Diagnosis & Management of Catheter-Associated Urinary Tract Infection (CA-UTI) in Residential/Long-Term Care/Nursing Home Residents

Results from the HALT Study

  • In the 2016 point-prevalence survey of Healthcare-associated infection and Antimicrobial use in Long-Term care facilities (“HALT”), 4.7% of residents in long-term care facilities (LTCFs) were on an antibiotic for either treatment or prophylaxis (prevention) of UTI.
  • The 2013 European HALT report found that residents of Irish LTCFs were more than twice as likely to be on an antibiotic as their European counterparts.
  • In HALT 2016, UTI prevention accounted for 68% of prophylactic prescribing. 17% of residents prescribed UTI prophylaxis in 2016 were reportedly catheterised (n=50 of 294), although UTI prophylaxis is not recommended for catheterised patients.
  • UTI prophylaxis prevalence decreased from 3.8% to 2.9% between 2010 and 2016.

Diagnosis of a CA-UTI

Diagnosis of CA-UTI should be based on a full clinical assessment. It is acknowledged that this diagnosis can be difficult and without other obvious cause, a trial of treatment may be justified.

✔ Residents may have non-specific signs including confusion, lethargy, decreased oral intake and/or agitation but loin pain and fever >38°C are significant indicators of a CA-UTI in patients with this symptom complex.

✔ Consider COVID-19 for patients with non-specific signs and symptoms.

✘ Cloudy urine is NOT an indicator of CA-UTI in the absence of symptoms and signs

✘ Foul-smelling urine is NOT an indicator of CA-UTI in the absence of symptoms and signs

Should I do a urine dipstick?

✘ No. Dipsticks are not useful in assessing this group of patients for infection.

When should I send a urine to the lab for culture?

✔ Send urine to the lab in residents only where CA-UTI is suspected on clinical grounds. The results can be used to guide treatment should the resident fail to respond to empiric choice.

Antibiotic Prophylaxis

Should I consider Antibiotic Prophylaxis?

✘ Antibiotic prophylaxis is generally not appropriate for the prevention of UTI in catheterised patients because of the risk of antibiotic-associated harm to the patient.

✘ Antibiotic prophylaxis is NOT appropriate for urinary catheter changes unless there is a definite history of UTIs due to catheter change. 

How to interpret urine culture results in residents with a urinary catheter

  • Laboratory microscopy should not be used to diagnose UTI in catheterised residents as urine white cells are often elevated due to the presence of the catheter
  • If the urine culture result is positive, treat only if the resident has symptoms or signs suggestive of CA-UTI and no other source is identified. Urinary catheters are often colonised with bacteria. A positive urine culture result in a catheterised resident does not indicate infection, unless there are symptoms or signs suggestive of CA-UTI (such as loin pain, fever >38°C).
  • In the presence of a urinary catheter, antibiotics will not eradicate bacteriuria. 

Empirical treatment of CA-UTI in Residents

  1. Only consider empiric antibiotic therapy in SYMPTOMATIC residents.
  2. All CA-UTI should be treated as upper UTI.
  3. Antibiotics (particularly ciprofloxacin and cephalosporins) are associated with C. difficile infection. Give antibiotics only if clinically indicated and avoid these agents where there is an alternative.
  4. N.B. Check the resident’s previous culture results and do not use an antibiotic empirically if an organism resistant to that antibiotic has recently been cultured (within 12 weeks).
  5. Modify treatment according to culture result when available.

empiric treatment of CA UTI

Other considerations in management of CA-UTI

  • Delayed response
    • N.B. Check urine culture results (usually available 3-4 days after sending urine). Failure to respond or delayed response may be due to a resistant organism.
    • If there is a delayed response despite a susceptible organism, consider referral for further investigations (e.g. renal ultrasound), if appropriate. 10- 14 days’ treatment may be necessary if there is delayed response to treatment and the organism is susceptible.
  • Review ongoing need for the catheter. If an indwelling catheter has been in place for >2 weeks at the onset of UTI and is still required, the catheter should be replaced while on antibiotics.
  • See further advice for preventing CA-UTIs including the importance of hydration to reduce risk of infection.
  • Consider discussion with local clinical microbiologist particularly for complex patients or those with previous resistant organisms.

Patient Information

Safe Prescribing

Reviewed November 2020