UTI ( Catheter ) antibiotics

NICE has published a guideline on management of UTIs in people with a urinary catheter. 

This was published in November 2018 and NICE has reviewed current evidence / experience on this topic and produced this very useful guidance. An easy to use visual is produced here for quick reference

Catheter-associated urinary tract infection 
( UTI ) -symptomatic infection of the bladder or kidneys in a person with a urinary catheter
 NICE guidance suggests that longer the catheter is in place – more likely bacteria will be found in the urine and after 1 month nearly all people will have bacteriuria
 NICE advice against antibiotic treatment 
( as you may note in microscopy results advice ) for asymptomatic bacteriuria

Asymptomatic bacteriuria is defined as the presence of significant levels of bacteria in the urine with no symptoms of UTI

Give advice on self management for eg
○ using paracetamol for pain
○ drinking enough fluids to avoid dehydration
 NICE advice removing the catheter – anticipating the difficulties with this recommendations the guidance states
○ if this cannot be done changing the catheter as soon as possible in people with catheter-associated UTI if it has been in place for more than 7 days
( mnemonic CA-UTI used here )
 Do not delay antibiotic treatment while you wait for the nurses to remove or change catheter
 Specimen – obtain and label as ” Suspected catheter-associated infection ” for C/S before antibiotics are taken

○ use the sampling port provided
○ use aseptic technique
○ if catheter changed – obtain sample from the new catheter
○ If catheter removed- obtain a midstream sample

When prescribing antibiotics take into account
 severity of symptoms risk of complications previous urine C/S result previous antibiotic use local antimicrobial resistance data
most healthboards produce own recommendations for first line antibiotics- use one if available for CA-UTI

When urine C/S results becomes available review the choice and change accordingly if the bacteria are resistant using narrow spectrum antibiotics wherever possible

Refer to previous C/S results, previous prescribing Nitrofurantoin -can be used with caution if eGFR 30-44 in uncomplicated lower UTI caused by suspected or proven multi-drug resistant bacteria and potential benefit ouweighs the risk ( BNF 2018 ) Nitrofurantoin and pivmecillinam – only licensed for uncomplicated lower UTIs and not suitable in upper UTI symptoms or a blocked catheter Mindful of growing antibiotic resistance NICE specifies
○ Low risk of resistance – is when not used in last 3 months ♦ previous culture shows susceptibility ( but wasn’t used ) ♦ in younger people where data shows low resistance
○ Higher risk of resistance is ♦ likely with recent use ♦ older people in care homes Fluoroquinolone antibiotics – NICE quotes EMA recommendations about disabling and potentially long lasting SEs involving muscles, tendons ,bones and the nervous system, but they are an option in CA-UTI with upper UTI symptoms which is a severe infection

Possible SEs particularly diarrhoea Seeking medical help if symptoms worsen at any time or do not start to improve within 48 hrs or the person becomes systemically unwell

First choice oral antibiotic if no upper UTI symptoms- nitrofurantoin , trimethoprim , amoxicillin

Second-choice oral antibiotic if no upper UTI symptoms and first choice not suitable- Pivmecillinam ( penicillin based )

First choice oral antibiotic if upper UTI symptoms- cefalexin, trimethoprim, ciprofloxacin

Reassess at any time if
○ they worsen
○ do not start to improve within 48 hrs of taking the antibiotic

NICE recommends to consider the following scenario if the above happens

○ other possible diagnoses
○ more serious illness or condition such as sepsis
○ drug resistance

Refer to hospital if more serious illness or condition suspected eg sepsis
 Consider referring or seeking specialist advice for people with CA-UTI if they
○ are significantly dehydrated or unable to take oral fluids and medicines or
○ are pregnant or
○ high risk of developing complications for eg
 ♦ people with known or suspected structural or functional abnormality of GU tract or
 ♦ underlying disease eg diabetes or immunosuppression
○ recurrent catheter associated UTIs or
○ have bacteria that are resistant to oral antibiotics

References Urinary tract infection ( catheter-associated ) : antimicrobial prescribing NICE guideline November 2018 https://www.nice.org.uk/guidance/ng113/resources/