The most important strategy for reducing the risk of CA-UTI is to minimize the inappropriate use of urinary catheters. Indwelling urinary catheters should only be placed for acceptable indications and they should be removed as soon as they are no longer necessary.41 Urinary catheters should be placed using aseptic technique and sterile equipment.41 A closed catheter drainage system should be used and the drainage bag and connecting tube should always be kept below the level of the bladder; disconnection of the catheter junction should be minimized.41, 45 Prophylaxis with systemic antimicrobials and catheter irrigation with antimicrobials are not recommended, and addition of antimicrobials or antiseptics to the drainage bag should be avoided.41 Daily meatal cleansing with povidone-iodine solution, silver sulfadiazine, or antibiotic creams is not recommended.41
A 49-year-old woman with severe osteoarthritis of the knees underwent a right total knee joint replacement. On hospital day 2, she developed fever with a temperature of 38.2°C (100.8°F). Urinalysis performed on a catheterized urine specimen showed 10 to 25 leukocytes per high-power field. She was presumptively diagnosed with CA-UTI and was given empiric oral ciprofloxacin, although a urine culture that was obtained prior to starting antibiotic therapy subsequently showed no growth. She did not have further fever. Ciprofloxacin was discontinued after the urine culture result returned, although she received a total of 3 days of antibiotic therapy. She was discharged to an acute rehabilitation facility on hospital day 5.
Four days later, she developed watery diarrhea. The following day, she developed fever with a temperature of 38.3°C (101°F), profuse diarrhea (> 10 watery bowel movements), severe abdominal pain, and altered mental status. A stool enzyme immunoassay for C difficile toxin A/B was positive. She was started on oral metronidazole and was admitted to the intensive care unit. She had a temperature of 38.8°C (101.8°F), blood pressure of 79/45 mm Hg, and heart rate of 118 bpm. She required 5 L of intravenous fluids. The peripheral blood leukocyte count was 25,500 cells/mm3, with 34% band forms. The serum creatinine was elevated at 2.5 mg/dL. Computed tomography of the abdomen and pelvis showed extensive thickening of the wall of the ascending colon with pericolonic infiltration, and thickening of the transverse, descending, and sigmoid colon as well (Figure 50-5). There was no free intraperitoneal air, bowel wall pneumatosis, or toxic megacolon.