What is the optimal management in patients with CA-UTI?
When the patient with a catheter has only local symptoms and has no signs of a systemic infection, it is recommended to wait for the results of the cultures.
If there is a systemic infection, the patient should be treated as described in the General section for patients with a complicated UTI.
A patient who has had an indwelling catheter for a prolonged period or was catheterized intermittently must be treated empirically with a regimen including an aminoglycoside, to cover less common uropathogens like Pseudomonas, Serratia, Providencia, and Acinetobacter.
For patients with a urinary catheter in place for at least 10 days the best empirical treatment which covers enterococci is the combination of co-amoxiclav with gentamicin. Excluding enterococci makes a third-generation cephalosporin with gentamicin the most adequate recommendation.
If an indwelling catheter has been in place for more than 2 weeks at the onset of CA-UTI and cannot be removed, the catheter should be replaced to hasten resolution of symptoms and to reduce the risk of subsequent CA-bacteriuria and CA-UTI.
This guideline does not include individual introductions to each module. A general introduction can be found in the attachments under the heading 'related'.
In patients with short-term use of catheter the most prevalent cultured micro-organism is E. coli. In patients with suprapubic catheterization the most prevalent cultured micro-organism is Staphylococcus epidermidis [(94) C].
In patients with long-term catheter E. Coli is the most prevalent pathogen, but enterococci, staphylococci, Pseudomonas, Serratia, Providencia, Acinetobacter and yeasts are also frequently cultured [ (95) C; (26) C; Spoorenberg submitted, B].
Patients with a urinary catheter have an increased risk to have a fluoroquinolone-resistant micro-organism [(7) B].
For patients with a urinary catheter in place for at least 10 days the best empirical treatment which covers enterococci was the combination of co-amoxiclav with gentamicin. Excluding enterococci made a third-generation cephalosporin with gentamicin the most adequate recommendation [Spoorenberg submitted, B].
When the indwelling catheter is changed at the time of treatment of a symptomatic UTI, a higher percentage of patients has disappearance of the bacteriuria and a more rapid recovery from the symptoms [(96) A2].
When a symptomatic UTI is present, pyuria disappears faster during intermittent compared to suprapubic or indwelling catheterization [(97) B].
In patients with short-term catheter the most prevalent cultured micro-organism is E. coli, In patients with suprapubic catheterization the most prevalent cultured micro-organism is Staphylococcus epidermidis (94).
In patients with a long-term indwelling catheter, in addition to more common Enterobacteriaceae, also Serratia, Providencia, Acinetobacter, enterococci, yeasts and staphylococci are often cultured (28), (95).
Recently two Dutch studies were performed, one in the urology and internal medicine departments of 19 Dutch hospitals (mentioned above, Spoorenberg et al. submitted), and the other at primary care centers and in emergency rooms (26). The most common isolated pathogens in, respectively, 174 and 62 patients with a urinary catheter in place for at least 10 days were E. coli (25-39%), Klebsiella sp (10-12%), enterococci (5-10%), P. mirabilis (9-12%) and P. aeruginosa (8-9%) (26).
In this patient group the combination of co-amoxiclav with gentamicin was the most adequate (inadequate treatment rate of 3%). Excluding enterococci decreased the inadequate treatment rates for the regimens of a cephalosporin combined with gentamicin or a fluoroquinolone, making a third-generation cephalosporin with gentamicin the most adequate recommendation (inadequate treatment rate of 2%) (Spoorenberg et al. submitted).
Therefore, patients with a catheter need recommendations other than those described in the general treatment recommendations for a complicated UTI. Patients with a urinary catheter have an increased risk to have a fluoroquinolone-resistant micro-organism (OR 3.1, 95% CI 0.9-11.6) (7).
A prospective RCT evaluated whether long-term urinary catheters should be replaced prior to treatment of CA-UTI (96). Twenty-one male and 33 female elderly nursing home residents with long-term indwelling urinary catheters (time since last replacement, 2.5-5 weeks) and CA-UTI were randomized to indwelling catheter replacement or no replacement before initiating antimicrobial therapy with a fluoroquinolone. Patients who underwent catheter replacement had significantly decreased polymicrobic CA-bacteriuria 28 days after antimicrobials were discontinued (P=0.02), a shorter time to improved clinical status at 72 hours after the initiation of therapy (P<0.001), and a lower rate of CA-UTI within 28 days after therapy (P=0.015). These findings support catheter replacement prior to antimicrobial treatment for CA-UTI if the catheter has been in place for at least 2 weeks and cannot be discontinued.
In another study it was shown that when a symptomatic UTI is present, pyuria disappears faster during intermittent compared to suprapubic or indwelling catheterization (97).
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.
Catheter-associated UTIs are often polymicrobial and caused by multiple-drug resistant uropathogens. Urine cultures are recommended prior to treatment in order to confirm that an empiric regimen provides appropriate coverage and to allow tailoring of the regimen based on antimicrobial susceptibility data (80).
In patients with long-term catheter and systemic symptoms, empirical treatment with fluoroquinolones or gentamicin is warranted to cover less common micro-organisms such as Pseudomonas, Serratia, Providencia, Acinetobacter. However, a study from the Netherlands demonstrated that patients with a urinary catheter have an increased risk to have a fluoroquinolone-resistant micro-organism, which only leaves the aminoglycosides for empirical treatment in this patient group. Enterococcus species usually have low virulence, and it is debatable whether they should be covered in empirical therapy. Therefore, the Guideline committee decided to give recommendations with and without the coverage of enterococci.
As earlier antimicrobial treatment remains the strongest predictor for resistant causative micro-organisms (7), in a patient with a catheter who only has local symptoms we recommend to wait for the results of the cultures.
The Guideline committee is of the opinion that the faster disappearance of pyuria with intermittent catheterization is not important enough to recommend intermittent catheterization for all patients with a symptomatic UTI.
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.