RECURRENT URINARY TRACT INFECTIONS IN OLDER ADULTS WITH LONG-TERM INDWELLING URETHRAL CATHETERS: AN INTEGRATIVE REVIEW

Abstract

Background: Long term indwelling urethral (foley) catheterisation is often used in older adults who are frail, have neurogenic bladder, chronic urinary retention, non-healing sacral wounds or for end of life comfort. It is the single most important risk factor for recurrent catheter associated urinary tract infections (CAUTI) in this patient group.

Outcomes: To synthesize up-to-date, evidence-based information regarding the epidemiology, pathophysiology, diagnosis, treatment and most importantly, prevention of recurrent CAUTI in older adults with an indwelling permanent catheter, and to provide a clinical framework for clinicians, nurses and LTC teams.

Methods: An integrative review was conducted, which included evidence from randomised trials, systematic reviews, large cohort of older adults with an indwelling urinary catheter (IUC), and society guidance from 2020 to 2026 from PubMed, The Cochrane Library, and targeted searches within PubMed and selected journals for catheter-associated urinary tract infection (CA-UTI), indwelling catheter, older adults, asymptomatic bacteriuria (ABU), biofilm, encrustation, and methenamine.

Results: Most patients with a permanent catheter will develop “bacteriuria” within a few weeks and the central clinical question is whether they have asymptomatic bacteriuria (which should not be treated) or true symptomatic infection (which in cognitively impaired or non-verbal older adults may be presented by failure to have dysuria or fever, but rather by sudden delirium, new incontinence, or sudden loss of function). Crystalline biofilms formed by Proteus mirabilis, catheter encrustation and blockage are important factors that contribute to recurrent infection, in addition to antibiotic failure. Resistance risk should be considered when using antibiotic prophylaxis in continuous use; the latter is used as a last resort in selected patients; non-antibiotic prophylaxis, e.g. methenamine hippurate, should be used in lieu of antibiotic use, and structured catheter-care bundles, individualised (not fixed-interval) catheter change schedules, and diagnostic stewardship (to avoid unnecessary antibiotic exposure for asymptomatic bacteriuria) should be used for prevention.

Conclusion: Recurrent CAUTI in the permanently catheterised older adult should be treated as a chronic problem involving the biofilm related to the device, not a string of individual infections. Stewardship, not necessarily a multidisciplinary approach focused on prevention, decreases the amount of unnecessary antibiotic use and ensures patients are kept safe from true complications of blockage, pyelonephritis, and urosepsis.

Keywords: Catheter-Associated Urinary Tract Infection; Indwelling Urinary Catheter; Older Adults; Asymptomatic Bacteriuria; Biofilm; Methenamine Hippurate; Antimicrobial Stewardship; Geriatrics; Integrative Review