• Proper catheter care, including hand hygiene, maintaining a closed drainage system, keeping the collection bag below bladder level, and regular perineal hygiene, can help prevent CAUTIs, as suggested by the Centers for Disease Control and Prevention and the IDSA 3, 6, 9

Patient Risk Factors and Outcomes

• Patients at increased risk of CAUTI include those who have undergone recent pelvic surgery, are immobilized, sedated, or have epidural analgesia, as well as those with comorbidities such as diabetes mellitus, hypertension, cerebrovascular disease, spinal cord lesions, and neurogenic bladder, and immunocompromised patients, including oncology patients, especially during neutropenia, AIDS patients, and transplant recipients, as stated by the Infectious Diseases Society of America 6, 7, 10
• CAUTIs are associated with increased mortality, hospital length of stay, healthcare costs, antimicrobial resistance, and risk of complications including pyelonephritis and sepsis, as reported by the Clinical Infectious Diseases journal and the Infectious Diseases Society of America, and pregnant women, diabetics, or immunocompromised patients should have a lower threshold for hospitalization and IV antibiotics due to increased risk of complications, as recommended by the IDSA 3, 11, 12

Diagnostic Testing and Antimicrobial Stewardship

• Urine samples should be obtained from the catheter's sampling port, not from the drainage bag, to minimize contamination, and should be transported to the laboratory and processed within 1 hour to avoid bacterial multiplication, as recommended by the Infectious Diseases Society of America 13
• Routine urine cultures are not recommended for asymptomatic patients, as stated by the Infectious Diseases Society of America, and urine culture should only be ordered if pyuria (≥10 WBCs/high-power field) or positive leukocyte esterase/nitrite test is present, as recommended by the American Geriatrics Society 3, 14
• Prophylactic antimicrobials should not be administered at the time of catheter placement, removal, or replacement, as recommended by the Infectious Diseases Society of America, and asymptomatic bacteriuria should not be treated with antibiotics, according to the Infectious Diseases Society of America, with an A-I level recommendation 3, 15
• Culture and susceptibility testing is essential and should be obtained before starting antibiotics, but treatment should not be delayed in symptomatic patients, as recommended by the Infectious Diseases Society of America 3