urinary tract infection if indwelling catheter

Last edited 11/2018 and last reviewed 06/2021

Between two and seven per cent of patients with indwelling urethral catheters acquire bacteriuria each day, even with the application of best practice for insertion and care of the catheter. All patients with a long term indwelling catheter are bacteriuric, often with two or more organisms (1)

Catheter-associated UTI is defined as the presence of symptoms or signs compatible with a UTI in people with a catheter with no other identified source of infection plus significant levels of bacteria in a catheter or a midstream urine specimen when the catheter has been removed within the previous 48 hours (2)

• catheter-associated UTI is a symptomatic bladder or kidney infection in a person with a catheter
• bacteria are more likely to be present in urine the longer a catheter is in place (after 1 month most people have bacteriuria)
• antibiotic treatment is not routinely needed for asymptomatic bacteriuria in people with a catheter

• duration of catheterisation is strongly associated with the risk of infection (1)
  • longer the catheter is in place the greater the likelihood of infection
  • intermittent catheterisation is associated with a lower incidence of asymptomatic bacteriuria
• presence of a short- or long term indwelling catheter is associated with a greater incidence of fever of urinary tract origin (1)
  • fever without any localising signs is a common occurrence in catheterised patients and urinary tract infection accounts for about a third of these episodes
  • in patients with short- or long-term catheters fever is associated with a higher occurrence of local urinary tract and systemic complications such as bacteraemia
    
    
• diagnosis of urinary tract infection
• do not rely on classical clinical symptoms or signs for predicting the likelihood of symptomatic UTI in catheterised patients
• signs and symptoms compatible with catheter-associated UTI include (1):
  • new onset or worsening of fever, rigors, altered mental status, malaise, or lethargy with no other identified cause
  • flank pain
  • costovertebral angle tenderness
  • acute haematuria
  • pelvic discomfort and
  • dysuria, urgent or frequent urination, or supra-pubic pain or tenderness in those whose catheters have been removed
• do not use dipstick testing to diagnose UTI in patients with catheters
• if possible catheter associated UTI then (2):
  • consider removing or, if not possible, changing the catheter if it has been in place for more than 7 days. But do not delay antibiotic treatment
  • send a urine sample for culture and susceptibility testing
  • antibiotic treatment should be offered
  • advise managing symptoms with self-care

Advice/Safety netting (2)

• inform about possible adverse effects of antibiotics include diarrhoea and nausea
• advise to seek medical help if symptoms worsen at any time or do not start to improve within 48 hours, or the person becomes systemically very unwell

When MSU results available:

• review choice of antibiotic
• change antibiotic according to susceptibility results if bacteria are resistant - when possible use narrow spectrum antibiotics

If symptoms worsen or do not start to improve within 48 hours

• then reassess taking account of:
  • other possible diagnoses
  • any symptoms and signs suggesting a more serious illness or condition, such as sepsis
  • previous antibiotic use, which may have led to resistant bacteria

Referral to hospital is indicated if the person has any symptoms or signs of a more serious illness or condition (for example, sepsis)

• also consider hospital referral or seeking specialist advice for people if they:
  • are significantly dehydrated or unable to take oral fluids and medicines OR
  • are pregnant OR
  • have a higher risk of developing complications (for example, people with known or suspected structural or functional abnormality of the genitourinary tract, or underlying disease [such as diabetes or immunosuppression]) OR
  • have recurrent catheter-associated UTIs OR
  • have bacteria resistant to oral antibiotics

Reference:

• 1) SIGN (August 2012). Management of suspected bacterial urinary tract infection in adults.
• 2) NICE (November 2018).Urinary tract infection (catheterassociated): antimicrobial prescribing.