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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

A 72-year-old woman is reviewed at home 10 days after elective hip arthroplasty. An indwelling urethral catheter was inserted peri-operatively because of transient immobility. She had normal voiding before admission and is now independently mobile; there is no ongoing indication for catheterisation. For 24 hours she has had new suprapubic discomfort and feels generally unwell. She has no fever, rigors, loin pain, vomiting, confusion or haemodynamic instability. The catheter is draining freely. There is no other apparent infective focus. Her eGFR is 52 mL/minute/1.73 m², she has no drug allergies and has not received antibiotics in the previous 3 months. What is the most appropriate immediate management?

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Correct answer: E — Remove the catheter, obtain a midstream urine specimen for culture, and start nitrofurantoin 100 mg modified-release twice daily for 7 days without delaying treatment.

This is a symptomatic catheter-associated UTI (CAUTI), rather than asymptomatic bacteriuria: she has new suprapubic discomfort and systemic malaise with no alternative source. As the catheter has been in place for more than 7 days and is no longer required, it should be removed promptly rather than retained or routinely exchanged. Once removed, the appropriate specimen is a midstream urine sample, obtained before antibiotics where feasible. She is clinically stable, can take oral treatment, has no features of upper UTI or sepsis, and has an eGFR above 45 mL/minute/1.73 m². Nitrofurantoin 100 mg modified-release twice daily for 7 days is therefore an appropriate empirical oral option for lower CAUTI. Catheter removal and specimen collection must not create a clinically meaningful delay to antibiotic treatment. A samples the old catheter despite planned removal; after removal, a midstream specimen is recommended. B incorrectly withholds antibiotics in a symptomatic CAUTI. C fails to remove a catheter that is no longer indicated and has been present for over 7 days. E over-escalates management: there are no features requiring intravenous therapy or hospital referral.

Reference: Urinary tract infection (catheter-associated): antimicrobial prescribing — Recommendations (Published 23 November 2018; updated May 2025) — https://www.nice.org.uk/guidance/ng113/chapter/recommendations Urinary tract infection (catheter-associated): antimicrobial prescribing — Recommendations (Published 23 November 2018; updated May 2025) — https://www.nice.org.uk/guidance/ng113/chapter/recommendations Urinary tract infection (catheter-associated): antimicrobial prescribing — Table 1 (Published 23 November 2018; updated May 2025) — https://www.nice.org.uk/guidance/ng113/chapter/recommendations