Urinary Catheterisation Prophylaxis in Adults - Guideline for Antimicrobial Prophylaxis

Publication: 30/11/2010  
Last review: 26/04/2019  
Next review: 26/04/2022  
Clinical Guideline
CURRENT 
ID: 1878 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2019  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guideline for antimicrobial prophylaxis during urinary catheterisation in adults: inpatient guidance

Summary
Urinary Catheterisation Prophylaxis in Adults

Procedure

Prophylaxis recommended?

Evidence level

Prophylaxis-aims to reduce

Antimicrobial dose/route.
Give IV/IM agents <1 hour prior to catheter manipulation

A. All catheter insertions/change/removal

i) In patients with endocarditis risk factors

NO. But follow this guideline for other indications.

C 1 2

-

-

ii) In patients with established prosthetic joints, vascular grafts and other medical implants

NO. As above. See also B(v) for recent joint surgery in previous 6 weeks.

D

-

-

B. Short term catheterisation (<28 days)3

i) insertion for painful (acute) urinary retention

NO. But follow UTI guideline if symptomatic.

B

-

-

ii) insertion for painless (chronic) urinary retention

YES (send CSU after catheterisation and treat if confirmed UTI)

D

Bacteraemia

*Gentamicin 1.5mg/kg IV/IM single dose

iii) insertion pre-operation

NO. But catheterise after any routine surgical antimicrobial prophylaxis has been given

B

-

-

iv) insertion for fluid monitoring, incontinence

NO

B

-

-

v) insertion or removal <6 weeks post joint replacement

YES

D

Prosthesis infection

*Gentamicin 1.5mg/kg IV/IM single dose

vi) removal- post prostatic surgery

YES

D

UTI, bacteraemia

*Gentamicin 1.5mg/kg IV/IM single dose

vii) removal- all other indications

NO. Unless Staphylococcus aureus (including MRSA) has been cultured from urine or meatus at any time in the preceding 12 months.

D

Bacteraemia

*Gentamicin 1.5mg/kg IV/IM single dose

C. Long term catheterisation (≥28 days)3

i) First time insertion

NO

B

-

-

ii) Suprapubic catheter insertion

NO

D

-

-

iii) catheter change/removal

If the patient is symptomatic for CA-UTI refer to that guideline

Antimicrobial prophylaxis should only be given following risk assessment.

Risk factors that necessitate prophylaxis are any of the following:

  • Discharge at exit site/meatus [Evidence level B] and/or previous MSSA/MRSA cultured from this site in the last 12 months [Evidence level D]
  • If multiple or traumatic attempts at catheterisation have occurred**
  • Infection associated with previous catheter change

The following represent less well defined risk and prophylaxis may be indicated, particularly if multiple factors are present:

  • Male >75 years [Evidence level D]
  • Multiple co-morbidities, including residence in a care/nursing home [Evidence level B/D]
  • Severe immunosuppression ***  [Evidence level B]
  • Abnormal renal tract [Evidence level B]

For more details please see main text.

B3 D

Bacteraemia

*Gentamicin 1.5mg/kg IV/IM single dose

CSU, catheter specimen of urine; UTI, urinary tract infection;
*depending on susceptibility and vascular access – please check previous results for resistance and, if required, call microbiology.
**if catheterisation has failed at the first attempt, prophylaxis should be given prior to the next attempt.  If prophylaxis was not indicated prior to catheterisation and then then it is noted to have been traumatic, it would be pragmatic to give the ‘prophylaxis’ dose immediately after catheterisation.
*** Defined here as primary or acquired immunodeficiency or  current or recent treatment with immunosuppressive therapy, as taken from Chapter 6 of ‘The Green Book: Immunisation against infectious disease’

Introduction

The aim of this guideline is to standardise the use of antimicrobial prophylaxis for urinary bladder catheterisation.

A review of antimicrobial prophylaxis recommendations for urinary bladder catheterisation in Leeds has been prompted by:

  • a general lack of clarity in the organisation about the need (or not) for antimicrobials in this situation and a desire for a standardised approach;
  • root cause analysis (RCA) identifying urinary catheterisation as a root cause of meticillin-resistant Staphylococcus aureus (MRSA) bacteraemia;
  • ongoing problems with Clostridium difficile infection in the Trust;
  • publication of endocarditis prophylaxis guidelines by NICE.

Urinary tract infections (UTI) have previously been reported to account for about 40% of hospital-acquired (nosocomial) infections (HAIs), and about 80% of urinary tract infections acquired in hospital are associated with urinary catheters 4 5. More recent studies have found UTIs to account for 19-24.5% of HAIs6,7.

5.7-9% of hospital-acquired bacteraemias are caused by urinary catheter-associated urinary tract infections (CA-UTI) 8 and attributable mortality has been reported to be 12.7% 9. Relative to the number of catheters inserted, secondary bacteraemia is an uncommon complication occurring in <4% of patients with urinary catheter-associated bacteriuria 10.

Insertion of urethral catheters is a very common procedure, carried out in 11% of inpatients in one European study 11 and has a variety of indications including: peri-operative urine collection, management of urinary incontinence/retention and to measure urine output in acutely unwell patients.

Many factors have been associated with catheter-associated urinary tract infections and there are multiple approaches to reducing these infections but these guidelines are solely concerned with systemic antimicrobial prophylaxis.

Where the recommendations in these guidelines do not seem appropriate for a particular patient, discussion of the patient with a Microbiologist is advised.

In this guideline, the term catheter manipulation refers to either insertion, removal or change of a urinary catheter. This guideline does not cover patients who intermittently self catheterise.

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Background

There are relatively few studies of prophylaxis for routine catheter insertion. Most are not powered to detect any statistically significant difference in the rates of infection.  A recent Cochrane review only found one study regarding antimicrobial use at catheter changes, and this was underpowered to offer statistically significant result, and predominately looked for catheter colonisation rather than a diagnosis of catheter-associated UTI12. These Leeds guidelines draw on national guidelines where available, a review of available evidence for specific areas of concern/controversy and local consensus.

There is considerable variation in the practise of prophylaxis for urethral catheter insertion in the UK 13. Practise in the UK varies with patient group and between healthcare professionals 14. Gentamicin is commonly used for insertion, change and removal; without a clear evidence base 13. The European Association of Urology guidelines on urological infection have recently recommended against antimicrobial prophylaxis for urinary catheter insertions 15.

Because urinary catheters are used in many different settings with different risks, a blanket approach to systemic antimicrobial prophylaxis would result in many patients receiving antimicrobials unnecessarily. These guidelines therefore deal with the common situations separately. Where a situation is not covered by the guideline or clinical circumstances require a different approach, discussion with Microbiology is recommended.

As a general principle, the risk of bacteraemia associated with catheterisation depends on prior urine colonisation or infection 16.

Recommendation: Patients with urinary tract infections (UTI) who require catheter insertion should be started on antimicrobial treatment prior to catheterisation wherever possible. Follow Guidelines for the diagnosis and treatment of UTI.
[Evidence level D]

Recommendation: Uncatheterised patients known to have asymptomatic bacteriuria who require catheter insertion should be given a dose of antimicrobial prophylaxis prior to catheterisation according to susceptibilities of the urinary isolate.
[Evidence level D]

Recommendation: Catheterised patients with urinary tract infections should be commenced on empirical treatment prior to catheter changes. Guidelines for the diagnosis and treatment of UTI.
[Evidence level D]

Part A. Endocarditis, joint prostheses and other medical implants.

  • Recommendation: Routine use of antimicrobial prophylaxis for urinary catheter insertion/change/removal solely for the prevention of endocarditis is no longer recommended 2.
    [Evidence level C]

    Recent NICE guidelines (reviewed and updated in 2016) have recommended against routine endocarditis prophylaxis for urological procedures (including catheter insertion) but advised appropriate investigation and treatment of infections in patients at increased risk of endocarditis.
     
  • Recommendation: Routine use of antimicrobial prophylaxis for urinary catheter insertion/change/removal solely for the prevention of infection of established prosthetic joints and other medical implants is not recommended.
    [Evidence level D]

    Infections of established indwelling prostheses with urinary pathogens is a very rare complication of catheter withdrawal and does not justify the risks associated with routine prophylaxis 17, 18.

Part B Short term urinary catheters

  • Recommendation: Routine antimicrobial prophylaxis is not recommended for insertion of urinary catheters in patients with acute painful urinary retention.
    [Evidence level B]

    Acute painful urinary retention is not usually associated with urinary tract infection therefore prophylaxis is not advised. One evidence-based review concluded that prophylaxis could not be recommended for this scenario 19

    A urine sample should be routinely collected for culture at the time of catheter insertion (clearly labelled as such), any UTI, if confirmed should be treated according to LTHT guidelines.

  • Recommendation: Routine antimicrobial prophylaxis is recommended for insertion of urinary catheters in patients with chronic painless urinary retention.
    [Evidence level D]

    Chronic painless urinary retention is associated with urinary tract infection in a high proportion of cases. Therefore antimicrobial prophylaxis is advised for catheter insertion in this setting. A urine sample should then be collected for culture after catheterisation and empirical treatment commenced for urinary tract infection if clinically appropriate.

    Recommendation: A urine sample should be routinely collected for culture at the time of catheter insertion; UTI, if confirmed, should be treated according to LTHT guidelines.

    [Evidence level B]

  • Recommendation: Routine antimicrobial prophylaxis is not recommended for insertion of short term urinary catheters pre-operatively.
    [Evidence level B]

    A Cochrane review concluded that evidence for prophylactic antibiotics reducing the rate of bacteriuria and signs of infection in patients with short term catheters is weak 5. In a small placebo controlled trial of ciprofloxacin prophylaxis for removal of short term urethral catheters, there was no significant difference in rates of UTI between groups and ciprofloxacin resistance was common among the causes of post-removal UTIs 20. A cost effectiveness analysis did not recommend routine use of antimicrobial prophylaxis 21

    Many procedures requiring urinary catheter insertion will also require antimicrobial prophylaxis for surgical site infection. It is a pragmatic recommendation that urinary catheters should be inserted after routine per-operative prophylaxis has been given because there is a small risk of bacteriuria at the time of any catheter insertion and Gram negative bacteria are a well recognised cause of surgical site infection.

N.B Early work on urological procedures revealed that bacteraemia rarely occurred when pre-operative urine was sterile.

N.B. Currently antimicrobial prophylaxis for caesarean section is given after delivery of the baby. It is therefore not possible to follow the recommendation herein to give routine surgical prophylaxis prior to catheter insertion. This may change when prophylaxis for this indication is reviewed.

  • Recommendation: Routine antimicrobial prophylaxis is not recommended for insertion of short term urinary catheters for fluid monitoring or incontinence management.
    [Evidence level B]

    A Cochrane review concluded that evidence for prophylactic antibiotics reducing the rate of bacteriuria and signs of infection in patients with short term catheters is weak 5.

  • Recommendation: Routine prophylaxis is recommended for insertion or removal of urinary catheters in the six weeks after joint replacement surgery.
    [Evidence level D]

    Gram negative bacilli are a well recognised cause of early prosthetic joint infection (PJI) but a rare cause of late infections. Although, the urinary tract is a potential source of these early Gram negative infections 22 a large case control study of risk factors for PJI did not find a significant difference in either pre-operative pyuria or bacteriuria or post operative nosocomial urinary tract infection between 462 cases and matched controls 23. There is, however, a local consensus among orthopaedic surgeons that Gentamicin should be given for catheter insertion, change or manipulation during the early post-operative phase. To be consistent with Leeds early prosthetic joint infection guidelines, the early post operative phase is (arbitrarily) defined as up to six weeks post operation.

  • Recommendation: Routine prophylaxis is recommended for catheter removal post prostatic surgery.

    In addition to single dose antimicrobial prophylaxis for prostatic surgery it has been argued that prophylaxis should be given to cover urethral catheter removal because of the long established risk of bacteraemia.
    [Evidence level D]

  • Recommendation: Prophylaxis is NOT recommended for catheter removal for all other indications EXCEPT where Staphylococcus aureus (including MRSA) has been cultured from urine or meatus at any time in the preceding 12 months.
    [Evidence level D]
    The is no evidence to support the use of prophylactic antimicrobials for catheter removal but catheter removal appears to be a risk factor for Staphylococcus aureus bacteraemia (including MRSA: LTHT root cause analyses) in patients with urine known to be colonised with Staphylococcus aureus. The pragmatic recommendation is to offer prophylaxis in this situation. (see also long term catheterisation section for rationale).

Part C Long term indwelling urinary catheters.

  • Recommendation: Antimicrobial prophylaxis is not recommended at the time of initial insertion of long term indwelling urinary catheters, provided there is NO clinical urinary tract infection OR known asymptomatic bacteriuria at the time of insertion (from previous urine samples).
    [Evidence level B]

    Long-term urinary catheters inevitably become colonised with bacteria regardless of antimicrobial prophylaxis at the time of insertion so prophylaxis offers no benefit. 21 24.

  • Recommendation: Antimicrobial prophylaxis is not recommended at the time of suprapubic urinary catheter insertion, provided there is no urinary tract infection at the time of insertion.
    [Evidence level D]

  • Recommendation: Antimicrobial prophylaxis is not recommended at the time of all routine catheter changes, except in the following at risk groups:
    • Discharge at exit site/meatus [Evidence level B] and/or previous MSSA/MRSA cultured from this site in the last 12 months [Evidence level D]
    • If multiple or traumatic attempts at catheterisation have occurred**
    • Infection associated with previous catheter change
  • The following represent less well defined risk and prophylaxis may be indicated, particularly if multiple factors are present:
    • Male >75 years [Evidence level D]
    • Multiple co-morbidities, including residence in a care/nursing home [Evidence level B/D]
    • Severe immunosuppression (defined here as primary or acquired immunodeficiency or recent or current treatment with immunosuppressive therapy*) [Evidence level B]
    • Abnormal renal tract [Evidence level B]

* Taken from ‘The Green Book: Immunisation against infectious disease’
chapter 6 “contraindications and special considerations”

A recent Cochrane review only found one study regarding antimicrobial use at catheter changes, and this was underpowered to offer statistically significant results, and predominately looked for catheter colonisation rather than a diagnosis of catheter-associated UTI12.  Therefore Cochrane states that there is not enough evidence to say whether the use of antibiotics at the time of catheter change to prevent infection is effective12.  NICE guidelines recommend that prophylaxis is not required for routine changes of indwelling urethral catheters on the basis of low rates of infective complications coupled with a lack of evidence that prophylaxis is effective3, 12, except where patients have a history of symptomatic urinary tract infection after a catheter change, or where they experience trauma during the procedure (frank haematuria or 2 or more attempts of catheterisation)25.
There is a high likelihood of development of resistance associated with prophylaxis strategies as illustrated by a study comparing Norfloxacin Description: electronic Medicines Compendium information on Norfloxacin and placebo in elderly nursing home patients with indwelling urethral catheters 26. Although a significant reduction of catheter-associated UTI was demonstrated, 25% of strains in placebo patients compared with 90% of strains in Norfloxacin Description: electronic Medicines Compendium information on Norfloxacin patients were resistant to Norfloxacin Description: electronic Medicines Compendium information on Norfloxacin at the end of the prophylaxis period, highlighting that any benefit of prophylaxis is short-lived 26.
A  2015 case control study identified male sex, urinary tract abnormalities and recent hospital admission (prior 3 months) as statistically significant risk factors for catheter associated blood stream infections; multi-variate analysis further identified age-adjusted Charlson comorbidity index and chronic kidney disease, the latter of which is consistent with previous studies27.  A 2017 case control study addressing risk factors for bacteraemia in patients with catheter-associated bacteriuria identified male sex, treatment with immunosuppressants and urinary tract procedures as independent risk factors in patients with short term catheters.   Continued presence of a catheter after identification of catheter-associated-bacteruria (definition based on American CDC/National Healthcare Safety network) was also associated with an increased risk of bacteraemia28
We recommend a risk assessment is undertaken based on the above findings and previous history of infections with catheter changes and local examination findings and urine or meatal culture results. If a patient meets any of the following criteria then prophylaxis is recommended as per the summary table.  These risk factors are based on case control study evidence and local expert consensus.  Urinary procedure prophylaxis is addressed in a separate guideline. It has been proposed that the pathogenesis of catheter-associated UTI differs between Gram positive (staphylococci and enterococci) and Gram negative urinary pathogens, the former being far more likely to be extraluminally acquired 29 though this study had methodological flaws. Whether this relates to an increased risk of bacteraemia with Gram positive pathogens on catheter removal is not known.
The choice of antimicrobial agent for prophylaxis is based on spectrum of activity and renal excretion. Gentamicin has a broad anti gram negative activity but also has effective antistaphylococcal activity. It is excreted primarily in the urine, has a low propensity to cause Clostridium diffiicle infection or MRSA colonisation and is therefore an ideal agent for prophylaxis of UTI during catheter manipulation. The down-sides to use of Gentamicin are the requirement for parenteral administration and a small risk of nephrotoxicity (with single doses). Following IM administration of Gentamicin peak serum levels are achieved between 30 and 90 minutes, and for IV administration between 30 and 60 minutes following the end of the infusion.  Therefore, ideally the gentamicin dose would be given 30 minutes prior to catheterisation; practically this timeframe will be approximately achieved by administering the dose and then undertaking the preparation of the patient and equipment for aseptic technique insertion.
In previous versions of this guidance doxycycline was offered as an alternative to gentamicin in patients where this was contra-indicated.  It has been removed as its local activity against gram negative organisms is not known as it is not routinely tested on urine isolates, and therefore it could only be advocated for prophylaxis in patients whose only indication was MSSA/MRSA at the meatus/in the urine that was shown to be sensitive.  This is a small group and they are likely to also have gram negative risk factors, therefore an alternative to doxycycline would be preferable.  It is local experience that gentamicin is the most commonly used option for catheterisation prophylaxis and therefore it is now offered as the only option in this guidance.  If the patient is known to have resistant organisms or have another reason that gentamicin cannot be administered, please contact Microbiology to discuss a suitable alternative.

Part D Urinary tract infection.

  • Urinary catheters involved in urinary tract infection may need removal: see UTI guideline.

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Provenance

Record: 1878
Objective: To standardise the approach to antimicrobial prophylaxis for urinary catheter manipulation in Leeds.
Clinical condition:
Target patient group: Any patient undergoing manipulation (insertion/change/removal) of a urinary catheter
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Pharmacists
Adapted from:

Evidence base

References

  1. Gould FK, Elliott TS, Foweraker J, Fulford M, Perry JD, Roberts GJ, et al. Guidelines for the prevention of endocarditis: report of the Working Party of the British Society for Antimicrobial Chemotherapy. J Antimicrob Chemother 2006;57(6):1035-42.
  2. NICE. Prophylaxis against infective endocarditis: antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures. NICE clinical guideline 64: National Institue for Health and Clinical Excellence, 2008. Updated 2015
  3. NICE. Infection Control clinical guideline 02: National Institute for Health and Clinical Excellence, 2008.
  4. Meares EM, Jr. Current patterns in nosocomial urinary tract infections. Urology 1991;37(3 Suppl):9-12.
  5. Niel-Weise BS, van den Broek PJ. Antibiotic policies for short-term catheter bladder drainage in adults. Cochrane database of systematic reviews (Online) 2005(3):CD005428.
  6. Summary: Point prevalence survey of healthcare-associated infections and antimicrobial use in European hospitals 2011–2012 https://ecdc.europa.eu/sites/portal/files/media/en/healthtopics/Healthcare-associated_infections/point-prevalence-survey/Documents/healthcare-associated-infections-antimicrobial-use-PPS-summary.pdf
  7. National Point Prevalence Survey of Healthcare Associated Infection and Antimicrobial Prescribing 2016, NHS, National Services Scotland http://www.hps.scot.nhs.uk/resourcedocument.aspx?id=5964
  8. Anon. Surveillance of hospital acquired bacteraemia in English hospitals 1997-1999. London: Public Health Laboratory Service (PHLS), 2000:1-11.
  9. Bryan CS, Reynolds KL. Hospital-acquired bacteremic urinary tract infection: epidemiology and outcome. J Urol 1984;132(3):494-8.
  10. Krieger JN, Kaiser DL, Wenzel RP. Urinary tract etiology of bloodstream infections in hospitalized patients. J Infect Dis 1983;148(1):57-62.
  11. Stickler DJ, Zimakoff J. Complications of urinary tract infections associated with devices used for long-term bladder management. The Journal of hospital infection 1994;28(3):177-94.
  12. Cooper FPM, Alexander CE, Sinha S, Omar MI. Policies for replacing long-term indwelling urinary catheters in adults (Review). Cochrane database of systematic reviews 2016, Issue 7. Art No.: CD011115.
  13. Fraczyk L, Godfrey H. Current practice of antibiotic prophylaxis for catheter procedures. Br J Nurs 2004;13(10):610-7.
  14. Wazait HD, van der Meullen J, Patel HR, Brown CT, Gadgil S, Miller RA, et al. Antibiotics on urethral catheter withdrawal: a hit and miss affair. J Hosp Infect 2004;58(4):297-302.
  15. Grabe M, Bishop MC, Bjerklund-Johansen TE, Botto H, Çek M, Lobel B, et al. Guidelines on urological infections.: European Association of Urology, 2009, updated 2015
  16. Ibrahim AI. Hospital acquired pre-prostatectomy bacteriuria: risk factors and implications. East Afr Med J 1996;73(2):107-10.
  17. Polastri F, Auckenthaler R, Loew F, Michel JP, Lew DP. Absence of significant bacteremia during urinary catheter manipulation in patients with chronic indwelling catheters. J Am Geriatr Soc 1990;38(11):1203-8.
  18. Bregenzer T, Frei R, Widmer AF, Seiler W, Probst W, Mattarelli G, et al. Low risk of bacteremia during catheter replacement in patients with long-term urinary catheters. Arch Intern Med 1997;157(5):521-5.
  19. Garnham F, Smith C, Williams S. Best evidence topic report. Prophylactic antibiotics in urinary catheterisation to prevent infection. Emerg Med J 2006;23(8):649.
  20. Wazait HD, Patel HR, van der Meulen JH, Ghei M, Al-Buheissi S, Kelsey M, et al. A pilot randomized double-blind placebo-controlled trial on the use of antibiotics on urinary catheter removal to reduce the rate of urinary tract infection: the pitfalls of ciprofloxacin. BJU Int 2004;94(7):1048-50.
  21. Platt R, Polk BF, Murdock B, Rosner B. Prevention of catheter-associated urinary tract infection: a cost-benefit analysis. Infect Control Hosp Epidemiol 1989;10(2):60-4.
  22. Wroblewski BM, del Sel HJ. Urethral instrumentation and deep sepsis in total hip replacement. Clin Orthop Relat Res 1980(146):209-12.
  23. Berbari EF, Hanssen AD, Duffy MC, Steckelberg JM, Ilstrup DM, Harmsen WS, et al. Risk factors for prosthetic joint infection: case-control study. Clin Infect Dis 1998;27(5):1247-54.
  24. Saint S, Lipsky BA. Preventing catheter-related bacteriuria: should we? Can we? How? Arch Intern Med 1999;159(8):800-8.
  25. Healthcare-associated infections: prevention and control in primary and community care. Clinical guideline [CG139] Published date: March 2012 Last updated: February 2017 https://www.nice.org.uk/guidance/cg139/evidence/appendix-a-summary-of-new-evidence-pdf-4355390702
  26. Rutschmann OT, Zwahlen A. Use of norfloxacin for prevention of symptomatic urinary tract infection in chronically catheterized patients. Eur J Clin Microbiol Infect Dis 1995;14(5):441-4.
  27. Bursle EC, Dyer J, Looke DFM, MacDougall DAJ, Paterson DL & Playford EG.  Risk factors for urinary cathether associated bloodstream infection. Journal of infection (2015) 70, 585-591
  28. Conway LJ, Liu J, Harris AD & Larson EL. Risk factors for bacteraemia in patients with urinary catheter-associated bacteriuria. American Journal of Critical Care Jan 2017, Vol 26, No 1 (43-52).
  29. Tambyah PA, Halvorson KT, Maki DG. A prospective study of pathogenesis of catheter-associated urinary tract infections. Mayo Clin Proc 1999;74(2):131-6.
  30. Ashley C, Currie A. The renal drug handbook. 2nd ed: Radcliffe Medical Press Ltd., 2004.
  31. The Green Book: Immunisation against infectious disease.  Public Health Englnad, Published 17 December 2013.  Chapter 6, last updated August 2017.  Last accessed online on 25/4/2019 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/655225/Greenbook_chapter_6.pdf

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 1.0

Related information

2018 Peer Review

Comment: Should the comment regarding previous resistance to prophylactic agents be added to the short term catheter table also?
Response: Amendment to tables to have asterixed comment regarding previous susceptibility to all instances of antibiotics.

Comment: Question regarding use of doxycycline as a suitable agent for preventing gram negative infections
Response: Following further discussion with colleagues it is apparent that doxycycline is a rarely used alternative as it is impracticable time-wise compared to gentamicin, and whilst it has reasonable anti-staphylococcal activity, the local resistance rates for gram negatives are not known as it is not routinely tested.  As such doxycycline has been removed from the guideline.

Comment: Consideration that multiple or traumatic catheterisation (attempts) and also those with known asymptomatic bacteriuria (positive urine result with no symptoms) to be included as indications for prophylaxis
Response: Many of these patients may be covered by indications already listed already, such as by age, but that it is reasonable to add them specifically for those who may fall out-with the listed categories.  Indications added.

Comment: Suggested removal of the table row regarding infective endocarditis as the text below is deemed sufficient
Response: Table row left in situ as the tables are used for quick reference and the full text is not always viewed; the mention in the table would often be the prompt to view specific text portions.

Comment: Request to give timing for catheter insertion after gentamicin administration.
Response: Already included in the table as <1hr; more detail added to the text regarding peak serum concentrations.

Comment: To add information about doxycycline being unlicensed for this indication.
Response: No longer relevant as doxycycline removed from the guideline.

Following peer review there was further discussion regarding the indications for prophylaxis for the change or removal of long term catheters.  The final text represents a local consensus on risk factors.

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