Catheter Associated UTI

[BAEandi20]

Hey all! New grad practicing EM here. Question about CAUTI. I’ve noticed a lot of UAs in patients with catheters look like a UTI but may not be. What’s your general approach to this if someone isn’t having fever, CVA tenderness, but they “feel” like they have a UTI. Do you just wait for the culture? Thanks in advanced! 

[dphy83]

Yeah, a lot of people with indwelling catheters are colonizers. But I think you'd be hard pressed to find an EM provider who won't treat most of those as people for UTI if the UA is dirty.

Think about it this way: what brought them to the ED? Fatigue, abd pain, nausea, back pain, weakness, confusion, etc? They probably didn't swing through just to say hi, so something clearly has them feeling less than good. There are a ton of symptoms that could be associated with a UTI so the truth is you usually just replace the Foley and treat these people. This is especially true if the patient is unreliable, has a lot of comorbidities, or is otherwise prone to a bad outcome. You don't want to be the person that sends the person home without treatment while waiting 2 days to see what the culture grows, only to have them come back worse/septic. Let the culture watch fall to the urologist or ID folks (though I think if you took it upon yourself to consult a urologist for this in the ED they'd tell you to just exchange the Foley and treat with cipro haha).

You can read about all of the studies of EBM but I wouldn't overthink this one. Just treat them and move on to your next patient.

Edited December 14, 2020 by dphy83

[ohiovolffemtp]

I see this frequently in patients sent in from our local (un)skilled nursing facilities.  The usual complaint is not UTI, it's confusion, dehydration, lethargy.  I also see it in patients in incontinence garments.  If the patient has a foley, it's often been in longer than 30 days.  So, if the UA looks like UTI, I look for old cultures ad treat based on them if available.  Otherwise it's 1 G ceftriaxone IV and a Rx for cefuroxime PO and change the foley.

Often I find significant elevated creatinine.  In the pre-COVID world, I'd admit these folks for several days of IVF and IV abx.  Now, I have the IV left in, send the patient back by EMS, with orders for IVF and repeat labs to be drawn in 1 - 1.5 days and results sent STAT to the patient's out-patient provider. I don't have beds to keep them any more.  So far, no bouncbacks.

[greenmood]

If you're getting a lot of repeaters who don't tick the box "looks sick" consider discussing this kind of thing with someone in infectious disease at your facility. They will be familiar with the local antibiogram. Over-treating patients with indwelling Foley catheters can cause tremendously bad outcomes over the trajectory of their lives. We get a ton of SNF patients with catheters and a syndrome that looks infectious. Many of them are admitted and the only dose of antibiotics they get is the one the ED provider gave them.

-Hospitalist