For formulary catheter guidance and products, please see Chapter 18. Continence

CA-UTI is defined as the presence of symptoms or signs compatible with an UTI in people with a catheter with no other identified source of infection, plus significant levels of bacteria in a catheter or a midstream urine specimen when the catheter has been removed within the previous 48 hours.

The longer a catheter is in place, the more likely bacteria will be found in the urine; after 1 month, nearly all people have bacteriuria.

Antibiotic treatment is not routinely needed for asymptomatic bacteriuria in people with a catheter, please see Asymptomatic bacteriuria for information.

Self-care advice:

• Consider paracetamol for pain
• Drink adequate fluids to avoid dehydration

Consider removing or, if this cannot be done, changing the catheter as soon as possible in people with a CA-UTI if it has been in place for more than 7 days. Do not allow catheter removal or change to delay antibiotic treatment.

Obtain a urine sample before antibiotics are taken. Take the sample from the catheter, via a sampling port if provided, using an aseptic technique.

• If the catheter has been changed, obtain the sample from the new catheter.
• If the catheter has been removed, obtain a midstream specimen of urine

Send urine for culture and susceptibility, noting a suspected catheter-associated infection and:

• review antibiotic choice when results are available, and
• change antibiotic if bacteria resistant and symptoms not improving

Do not routinely offer antibiotic prophylaxis to prevent CA-UTI in people with a short-term or a long-term (indwelling or intermittent) catheter.

Consider referring or seeking specialist advice for people if they:

• are significantly dehydrated or unable to take oral fluids and medicines or
• are pregnant or
• have a higher risk of developing complications (for example, people with known or suspected structural or functional abnormality of the genitourinary tract, or underlying disease [such as diabetes or immunosuppression]) or
• have recurrent CA-UTIs or
• have bacteria that are resistant to oral antibiotics

Seek specialist advice if the patient cannot take oral antibiotics to explore options for giving intravenous antibiotics at home or in the community, rather than in hospital, where this is appropriate e.g. via outpatient or home parenteral antibiotic therapy service where available

Refer to Catheter Acquired Urinary Tract Infection (CAUTI) Clinical Referral Guidelines:

• Southern Locality
• Western Locality

Antibiotics for non-pregnant women and men aged 16 years and over

Offer an antibiotic to people with CA-UTI; taking into account the considerations when prescribing antibiotics.

• The risk of developing complications is higher in people with known or suspected structural or functional abnormality of the genitourinary tract, or immunosuppression

1st line if no upper UTI symptoms

If the catheter has been removed and is not reinserted

Nitrofurantoin

• 100mg modified-release twice daily for 7 days

Notes

• Nitrofurantoin is contraindicated in patients with an estimated glomerular filtration rate (eGFR) of less than 45 mL/min/1.73m²
• A short course (3 to 7 days) may be used with caution in certain patients with an eGFR of 30 to 44 mL/min/1.73m². Only prescribe to such patients to treat lower urinary tract infection with suspected or proven multidrug resistant pathogens when the benefits of nitrofurantoin are considered to outweigh the risks of side effects
• Consider checking renal function when choosing to treat with nitrofurantoin, especially in the elderly
• An alternative agent to nitrofurantoin should be used if symptoms of upper urinary tract infection or systemic infection (loin pain, fever, rigors) are present, as nitrofurantoin lacks systemic activity.
• Closely monitor for signs of pulmonary, hepatic, neurological, haematological, and gastrointestinal side effects during treatment, as previously advised in the summary of product characteristics
• For more information see MHRA Drug Safety Update (February 2015)

If the catheter has been changed or remains in situ

Trimethoprim

• 200mg twice a day for 7 days

Notes

• A lower risk of resistance is likely if trimethoprim not used in the past 3 months, previous urine culture suggests susceptibility (but trimethoprim was not used)
• A higher risk of resistance is likely with recent use and in older people in care homes.

2nd line if no upper UTI symptoms

Consider 2nd line options when 1st line options are not suitable

Pivmecillinam

• 400mg initial dose, then 200mg three times day for a total of 7 days
• This is an extended-spectrum penicillin antibiotic

Alternative if no upper UTI symptoms (use only if culture results available and susceptible):

Amoxicillin

• 500mg three times a day for 7 days

1st line if upper UTI symptoms

Cefalexin

• 1g three times a day for 7 to 10 days

See section: 5.1.2 Cephalosporins, carbapenems, and other beta-lactams

If 1st line has failed, will not work due to resistance, or is unsafe to use in an individual patient

Ciprofloxacin

• 500mg twice a day for 7 days
• Systemic fluoroquinolones must now only be prescribed when other commonly recommended antibiotics are inappropriate (See MHRA Drug Safety Updates below)
• Patients should be advised to stop treatment at the first signs of a serious adverse reaction, such as tendinitis or tendon rupture, muscle pain, muscle weakness, joint pain, joint, feet, or abdomen swelling, peripheral neuropathy, rapid onset of shortness of breath, new-onset of heart palpitations, and central nervous system effects: including new or worsening depression or psychosis, and to seek immediate medical attention.

University Hospitals Plymouth NHS Trust laboratory tests and reports levofloxacin: where susceptibility is identified with levofloxacin, ciprofloxacin may be prescribed.

Levofloxacin

• 500mg once daily for 7 days
• Systemic fluoroquinolones must now only be prescribed when other commonly recommended antibiotics are inappropriate (See MHRA Drug Safety Updates below)
• Patients should be advised to stop treatment at the first signs of a serious adverse reaction, such as tendinitis or tendon rupture, muscle pain, muscle weakness, joint pain, joint, feet, or abdomen swelling, peripheral neuropathy, rapid onset of shortness of breath, new-onset of heart palpitations, and central nervous system effects: including new or worsening depression or psychosis, and to seek immediate medical attention.

Drug Safety Updates for Ciprofloxacin and Levofloxacin (refer to 5.1.12 Quinolones for further details).

• MHRA Drug Safety Update (November 2018): Systemic and inhaled fluoroquinolones: small increased risk of aortic aneurysm and dissection; advice for prescribing in high-risk patients.
• MHRA Drug Safety Update (December 2020): Systemic and inhaled fluoroquinolones: small risk of heart valve regurgitation; consider other therapeutic options first in patients at risk.
• MHRA Drug Safety Update (September 2023): Fluoroquinolone antibiotics: suicidal thoughts and behaviour.
• MHRA Drug Safety Update (January 2024): Fluoroquinolone antibiotics: must now only be prescribed when other commonly recommended antibiotics are inappropriate.

Alternative if upper UTI symptoms (use only if culture results available and susceptible):

Co-amoxiclav

• 500/125mg three times a day for 7 to 10 days

Trimethoprim

• 200mg twice daily for 14 days

See sections: 5.1.1 Penicillins and 5.1.8 Sulfonamides and trimethoprim

Antibiotics for pregnant women aged 12 years and over

Consider referring or seeking specialist advice for pregnant women aged 12 years and over

If no upper UTI symptoms

Cefalexin

• 500mg twice daily for 7 to 10 days
• If severe infection, use dose for upper UTI symptoms below

If upper UTI symptoms

Cefalexin

• 1g three times a day for 7 to 10 days

Consult local microbiologist if cefalexin is not suitable

Trimethoprim may be considered or advised by specialists. It is recommended that women who need to take trimethoprim during the first trimester also take high dose folic acid (5mg daily) until week 12 of pregnancy. Avoid trimethoprim if the woman has a low folate status or is on a folate antagonist (e.g. antiepileptic or proguanil)

See section: 5.1.2 Cephalosporins, carbapenems, and other beta-lactams, 5.1.8 Sulfonamides and trimethoprim, and Resources for: contraception for drugs with teratogenic potential, and prescribing in pregnancy and lactation

Antibiotics for children and young people under 16 years

Children under 3 months of age

Infants and children under 3 months with a possible UTI should be referred to a paediatric specialist.

Children aged 3 months and over

Consider referring or seeking specialist advice for children aged 3 months and over

Cefalexin

• Maximum dose for any age is 1g four times a day
• 3 months to 4 years:
  • If no upper UTI symptoms: 12.5mg/kg or 125mg twice a day for 7 to 10 days
  • If upper UTI symptoms or severe infections: 25mg/kg two to four times a day for 7 to 10 days
• 1 to 4 years:
  • If no upper UTI symptoms: 12.5mg/kg twice a day or 125mg three times a day for 7 to 10 days
  • If upper UTI symptoms or severe infections: 25mg/kg two to four times a day for 7 to 10 days
• 5 to 11 years:
  • If no upper UTI symptoms: 12.5mg/kg twice a day or 250mg three times a day for 7 to 10 days
  • If upper UTI symptoms or severe infections: 25mg/kg two to four times a day for 7 to 10 days
• 12 to 15 years:
  • If no upper UTI symptoms: 500mg twice or three times a day
  • If upper UTI symptoms or severe infections: 1g three times a day for 7 to 10 days

Trimethoprim

• Children and young people aged 3 months and over (doses given twice daily for 7 to 10 days):
  • 3 to 5 months: 4mg/kg (maximum 200mg per dose) or 25 mg
  • 6 months to 5 years: 4mg/kg (maximum 200mg per dose) or 50mg
  • 6 to 11 years: 4mg/kg (maximum 200mg per dose) or 100mg
  • 12 to 15 years: 200mg

Alternative option (use only if culture results available and susceptible):

Amoxicillin

• Children and young people aged 3 months and over (doses given three times a day for 7 to 10 days):
  • 3 to 11 months: 125mg
  • 1 to 4 years: 250mg
  • 5 to 15 years: 500mg

Co-amoxiclav

• Children and young people aged 3 months and over (doses given three times a day for 7 to 10 days):
  • 3 to 11 months: 0.25ml/kg (125/31 suspension) (dose doubled in severe infection)
  • 1 to 5 years: 5ml or 0.25ml/kg (125/31 suspension) (dose doubled in severe infection)
  • 6 to 11 years: 5ml or 0.15ml/kg (250/62 suspension) (dose doubled in severe infection)

See section: 5.1.1 Penicillins, 5.1.2 Cephalosporins, carbapenems, and other beta-lactams, and 5.1.8 Sulfonamides and trimethoprim