Is antimicrobial prophylaxis indicated at the time of catheter removal or replacement?
Prophylactic systemic or local antimicrobials should not be administered routinely to patients at the time of catheter placement to reduce CA-UTI, or at the time of catheter removal or replacement to reduce CA-bacteriuria.
This guideline does not include individual introductions to each module. A general introduction can be found in the attachments under the heading 'related'.
The incidence of fever and bacteremia following catheter (indwelling and suprapubic) changes is increased, but these episodes generally resolved promptly, even without antibacterial therapy [(80) A1; (85) C; (86) C; (87) C, (88) C].
Single-dose aztreonam vs. placebo before catheterization decreased the incidence of CA-UTI at 7 days [(89) A2].
Studies show a decrease in the incidence of bacteriuria, but report contradictory results regarding the effect of antibiotic prophylaxis after urinary catheter removal on the incidence of UTI [(93) A2 (negative result); (90) B (negative result); (92) A2 (positive result); (91) C (positive result)].
Fever and/or bacteremia can occur at the time of removal or replacement of a urethral catheter in a patient with CA-bacteriuria. In addition, CA-bacteriuria can occur after a catheter has been removed, although the frequency of occurence is not known. In a study of catheterized and bacteriuric women in long-term care facilities, Warren et al. reported an incidence of 2.1/100 resident days of fever within 24 hours of catheter replacement compared with 1.1/100 days without replacement (85). These episodes of fever generally resolved promptly, even without antibacterial therapy.
Several studies evaluating the risk of bacteremia with catheter removal or replacement have been performed. In a study of 115 men and women who were chronically catheterized Jewes et al. reported bacteremia following 20 of 197 (10%) of urethral catheter changes and 5% of suprapubic catheter changes: all bacteremic episodes were asymptomatic and patients were afebrile (86). Other prospective studies in geriatric populations with long-term catheters and bacteriuria have found an approximately 4% rate of transient bacteremia in patients who had removal or replacement of their indwelling catheters, and none were clinically symptomatic (87), (88), (80).
Studies have evaluated the effectiveness of antimicrobial prophylaxis in preventing CA-bacteriuria in patients who are having a catheter placed or removed. In a randomized double-blind, placebo-controlled trial in 162 elderly hospitalized patients who needed indwelling urethral catheterization, single-dose aztreonam vs. placebo 3 hours before catheterization resulted in no CA-UTI at 7 days in 89% of the patients in the aztreonam group vs. 46% in the placebo group (89). Concerns about this study include the unexpectedly high rates of CA-UTI in the first week of catheterization, short follow-up, and absence of data on antimicrobial resistance in infection episodes. In another randomized, double-blind, placebo-controlled study of 48 patients across specialties with a urethral catheter in situ for 2-7 days, patients (15% with CA-bacteriuria) assigned to a 48-hour course of either ciprofloxacin or placebo tablets starting 2 hours before catheter removal reported no difference in the rates of CA-bacteriuria by 2 weeks after removing the urethral catheter, i.e. 16% vs. 13%, respectively (90). On the other hand, results of a survey in two Dutch district hospitals which investigated the impact of concurrent administration of antibiotics on the incidence of CA-UTI, showed that 61% of catheterized patients received antibiotics at some stage during bladder drainage. The use of antibiotics within 48 hours prior to catheter removal reduced the risk of bacteriuria fivefold. Multivariate analysis of patients who were catheterized for 3-14 days indicated that, apart from the duration of catheter employment, the use of antibiotics was the only variable significantly and independently associated with the development of bacteriuria.. Patients with bacteriuria at the time of catheter removal were more likely to have a febrile illness compared to those who remained free of CA-UTI (91).
Also a more recent prospective randomized non-blinded trial of 239 patients undergoing elective abdominal surgery in which patients were randomized to 3 doses of TMP-SMX or no treatment at urinary catheter removal showed significantly fewer CA-UTI (4.9% vs. 21.6%, P<0.001) and CA-bacteriuria (16.5% vs. 41.2%; P<0.001) in the treatment group (92).
There are no published studies of prophylactic antimicrobials in preventing CA-bacteriuria or CA-UTI in patients whose catheters are being replaced, or in preventing bacteremia in patients whose catheters are being removed or replaced.
In a double-blind, placebo-controlled randomized trial from the Netherlands the effect of single-dose prophylaxis using TMP-SMX (960 mg) (n=46) or ciprofloxacin (500 mg) (n=43) vs. placebo (n=51) before urinary catheter removal on bacteriuria (primary outcome) and UTI in surgical patients with scheduled bladder drainage for 3-14 days was assessed. Bacteriuria was determined directly after catheter removal, and UTI 12-14 days after catheter removal. After 12-14 days, incidences of bacteriuria were 19%, 19% and 33% for patients receiving ciprofloxacin, TMP-SMX and placebo, respectively. However, the incidences of symptomatic UTI were 3%, 0% and 3% for patients receiving ciprofloxacin, TMP-SMX and placebo, respectively (93).
Search and select
Databases were Pubmed and the Cochrane Library.
Keywords: urinary tract infection AND catheter or bacteriuria AND catheter
Limits: Last 3 years for Pubmed (guideline Catheter-associated UTI was published in 2009), English, adults, humans, clinical trials, guideline, meta-analysis, RCT
Pubmed: 36 results, all titles screened, 3 abstracts screened, 3 additional articles included
Cochrane Library: 12 results, all titles screened, 2 abstracts screened, 2 reviews included
Articles about special catheters as prevention methods or after certain procedures (for example, after operations/interventions) were excluded.
Some parts are used from the original text of the Catheter-Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America (80).
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This guideline does not include evidence tables.
Based on these observations, the contradictory results on the most important outcome, namely symptomatic UTI, and concerns about rising antimicrobial resistance, prophylactic antimicrobials are not routinely recommended for catheter placement, removal or replacement. This recommendation is also supported by the low rate of serious complications in the large number of patients undergoing long-term intermittent catheterization with clean technique in the setting of chronic bacteriuria.
Authorization date and validity
Last review : 01-03-2013
Last authorization : 01-03-2013
This guideline was developed and approved by representatives of the professional medical societies, mentioned in the introduction and methods sections and therefore represents the current professional standard in 2013. The guideline contains general recommendations. It is possible that, in individual cases, these recommendations do not apply. Applicability of the guideline in clinical practice resorts to the responsibility of every individual practitioner. Facts or circumstances may occur, in which deviation of the guideline is justified, in order to provide optimal quality of care for the patient.
Initiative and authorization
Development of this guideline was supported and financed by the SKMS (Kwaliteitsgelden Medisch Specialisten).
Scope and target group
The objective of these guidelines is to update clinicians with regard to important advances and controversies in the antibiotic treatment of patients with complicated urinary tract infections (UTIs).
The guidelines described here cover the empirical antimicrobial therapy of adult patients (for this guideline 12 years or older) with a complicated UTI admitted to a hospital (emergency room or ward) in the Netherlands. Uncomplicated UTIs are treated predominantly by the general practitioner. For the relevant guidelines, see the recently updated Standard for Urinary Tract Infections of the Dutch Society of General Practitioners (NHG). We have tried to adhere to this standard insofar as possible. Urethritis and epididymitis are not included in this guideline.
The Guidelines give a general therapy advice for all UTI with systemic symptoms because, at first presentation of a patient, it is not always possible to differentiate between an acute prostatitis, pyelonephritis or urosepsis. In addition, this differentiation has no consequences for the choice of empirical antimicrobial therapy. Apart from these general guidelines, we give specific advice for certain groups of patients separately.
Members of the guideline panel
Preparation of the guideline text was carried out by a multidisciplinary committee consisting of experts, delegated from the professional societies for infectious diseases (VIZ), medical microbiology (NVMM), hospital pharmacists (NVZA), urology (NVU), gynaecology (NVO), nephrology (NFN) and general practice (NHG). After consultation with the members of these professional societies, the definitive guideline was drawn up by the delegates and approved by the board of SWAB.
- Dr. S.E. Geerlings (coordinator, SWAB), Internal Medicine/Infectious Diseases specialist, Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Center, Amsterdam
- Dr. C. van Nieuwkoop (VIZ, NIV), Internal Medicine, Emergency Medicine and Infectious Diseases specialist, Department of Internal Medicine, Hagaziekenhuis, the Hague
- E. van Haarst (NVU), Urologist, Department of Urology, St. Lucas Andreas Hospital, Amsterdam
- Dr. M. van Buren (NFN), Internal Medicine and Nephrology specialist, Department of Internal Medicine, Hagaziekenhuis, the Hague
- Dr. B.J. Knottnerus (NHG), General Practitioner, Department General Practice, Academic Medical Center, Amsterdam
- Dr. E. E. Stobberingh (NVMM), Medical microbiologist, Lab Medical Microbiology, Maastricht Univerisity Medical Center, Maastricht
- Prof. dr. C.J. de Groot (NVOG), Gynaecologist, Department of Obstetrics and Gynaecology, Vrije Universiteit Medical Center, Amsterdam
- Prof. dr. J.M. Prins (SWAB), Internal Medicine/Infectious Diseases specialist, Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Center, Amsterdam
The Guideline committee would also like to thank Frederique Bemelman (nephrologist) for her comments on the chapter about renal transplantation and Albert Vollaard (infectious disease specialist) for his comments on the subchapter about methenamine.
Declaration of interest
The SWAB employs strict guidelines with regard to potential conflicts of interests as described in the SWAB Format for Guideline Development (www.swab.nl). Members of the preparatory committee reported the following potential conflicts of interest:
SE Geerlings: for the RCTs mentioned in the reference numbers 84 en 168 (Beerepoot et al.): Ref 84: Cranberry capsules and placebo capsules for this trial were delivered by Springfield Nutraceuticals, Oud Beijerland, The Netherlands. Ref 168: Chr Hansen A/S, Denmark has the patents for Lactobacillus rhamnosus GR-1 and Lactobacillus reuteri RC-14 and donated the placebo capsules for this trial.
E v Haarst: has received speaker fees on a national urological symposium from GlaxoSmithKline, the manufacturer of amoxicillin-clavulanic acid.
Other authors: no potential conflicts of interest declared.
This guideline does not include patient involvement.
Method of development
This guideline does not include an implementation strategy.
Methods and proces
This guideline was drawn up according to the recommendations for evidence-based development of guidelines (6), (Evidence-Based Richtlijn-Ontwikkeling (EBRO) and Appraisal of Guidelines Research and Evaluation (AGREE), www.agreecollaboration.org). The guidelines are derived from a review of literature based on the 9 key questions concerning the treatment of UTI. Studies were assigned a degree of evidential value according to the handbook of the Dutch Institute for Healthcare Improvement (Centraal Begeleidingsorgaan/Kwaliteitsinstituut voor de gezondheidszorg, CBO) (CBO. Evidence-based Richtlijnontwikkeling, handleiding voor werkgroepleden. Utrecht: CBO; 2007). Conclusions were drawn, completed with the specific level of evidence, according to the grading system adopted by SWAB (Table 1 and 2). The only exception concerns Nethmap, an annual report from which the resistance surveillance data were used. The Guideline committee cannot give Nethmap a level of evidence and decided to use an asterix (*), but is of the opinion that the results can be given substantial weight, since the surveillance data described in Nethmap cover 30% of the Dutch population. Subsequently, specific recommendations were formulated.
In order to develop recommendations for the optimal treatment of UTI, the literature was searched for the key questions. For each question a literature search was performed in the PubMed database (January 1966 to January 2012) as well as in the Cochrane Register of Controlled Trials (CENTRAL). For resistance surveillance data NethMap 2011 was used, and for the interpretation of susceptibility test results, in addition, reports of the European Committee on Antimicrobial Susceptibility Testing (EUCAST) were used. When scientific verification could not be found, the guideline text was formulated on the basis of the opinions and experiences of the members of the Guideline committee.
Searches are available upon request. Please contact the Richtlijnendatabase.