Catheter-related urinary tract infection: practical management in the elderly

From 5-10% of elderly residents of long-term care facilities require chronic indwelling catheters for management of urine voiding. These residents are always bacteriuric, because of biofilm formation along the catheter, and experience increased morbidity associated with urinary tract infection. A wide variety of bacteria or yeast species are isolated. Occasional episodes of symptomatic infection may be accompanied by localizing genitourinary findings. However, when fever is present and there are no localizing findings, symptomatic infection is a diagnosis of exclusion. Many of these episodes are not from a urinary source, so critical clinical evaluation is always necessary. A urine specimen for culture should be obtained from patients with symptomatic infection prior to institution of antimicrobial therapy. When the catheter has been present for 2 weeks or longer, it should be replaced and the urine specimen collected through the new catheter. This provides a specimen of bladder urine without biofilm contamination, and catheter replacement also improves clinical outcomes. Treatment algorithms with a goal of limiting inappropriate treatment of asymptomatic bacteriuria have been developed. Empiric antimicrobial therapy should be avoided when possible. Guidelines for prevention of catheter-acquired urinary infection should be followed. The most important of these is to avoid use of a urinary catheter whenever possible and, when there is no longer an indication for the catheter, to remove it promptly.