Antibiotic treatment for catheter associated UTI

Antibiotic treatment of acute infection

• do not treat catheterised patients with asymptomatic bacteriuria with an antibiotic
• do not routinely prescribe antibiotic prophylaxis to prevent symptomatic UTI in patients with catheters
• it has been suggested to 'change long term indwelling catheters before starting antibiotic treatment for symptomatic UTI..' (1)
  

Choice of antibiotic: non-pregnant women and men aged 16 years and over (2,3)

first choice oral antibiotic if no upper UTI symptoms2

• nitrofurantoin
  • if eGFR >=45 ml/minute3,4
    • 100 mg modified-release twice a day for 7 days
• trimethoprim
  • if low risk of resistance5
    • 200 mg twice a day for 7 days
• amoxicillin (only if culture results available and susceptible)
  • 500 mg three times a day for 7 days

second choice oral antibiotic if no upper UTI symptoms (first choice not suitable)2

• pivmecillinam (a penicillin)4
  • 400 mg initial dose then 200 mg three times a day for a total of 7 days

first choice oral antibiotic if upper UTI symptoms2

• cefalexin
  • 500 mg twice or three times a day (up to 1 to 1.5 g three or four times a day for severe infections) for 7 to 10 days
• co-amoxiclav (only if culture results available and susceptible)
  • 500/125 mg three times a day for 7 to 10 days
• trimethoprim (only if culture results available and susceptible)
  • 200 mg twice a day for 14 days
• ciprofloxacin (consider safety issues6)
  • 500 mg twice a day for 7 days

first choice intravenous antibiotic (if vomiting, unable to take oral antibiotics or severely unwell). Antibiotics may be combined if susceptibility or sepsis a concern2,7

• co-amoxiclav (only in combination or if culture results available and susceptible)
  • 1.2 g three times a day
• cefuroxime
  • 750 mg to 1.5 g three or four times a day
• Ceftriaxone
  • 1 to 2 g once a day
• ciprofloxacin (consider safety issues6)
  • 400 mg twice or three times a day
• gentamicin
  • Initially 5 to 7 mg/kg once a day, subsequent doses adjusted according to serum-gentamicin concentration8
• amikacin
  • Initially 15 mg/kg once a day (maximum per dose 1.5 g once a day), subsequent doses adjusted according to serum-amikacin concentration (maximum 15 g per course)8
    
    
  • 1See BNF for use and dosing in specific populations, for example, hepatic and renal impairment, breastfeeding and for administering intravenous antibiotics.
  • 2Check any previous culture and susceptibility results, and previous antibiotic prescribing and choose antibiotics accordingly.
  • 3May be used with caution if eGFR 30-44 ml/minute to treat uncomplicated lower UTI caused by suspected or proven multidrug resistant bacteria and only if potential benefit outweighs risk (BNF, August 2018).
  • 4Nitrofurantoin and pivmecillinam are only licensed for uncomplicated lower UTIs, and are not suitable for people with upper UTI symptoms or a blocked catheter.
  • 5Low risk of resistance is likely if not used in the past 3 months, previous urine culture suggests susceptibility (but this was not used), and in younger people in areas where data suggests low resistance. Higher risk of resistance is likely with recent use and in older people in care homes
  • 6The European Medicines Agency's Pharmacovigilance Risk Assessment Committee has recommended restricting the use of fluoroquinolone antibiotics following a review of disabling and potentially long-lasting side effects mainly involving muscles, tendons, bones and the nervous system (press release October 2018), but they are an option in catheter-associated UTI with upper UTI symptoms, which is a severe infection.
  • 7Review intravenous antibiotics by 48 hours and consider stepping down to oral antibiotics.
  • 8Therapeutic drug monitoring and assessment of renal function is required (BNF, August 2018).

Choice of antibiotic: pregnant women aged 12 years and over

First choice oral antibiotic2

• cefalexin
  • 500 mg twice or three times a day (up to 1 to 1.5 g three or four times a day for severe infections) for 7 to 10 days

First choice intravenous antibiotic (if vomiting, unable to take oral antibiotics or severely unwell)2, 3

• cefuroxime
  • 750 mg to 1.5 g three or four times a day

Second choice antibiotics or combining antibiotics if susceptibility or sepsis is a concern

• consult local microbiologist
  
  
  • 1 See BNF for appropriate use and dosing in specific populations, for example, hepatic and renal impairment, and for administering intravenous antibiotics.
  • 2Check any previous urine culture and susceptibility results, and antibiotic prescribing, and choose antibiotics accordingly.
  • 3Review intravenous antibiotics by 48 hours and consider stepping down to oral antibiotics where possible

Antibiotic prophylaxis

• antibiotic prophylaxis should not be routinely offered to people with a long-term (indwelling or intermittent) catheter
• prophylactic antibiotics are not routinely required when changing catheters in patients at increased risk of endocarditis such as those with a heart valve lesion, septal defect, patent ductus, or prosthetic valve (1)
• routine use of antimicrobial prophylaxis during catheter change should be avoided (1)
  • consider antibiotic prophylaxis in patients for whom the number of infections are of such frequency or severity that they chronically impinge on function and well-being.
  • when changing catheters, antibiotic prophylaxis should only be used for people with a history of catheter-associated urinary tract infection following catheter change
  • in a hospital setting, when prophylaxis for catheter change is required, consider using a narrow spectrum agent such as gentamicin rather than ciprofloxacin to minimise the risk of C.difficile infection

Reference:

• SIGN (August 2012). Management of suspected bacterial urinary tract infection in adults.
• NICE (November 2018).Urinary tract infection (catheterassociated): antimicrobial prescribing.
• Public Health England (June 2021). Managing common infections: guidance for primary care