Management of Catheter-Associated Urinary Tract Infections

General Principles

Replace the catheter before starting antimicrobials if it has been in place ≥2 weeks, as biofilms protect uropathogens from antimicrobials and host immune response, making bacteria inherently resistant to treatment, and this approach decreases polymicrobial bacteriuria, shortens time to clinical improvement, and lowers recurrence rates within 28 days 1
Obtain urine culture from the new catheter before initiating antibiotics to guide appropriate therapy 1
Remove the catheter entirely after completing antibiotic treatment if no longer medically indicated 2
Duration of treatment is typically 7 days for prompt symptom resolution or 10-14 days for delayed response 2

Remove nontunneled catheters and treat with appropriate antimicrobials for 10-14 days when there is no evidence of septic thrombosis or endocarditis, as recommended by the Infectious Diseases Society of America 3, 4
For tunneled catheters that cannot be removed in hemodynamically stable patients, treat for 14 days with systemic and antibiotic lock therapy, as suggested by the Infectious Diseases Society of America 3, 4
Quinolones such as ciprofloxacin with or without rifampin are preferred for retained catheters because they can be given orally and eradicate gram-negative bacilli from foreign bodies, according to the Infectious Diseases Society of America 3, 4
Strongly consider catheter removal for Pseudomonas species (other than P. aeruginosa), Burkholderia cepacia, Stenotrophomonas, Agrobacterium, and Acinetobacter baumannii, especially if bacteremia persists despite appropriate antimicrobials or the patient becomes unstable, as recommended by the Infectious Diseases Society of America 3, 4

Remove nontunneled catheters suspected as the source of S. aureus bacteremia and reinsert at a different site, as recommended by the Infectious Diseases Society of America 4
Perform transesophageal echocardiography (TEE) for patients without contraindications to identify complicating endocarditis requiring 4-6 weeks of therapy, according to the Infectious Diseases Society of America 4
Patients with negative TEE and catheter removal should receive 14 days of systemic antibiotic therapy, as suggested by the Infectious Diseases Society of America 3, 4

Treat all patients with candidemia; use amphotericin B for hemodynamically unstable patients or those with prolonged prior fluconazole therapy, as recommended by the Infectious Diseases Society of America 3, 4, 5
Hemodynamically stable patients without recent fluconazole therapy or with fluconazole-susceptible organisms can receive fluconazole instead of amphotericin B, according to the Infectious Diseases Society of America 3, 4, 5
Remove tunneled catheters in all cases of documented catheter-related fungemia, as recommended by the Infectious Diseases Society of America 3, 4, 5

Do not administer prophylactic antimicrobials routinely at catheter placement, removal, or replacement, as this promotes antimicrobial resistance without reducing CAUTI, as recommended by the Centers for Disease Control and Prevention 1
Do not routinely screen for or treat catheter-associated asymptomatic bacteriuria in patients with short-term or long-term indwelling catheters, according to the Centers for Disease Control and Prevention 1

Failing to replace catheters in place ≥2 weeks before starting antibiotics reduces treatment efficacy due to established biofilms, as noted by the Centers for Disease Control and Prevention 1, 2
Treating asymptomatic bacteriuria in catheterized patients (except specific circumstances) does not reduce subsequent CAUTI and increases antimicrobial resistance, according to the Centers for Disease Control and Prevention 1
Removing catheters before completing appropriate antibiotic treatment may lead to persistent infection, as warned by the Centers for Disease Control and Prevention 2
Not obtaining cultures before initiating antibiotics leads to inappropriate antibiotic selection given the high likelihood of resistant organisms, as cautioned by the Centers for Disease Control and Prevention 2