Prevention of Catheter-Associated Urinary Tract Infections

General Recommendations

Prophylactic antimicrobials should not be administered routinely to patients at the time of catheter placement, removal, or replacement to reduce catheter-associated bacteriuria or UTI, as recommended by the Infectious Diseases Society of America (IDSA) with strong evidence (A-I for catheter placement, B-I for catheter removal, A-III for catheter replacement) 1
Prophylactic gentamicin should not be administered during routine urinary catheter changes due to lack of evidence and potential contribution to antimicrobial resistance 1, 2
Prophylactic antibiotics like gentamicin during catheter changes do not appear to reduce mortality or improve outcomes in catheterized patients 2

Maintaining a properly functioning closed drainage system, minimizing disconnection of the catheter junction, keeping the drainage bag and connecting tube below bladder level, and considering using a preconnected catheter system are recommended to prevent catheter-associated UTIs, as suggested by the IDSA 1
Limiting catheter duration, removing the catheter within 48 hours when possible, and performing daily assessment to evaluate the ongoing need for catheterization can help prevent CA-UTI, as recommended by the IDSA and Clinical Infectious Diseases guidelines 1, 3

Evaluate the presence of systemic symptoms (fever, chills, hemodynamic instability) and verify if the urinary catheter is still in place, and assess for signs of sepsis using qSOFA (respiratory rate ≥22/min, altered mental status, systolic blood pressure ≤100 mmHg), as recommended by the European Urology guidelines 4
Obtain a urine specimen for culture prior to starting antimicrobial therapy to ensure appropriate treatment, as recommended by the Clinical Infectious Diseases guidelines 1
Treat uncomplicated infections for 7 days, and complicated infections or slow response for 10-14 days, as recommended by the European Urology guidelines 4
Extend treatment to 4-6 weeks for persistent bacteremia, and evaluate for complications, as recommended by the Clinical Infectious Diseases guidelines 5

For patients with recurrent UTIs who use intermittent catheterization, intravesical gentamicin instillations (not systemic gentamicin) may be considered as an alternative therapy when other treatments have failed, although this is an off-label use 1
Prophylactic antibiotics during catheterization may only be considered in select high-risk patients, such as immunocompromised patients, patients with recurrent UTIs, patients with uncontrolled diabetes, history of infected renal stones, or patients undergoing complex urological surgery with extensive instrumentation, and decisions should be made based on individual risk factors and local antimicrobial resistance patterns 2
Consider using amphotericin B for patients with hemodynamic instability, and initiate fluconazol (adjusted for renal function in hemodialysis) for fungal infection, with a dose administered after each hemodialysis session, and a duration of 14 days after the last positive culture, as recommended by the Clinical Infectious Diseases guidelines 6
Use local antibiotic susceptibility data to guide treatment, and consider broader coverage and longer duration of therapy for immunocompromised patients, as recommended by the IDSA and Clinical Infectious Diseases guidelines 1, 5

Avoid the use of fluoroquinolones as empirical treatment if the local resistance rate is >10% or if the patient has used fluoroquinolones in the last 6 months, and consider antimicrobial prophylaxis only in selected high-risk patients, as recommended by the European Urology guidelines 4
Use a 5-day regimen of levofloxacin for mild to moderate infections in patients who self-catheterize and develop catheter-associated urinary tract infection (CA-UTI), with high efficacy demonstrated in clinical trials for complicated UTI, as suggested by the IDSA and Clinical Infectious Diseases guidelines 1
Inappropriate use of prophylactic antibiotics carries significant risks, including selection of resistant organisms, adverse drug reactions, increased risk of Clostridioides difficile infection, and masking of symptoms that might indicate other problems, as recommended by the IDSA and Clinical Infectious Diseases guidelines 4, 1