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Difficulty: MediumUrologic Surgery

A 65-year-old man is evaluated on postoperative day 4 following a robotic-assisted laparoscopic radical prostatectomy for localized prostate adenocarcinoma. A urethral catheter was left in place at the end of the procedure. On postoperative day 2, he developed a fever of 38.8°C (101.8°F), chills, and suprapubic discomfort. Blood and urine cultures were obtained, and empiric intravenous piperacillin-tazobactam was initiated. Today, the patient is afebrile, and his vital signs are within normal limits. He reports complete resolution of his chills and suprapubic pain. The abdomen is soft and non-tender, and the urethral catheter is draining clear yellow urine. The blood cultures show no growth. The urine culture from postoperative day 2 returns with the following results:

Organism>100,000 CFU/mL *Escherichia coli*
AntibioticSusceptibility
AmpicillinResistant
Piperacillin-tazobactamSusceptible
CefazolinSusceptible
CeftriaxoneSusceptible
Trimethoprim-sulfamethoxazoleSusceptible
CiprofloxacinResistant

Which of the following is the most appropriate next step in management?

  1. Transition to a targeted antibiotic and leave the urethral catheter in placeAnswer
  2. B
    Continue intravenous piperacillin-tazobactam and leave the urethral catheter in place
  3. C
    Remove the urethral catheter immediately to eradicate the infectious source
  4. D
    Obtain a computed tomography scan of the abdomen and pelvis
  5. E
    Perform a retrograde cystogram to evaluate for an anastomotic leak

Answer

Transition to a targeted antibiotic and leave the urethral catheter in place
The most appropriate next step is to transition the patient to a targeted antibiotic (such as cefazolin or ceftriaxone) and leave the urethral catheter in place. This patient developed a catheter-associated urinary tract infection (CAUTI) following a radical prostatectomy. While the general principle for managing a CAUTI involves removing or exchanging the infected catheter, doing so is strictly contraindicated in the early postoperative period (typically the first 1-2 weeks) following a radical prostatectomy. The catheter serves as a critical stent to allow the delicate vesicourethral anastomosis to heal. Premature removal can lead to acute urinary retention, anastomotic disruption, and urinary extravasation. If the patient goes into retention, blind placement of a new catheter carries a high risk of anastomotic perforation. Because the patient is clinically improving on empiric therapy, the next step is to adhere to antimicrobial stewardship principles and narrow the antibiotic coverage based on the culture susceptibilities.

Step-by-Step Solution

1
Interpret the clinical presentation and culture results.
The patient has a resolving CAUTI (fever, chills, E. coli >100,000 CFU/mL) on postoperative day 4 after a radical prostatectomy.
Establishing the current clinical status is essential to determine if the empiric treatment is working.
2
Evaluate the need for antibiotic modification.
The patient should be transitioned from broad-spectrum piperacillin-tazobactam to a narrower-spectrum agent (e.g., cefazolin or ceftriaxone).
Antimicrobial stewardship dictates de-escalation to targeted therapy once susceptibilities are known to prevent resistance.
3
Determine the appropriate management of the urinary catheter.
The catheter must be left in place despite being the likely source of the infection.
Following radical prostatectomy, the catheter stents the vesicourethral anastomosis. Early removal risks anastomotic disruption and severe complications.

Key Concept

Following radical prostatectomy, the urethral catheter must remain in place for 1-2 weeks to protect the vesicourethral anastomosis, even in the setting of a catheter-associated urinary tract infection (CAUTI). Appropriate management involves targeted antimicrobial therapy without early catheter removal.
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Urologic Surgery

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