A4Medicine

Catheter-Related UTI or Haematuria – Triage & Management Tool (Elderly Males, Non-Pregnant)

Catheter-associated urinary tract infections (CAUTIs) and catheter-related haematuria are prevalent and clinically significant issues in elderly males, particularly those with long-term indwelling catheters for conditions such as benign prostatic hyperplasia or chronic urinary retention. CAUTIs represent approximately 40% of all hospital-acquired infections (Nicolle, 2014), with elderly patients at higher risk due to immunosenescence, comorbidities, and prolonged catheterization.

Haematuria in catheterized individuals may be caused by infection, traumatic catheter insertion, or underlying malignancy (Feneley et al., 2015). In non-pregnant elderly men, these complications can lead to recurrent infections, urosepsis, and significant reduction in quality of life.

Effective primary care management requires early recognition, routine review of catheter need, urine culture-guided antibiotic prescribing, and prevention strategies per NICE NG113, which recommends avoiding unnecessary catheterization and not treating asymptomatic bacteriuria.

1. 🚨 Red Flag Screen

☐ Fever ≥38°C / ≥100.4°F with systemic signs
☐ Suspected sepsis or pyelonephritis
☐ Frank haematuria with clots or catheter blockage
☐ Unable to tolerate oral intake or vomiting
☐ New or worsening AKI or renal failure

If ANY checked → urgent referral or escalation

2. ⚠️ Catheter History

☐ Type: ☐ Urethral ☐ Suprapubic
☐ Duration: ☐ <7 days ☐ ≥7 days
☐ Recent change? Date: _____
☐ Visible blood: ☐ Fresh ☐ Old ☐ Clots
☐ Blocked or draining poorly
☐ Recent trauma or difficult insertion
☐ Recurrent CA-UTIs? Frequency: ____

3. 💬 UTI Symptoms

☐ Fever ≥38°C / ≥100.4°F
☐ Suprapubic or loin pain
☐ Confusion or acute delirium
☐ Cloudy/foul urine or haematuria
☐ Nausea, vomiting, malaise
☐ Bypassing, urgency, or incontinence
☐ Antibiotics in past 3 months

≥2 symptoms + catheter → likely symptomatic UTI

4. 💊 Bleeding Risk / Medication

☐ Anticoagulants (warfarin, DOACs, LMWH)
☐ Antiplatelets (aspirin, clopidogrel)
☐ INR: ____ (if on warfarin)
☐ Bleeding disorder or thrombocytopenia
☐ Recent catheter trauma or urological procedure

No UTI signs? Suspect iatrogenic or anticoagulant-related haematuria

5. 🧪 Initial Workup

☐ Urine culture from catheter port (post-change if ≥7d)
☐ Document symptoms + prior antibiotic use
☐ Consider catheter change if blocked or old
☐ Check vitals: Temp, HR, BP, urine output
☐ Review eGFR / renal function

6. 🏡 Conservative Advice

☐ Encourage hydration (aim 1.5 L/day if safe)
☐ Offer paracetamol (or ibuprofen if eGFR ok)
❌ Avoid cranberry, potassium/sodium citrate OTC
☐ Provide NHS/HSA leaflet on UTI in older adults

7. 🔄 Specialist Referral – When to Escalate

☐ Recurrent CA-UTIs (≥2 in 6 months)
☐ Resistant or atypical culture result
☐ Immunosuppressed / complex comorbidity
☐ Suspected urological cancer (e.g. persistent haematuria)
☐ Treatment failure ≥48h post-antibiotics

Practice Notes

❌ Do not treat asymptomatic bacteriuria in catheterized patients
✅ Replace catheter prior to antibiotics if possible
❌ Do not change long-term catheters routinely
❌ Avoid prophylactic antibiotics unless advised by urology
✅ Reassess catheter need regularly

💊 Antibiotic Choices – non-pregnant women and men aged 16 years and over

🧪 Clinical Context	Antibiotic	Dosage & Duration	Key Notes / Cautions
💊 Lower UTI symptoms (no systemic features)	Nitrofurantoin	100 mg MR BD (or 50 mg QDS) × 7 days	eGFR ≥45 mL/min (use ↓ caution if 30–44). Not for blocked catheters.
	Trimethoprim	200 mg BD × 7 days	Use only if low resistance risk ↑. Avoid if recent use or care home resident.
	Amoxicillin	500 mg TDS × 7 days	Only if urine culture confirms susceptibility.
	Pivmecillinam (Second-line)	400 mg stat, then 200 mg TDS × 7 days	Not for upper UTI or blocked catheter. Narrow-spectrum alternative.
🧨 Upper UTI symptoms (fever, flank pain, systemic signs)	Cefalexin	500 mg BD–TDS (↑ to 1–1.5 g QDS if severe) × 7–10 days	First-line oral for systemic UTI if tolerated.
	Co-amoxiclav	500/125 mg TDS × 7–10 days	Only if culture confirms susceptibility.
	Trimethoprim	200 mg BD × 14 days	Only if culture confirms susceptibility.
	Ciprofloxacin	500 mg BD × 7 days	↑ Reserved for cases where others unsuitable (MHRA warning).
💉 Severe/systemic infection (unable to take oral)	Co-amoxiclav IV	1.2 g TDS	Use in combination if needed. Confirm susceptibility.
	Cefuroxime IV	750 mg – 1.5 g TDS–QDS	Broad-spectrum; consider step-down after 48h.
	Ceftriaxone IV	1–2 g OD	Once-daily dosing preferred if IV access limited.
	Gentamicin IV	5–7 mg/kg OD	Requires TDM ↑; monitor renal function.
	Amikacin IV	15 mg/kg OD (max 1.5 g/dose)	TDM required. Max 15 g total/course.
	Ciprofloxacin IV	400 mg BD–TDS	Use only if others contraindicated (↑ MHRA restrictions).

Additional Considerations

Differential Diagnosis for Haematuria: In catheterized elderly males, haematuria may result from trauma, CAUTI, urolithiasis, or malignancy. A thorough history, including catheter duration, frequency of changes, and infection history, is critical. Urine cytology or culture may aid in distinguishing infection from other causes, though cytology has limited sensitivity for SCC.
Research Gap: The absence of routine surveillance for bladder cancer in catheterized patients is a recognized issue. Some studies suggest periodic cystoscopy for high-risk groups (e.g., spinal cord injury patients), but no UK consensus exists for elderly males with catheters.
Source: Welk, B., et al. (2013). The risk of bladder cancer in patients with spinal cord injury. The Journal of Urology, 190(6), 2134–2139. https://doi.org/10.1016/j.juro.2013.06.008
Primary Care Challenges: Differentiating catheter-related irritation from malignancy is complex, as symptoms overlap. Training on NG12 application and awareness of SCC risk in long-term catheter users can improve referral accuracy.

Treat any NG12 red flag (especially visible haematuria) in catheterised patients with the same urgency as in other patients. There is no automatic USC referral or imaging based solely on catheter duration, but long-term catheter use should lower your threshold for suspicion of bladder SCC. Ensure meticulous catheter care to limit CAUTI while remaining alert to signs that merit swift cancer referral.

Feneley, R. C., Hopley, I. B., & Wells, P. N. (2015). Urinary catheters: history, current status, adverse events and research agenda. Journal of Medical Engineering & Technology, 39(7), 459–470. https://doi.org/10.3109/03091902.2015.1085600
Nicolle, L. E. (2014). Catheter associated urinary tract infections. Antimicrobial Resistance and Infection Control, 3, 23. https://doi.org/10.1186/2047-2994-3-23

https://www.nice.org.uk/guidance/ng113/resources/visual-summary-pdf-6599495053