Foley Catheter Patients: Common ED Presentations / Management / Pearls & Pitfalls
- Nov 24th, 2016
- Aaron Schneider
Authors: Aaron Schneider, MD (EM Resident Physician, University of Kentucky) and William Sanderson, MD (Assistant Professor, Department of Emergency Medicine, University of Kentucky) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UT Southwestern Medical Center / Parkland Memorial Hospital) and Brit Long, MD (@long_brit)
It is hard to go a shift in the emergency department without encountering a patient with a urinary tract infection, ranging from uncomplicated cystitis to florid sepsis from an infected ureteral stone. Interpretation of presenting symptoms and laboratory studies becomes more complex when considering a patient with a currently existing Foley catheter, recently removed catheter, or in a patient who regularly perform in-and-out catheterization. Catheter associated urinary tract infections (CA-UTIs) are one of the most common nosocomial infection in the United States.1, 2 While minimizing new urinary catheter placement has garnered attention over the last several years, there are several important patient populations that present to the ED with urinary catheters already in place. These patients include those with spinal cord injuries, post-operative patients, patients with preexisting outflow obstruction, and residents of long term care facilities.3-5 This post will focus primarily on CA-UTIs and a catheter-focused history, physical exam, and management, as well as a brief discussion of other potential complications of catheters. To begin, two cases will be presented and then revisited later in the discussion.
Case 1: A 27 year-old male, well appearing, with a history of paraplegia sustained from a motor vehicle collision, without sensation below the umbilicus, and chronic in-and-out catheterization, presents with incontinence and increased bladder spasticity. He has not had any fevers. He worries about a UTI.
Case 2: A 62 year-old male 5 days s/p prostatectomy for prostate cancer presents with a foley catheter in place. He noticed his urine began to turn “cloudy” yesterday and now has worsening suprapubic abdominal pain and a temperature at home up to 100.7.
Based on the IDSA guidelines, a CA-UTI requires all of the following:6
- Currently anchored urinary catheter placed >48 hours ago OR urinary catheter removed in the last 48 hours (and in place for >48 hours prior to removal) OR regular in-and-out catheterization.
- New or changed symptoms associated with the urinary tract. This could include suprapubic pain, CVA tenderness, dysuria (if catheter recently removed), or, in a paraplegic patient, spasticity, autonomic dysreflexia, or a feeling of unease.
- Urinalysis consistent with infection. In the non-ED setting, this may also require cultures.
The second criteria for a CA-UTI – new or changed symptoms associated with the urinary tract – has the most potential for interpretation. A patient with normal neurologic function and normal mental status should have symptoms that localize to the urinary tract; more generalized, systemic symptoms are not sufficient.6 Catheters will inevitably develop colonization and biofilms, however if the patient is asymptomatic, no treatment is necessary.6,7 This parallels elderly patients who frequently have asymptomatic bacteriuria. Conversely, patients who have an existing urinary catheter in place and who present with systemic or non-localizing symptoms (e.g. altered mental status, fatigue or vomiting) should NOT have their symptoms ascribed solely to the catheter, even if the urinalysis is consistent with infection. For example, an elderly patient presenting with new, mild confusion who happens to have an existing urinary catheter in place should have other causes for their altered mental status investigated before attributing their AMS to a CA-UTI.
In addition to historical features related to the definition of a CA-UTI (timeline of catheterization, symptomatology), there are several other important details to elucidate that can influence management. Here are some key points to determine:8
- Why was the catheter placed?
- Post surgical?
- Outlet obstruction?
- Neurogenic bladder?
- Who placed the catheter?
- When was it placed?
- Any complications with and since placement?
- Is the placement intended indefinitely or for a specific time interval?
Investigate for any potential cause of symptoms NOT originating from infected urine itself. Findings other than the expected suprapubic tenderness may broaden the differential diagnosis; testicular tenderness should prompt consideration of epididymitis or testicular torsion; CVA tenderness may be an indication of pyelonephritis or nephrolithiasis.8,9
Some key things to look for and potential findings on exam:
- Urethra and urethral meatus: Abscesses along the urethra? Palpable irregularities?
- Scrotum: Testicular tenderness?
- Perineum: Any signs of recent surgery?
- Vagina: New or changed vaginal discharge? Bleeding?
Both men and women:
- Urethra and urethral meatus: Erosions/ulcerations?
- Abdomen, flanks: Suprapubic tenderness? CVA tenderness?
The IDSA guidelines primarily hinge diagnosis of a CA-UTI on urine culture, specifically 10^3 colony forming units per milliliter (cfu/mL). Unfortunately, in the Emergency Department, culture results are rarely available, and urinalysis is the test of choice. If the catheter has been in place more than 2 weeks, the catheter should be exchanged and a new UA and culture should be obtained from the new catheter prior to starting antibiotics. (This is assuming there is no specific contraindication to exchanging the catheter (i.e. prior difficult placement, surgical placement)). The interpretation of the urinalysis is similar to that of a non-catheterized patient. Pyuria, bacteriuria, positive leukocyte esterase, and/or positive nitrites are indicators that a urine specimen may be consistent with infection. Again, differentiating infection versus colonization must be determined by the patient’s symptoms and a definitive diagnosis of CA-UTI cannot be made on urinalysis (or culture) alone.6
Imaging may be indicated if a catheter related complication or infection, aside from a CA-UTI, is suspected. Ultrasound may be beneficial, especially to assess for signs of obstruction such as hydronephrosis or urinary retention not appropriately relieved by the catheter. A CT scan may be valuable in patients at risk for more serious infections (i.e. post-operative, immunocompromised) or when nephrolithiasis is on the differential.8
If a CA-UTI is diagnosed and the patient is appropriate for outpatient therapy, antibiotics should be prescribed for 10-14 days. If a patient has had a urinary catheter for an extended period of time, look for prior cultures that may aid with antibiotic choices. Antibiotics should be appropriate based on the hospital’s antibiogram and prior culture results if available, but an example would include TMP/SMX DS, 1 tablet by mouth twice daily. A course of Levaquin 750mg by mouth once daily may be appropriate. If the catheter is removed at the ED visit, shorter courses of antibiotics may suffice including TMP/SMX DS, 1 tablet twice daily for 3 days.6
Patients requiring hospitalization for CA-UTIs will require IV antibiotics which may include any one of the following: Cefepime 2g IV twice daily, Levaquin 750mg IV daily, or if a known or suspected ESBL, a carbapenem is appropriate such as Imipenem/cilastatin 500mg IV four times daily.6,10
Other complications and their management:
Other issues that may need addressing may include (although are by no means limited to) a catheter obstruction, catheter that is not correctly placed, and infections to parts of the urinary tract other than the bladder. Post-operative patients have their own variety of complications including wound infections.
When to Consult:
Consult for any post-operative patient! Catheters on post-operative patients should not be removed until discussed with a urologist directly. Your urologist will want to know about any infection that could be associated with recent surgery or instrumentation. Entities such as nephrolithiasis or pyelonephritis in catheterized patients will also likely warrant a phone call to urology.8
- It is ONLY a treatable CA-UTI if the patient is symptomatic.
- Be careful attributing generalized symptoms to a CA-UTI without thoroughly investigating other etiologies (e.g. altered mental status, fatigue, malaise, abdominal pain).
- Do NOT remove a Foley catheter from a recent post-operative patient without contacting your friendly urologist first.
- Similarly, find out if the urinary catheter placement was difficult to place initially: will a urologist be needed again?
- If the Foley catheter is able to be removed, change the catheter BEFORE the urinalysis and culture is sent.
Case 1: This patient is at high risk for CA-UTIs given the regular in-and-out catheterization. Obtain a UA: if consistent with infection, oral antibiotic treatment, such as Levaquin 750mg for 5 days, may be appropriate. If prior culture results are available, tailor antibiotic therapy to past susceptibilities. He is appropriate for discharge and should have follow-up, likely with his primary care physician or urologist, to follow culture results and improvement of symptoms.
Case 2: This patient is post-operative, so do not remove the Foley catheter until talking with urology! Obtain a UA and culture, and consult urology. Management will be guided by urology recommendations, which may include imaging to look for evidence of infection related to the operative site. The patient may need admission or at minimum close follow-up with urology as an outpatient.
- By definition a CA-UTI requires a Foley catheter in place over 48 hours, a UA consistent with infection and most importantly, a change in symptoms directly attributable to a urinary tract infection.
- Find out key historical points: Is the Foley catheter intended to be in place short or long term? Why does the patient have the Foley catheter? Is the Foley related to surgery?
- The usual treatment is with a 10 to 14 day course of most standard antibiotics for UTIs or potentially a 5 day course of Levaquin. Replace or remove the catheter if you are able.
- Consider consult when a urologist has been involved in a patient’s care previously, whether the patient is post-surgical or had a difficult initial Foley catheter placement.
- Other catheter complications may include obstruction of the catheter, misplacement of the catheter, and infection of other genitourinary structures aside from the bladder.
A corollary to treatment of CA-UTIs
As noted above, CA-UTIs are one of the most common nosocomial infections. The Emergency Department is responsible for placement of a large portion of catheters that are continued throughout a patient’s hospital stays. As Emergency Medicine providers, we should avoid placement of new Foley catheters when they are not truly indicated. This is currently a hot topic given the focus on avoidable in-hospital complications. New Foley placement should be, as a general guideline, reserved for the following:3,4,11
- Need for exact measurement of urine output
- Pre-operative for a urological procedure, as dictated by a urologist
- Critically ill patients, especially those intubated
- Need for bypass of bladder outlet obstruction
Note that these do not include convenience for nursing staff or to appease a request by the patient or their family.
References / Further Reading:
- Foxman B. Epidemiology of urinary tract infections: incidence, morbidity, and economic costs. Dis Mon. 2003;49(2):53-70.
- Magill SS, Edwards JR, Bamberg W, et al. Multistate point-prevalence survey of health care-associated infections. N Engl J Med. 2014;370(13):1198-208.
- Mulcare MR, Rosen T, Clark S, et al. A Novel Clinical Protocol for Placement and Management of Indwelling Urinary Catheters in Older Adults in the Emergency Department. Acad Emerg Med. 2015;22(9):1056-66.
- Mizerek E, Wolf L. To Foley or Not To Foley: Emergency Nurses’ Perceptions of Clinical Decision Making in the Use of Urinary Catheters in the Emergency Department. J Emerg Nurs. 2015;41(4):329-34.
- Carter EJ, Pallin DJ, Mandel L, Sinnette C, Schuur JD. A Qualitative Study of Factors Facilitating Clinical Nurse Engagement in Emergency Department Catheter-Associated Urinary Tract Infection Prevention. J Nurs Adm. 2016;46(10):495-500.
- Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis. 2010;50(5):625-63.
- Stickler DJ. Bacterial biofilms in patients with indwelling urinary catheters. Nat Clin Pract Urol. 2008;5(11):598-608.
- Diaz EC, Kimball DL, Jhun P, Bright A, Herbert M. Catheter-Associated Urinary Tract Infections: If You Hear Hoofbeats. Ann Emerg Med. 2015;66(4):437-40.
- Best J, Kitlowski AD, Ou D, Bedolla J. Diagnosis and management of urinary tract infections in the emergency department. Emerg Med Pract. 2014;16(7):1-23.
- Levine BJ. EMRA Antibiotic Guide. 17th edition. Irving, TX: Emergency Medicine Residents’ Association, 2017.
- Munasinghe RL, Yazdani H, Siddique M, Hafeez W. Appropriateness of use of indwelling urinary catheters in patients admitted to the medical service. Infect Control Hosp Epidemiol. 2001;22(10):647-9.