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Symptomatic catheter-associated urinary tract infection — MSRA MCQ

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HardInfectious DiseasesSymptomatic catheter-associated urinary tract infectionMSRA

A 73-year-old man is reviewed in general practice with a 24-hour history of new suprapubic discomfort and cloudy, foul-smelling urine. He has had an indwelling urethral catheter for 12 days following postoperative urinary retention after hip arthroplasty; a trial without catheter is planned in 2 days. He has no flank pain, rigors, vomiting or fever. His observations are normal and he is drinking adequately. There is no delirium or other source of infection. He has no drug allergies, his eGFR is 58 mL/minute/1.73 m², and he has not received antibiotics within the past 3 months. A previous urine culture 8 months ago grew Escherichia coli susceptible to nitrofurantoin and trimethoprim. He can take oral medication. Which is the most appropriate management today?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: A — Replace the catheter, obtain an aseptic urine specimen from the new catheter for culture, and start nitrofurantoin modified-release 100 mg twice daily for 7 days without delaying treatment.

Explanation lettering: B = shown as A · E = shown as B · D = shown as C · C = shown as D · A = shown as E

This is a symptomatic catheter-associated UTI (CAUTI), rather than asymptomatic bacteriuria: he has new suprapubic discomfort with urinary changes and no alternative infective focus. As the catheter has been in place for more than 7 days and remains necessary pending a planned trial without catheter, it should be changed promptly. After replacement, the urine specimen should be taken aseptically from the sampling port of the new catheter and sent for culture and susceptibility testing. Catheter change must not delay antibiotics. He has no features of upper UTI, sepsis or inability to take oral treatment. Nitrofurantoin is an appropriate first-choice oral option for lower CAUTI because his eGFR is at least 45 mL/minute/1.73 m²; a 7-day course is recommended. A samples the colonised old catheter and fails to replace it. C inappropriately delays treatment of symptomatic infection. D would be appropriate only if the catheter could safely be removed now; it remains clinically required. E uses a second-choice antibiotic despite suitable first-choice nitrofurantoin.

Reference: NICE NG113: Urinary tract infection (catheter-associated): antimicrobial prescribing — Recommendations (2018; accessed in current NICE version 2026) — https://www.nice.org.uk/guidance/ng113/chapter/recommendations NICE NG113: Urinary tract infection (catheter-associated): antimicrobial prescribing — PDF (2025) — https://www.nice.org.uk/guidance/ng113/resources/urinary-tract-infection-catheterassociated-antimicrobial-prescribing-pdf-66141596739013