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Symptomatic catheter-associated lower urinary tract infection — MSRA MCQ

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HardUrinary Tract InfectionsSymptomatic catheter-associated lower urinary tract infectionMSRA

An 81-year-old man with chronic urinary retention has had a urethral catheter in situ for 19 days while awaiting a trial without catheter. He develops new suprapubic discomfort and visible haematuria. The catheter is draining freely. He is afebrile, haemodynamically stable, and has no flank pain, rigors, nausea, vomiting, perineal pain or acute confusion. His eGFR is 58 mL/minute/1.73 m². A urine culture 2 months ago grew Escherichia coli susceptible to nitrofurantoin and resistant to trimethoprim. He has not received antibiotics in the past 3 months. What is the most appropriate immediate management?

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Correct answer: D — Replace the catheter, obtain an aseptic urine specimen from the new catheter, send it for culture, and prescribe nitrofurantoin MR 100 mg twice daily for 7 days

This is a symptomatic catheter-associated lower UTI: new suprapubic discomfort and haematuria in a catheterised patient are compatible symptoms, whereas bacteriuria alone would not justify treatment. He has no features suggesting upper UTI, sepsis or acute prostatitis. As the catheter has been in place for more than 7 days, it should be changed promptly; this should not delay antimicrobial treatment. Once changed, the urine specimen should be taken aseptically from the new catheter rather than the drainage bag or old catheter, then sent for culture and susceptibility testing. Nitrofurantoin MR 100 mg twice daily for 7 days is a first-choice oral option for catheter-associated UTI without upper-tract features when eGFR is at least 45 mL/minute/1.73 m². His prior susceptible isolate supports this choice, while prior trimethoprim resistance makes option E inappropriate. Ciprofloxacin is unnecessarily broad in a clinically stable lower UTI and should not be selected simply because the patient is catheterised. Deferring antibiotics is inappropriate because he is symptomatic. Removing the catheter without replacement is unsuitable because he still requires drainage for chronic retention.

Reference: NICE NG113: Urinary tract infection (catheter-associated): antimicrobial prescribing — Recommendations (2018) — https://www.nice.org.uk/guidance/ng113/chapter/recommendations NICE NG113: Urinary tract infection (catheter-associated): antimicrobial prescribing — Recommendations (2018) — https://www.nice.org.uk/guidance/ng113/chapter/recommendations NICE NG113: Urinary tract infection (catheter-associated): antimicrobial prescribing — Choice of antibiotic (2018) — https://www.nice.org.uk/guidance/ng113/chapter/recommendations