The Fight Against UTIs Continues

A healthy person who contracts a urinary tract infection (UTI) certainly has reason to be upset, but when that person is already sick and contracts a UTI from a catheter, the risk and outrage compounds. Data on the estimated cost of catheter-associated UTIs (CAUTIs) varies,⁴ but it is confirmed that this illness is the most common noscomial infection.⁵

Any immune-compromised person is at a higher risk of developing a UTI, according to Margaret Tsai, MD, from University Hospitals of Cleveland/Case Western Reserve University. Immobilized, catheterized, or dehydrated older adults, and incontinent and demented nursing home residents, are also at very high risk, Tsai says. Approximately 40 percent of nursing residents will contract a urinary tract infection.

Short-term catheterization complications include fever, acute pyelonephritis, bacteremia and death, she adds, and long-term catheterization includes the above complications as well as catheter obstruction, urinary tract stones, local periurinary infections, chronic renal inflammation, chronic pyelonephritis, and, over years, bladder cancer.

As of late, emphasis is still focused on prevention of CAUTIs which includes eliminating unnecessary catheter use, catheter removal at the earliest opportunity, aseptic insertion, hand-washing, limiting unnecessary flushing, etc., Tsai says.

Overstaying a Welcome

Patients with long-term indwelling Foley catheters are more likely to become infected than patients who require intermittent bladder catheterization, according to Rabih Darouiche, MD, professor and director of the Center for Prostheses Infection in the Baylor College of Medicine in Houston, Texas. Darouiche is also founder of the Multidisciplinary Alliance Against Device-Related Infections (MADRI).

Catheters remaining longer than necessary is a problem, Darouiche and other experts believe.

It depends on the facility but I would say generally we have not been able to induce significant reduction in the rate of catheter-related UTI, Darouiche says. I would say the most important and the most amenable (aspect) to change is removal of indwelling catheters when no longer clinically indicated.

Keeping catheters in too long is a part of healthcare culture that needs to be changed, according to Tracey Siegel, RN, MSN, APN, CWOCN, of the Charles E. Gregory School of Nursing in Old Bridge, N.J. Theres a lot of patients getting catheters inserted routinely,

Siegel says. From my own perspective what I see is patients coming into the emergency room and if theres any chance that they want to monitor urinary output theyre putting catheters in immediately and then patients are being transferred to medical surgical units and things like that and nobody thinks to ask, Can we take the catheters out? It acts as a foreign body and every time we have something in the body thats foreign, the body wants to fight against it, Siegel adds.

Less is More

Not only are catheters sometimes kept in too long, they are used too often, according to Darouiche.

I think (that catheters are overused), for two reasons, he says. One is because they are inserted and are kept in for a longer period than they should without healthcare providers knowing they are in place. Second is because to start with they are inserted without a correct indication. In some units nurses may insert Foley catheters just because the patient is incontinent and that would allow them to better care for their hygiene in the pelvic area if they have an indwelling catheter than if they have diapers.

Siegel agrees that overuse abounds.

Theyre never really meant to be put in routinely, Siegel says. You really need an indication to have catheters and there have been studies that show that were using way too many catheters.

While nurses are a vital and prolific part of the healthcare system, they may be significant culprits when it comes to the overuse of urinary catheters, according to Siegel.

Nurses are the ones who put the catheters in, were the ones that monitor catheter usage, yet so many times for our own convenience its just easier when a patient has a catheter, she says. So many times were saying, Oh do we really have to take it out? Because then well have to get out a bedpan and get the patient to the bathroom. Its very convenient when you have a patient with a catheter.

The healthcare industry is working very hard to reduce all nosocomial infections, but there is a systems issue to contend with, Siegel says.

We forget who has the catheter, who put it in so I think that from a systems perspective we could always do more, she says. Staff nurses are the first line and they need to be much more aware of whats going on with their patients at the bedside. The technology is just so overwhelming in acute care today. Patients come in and theyre so sick. It sounds terrible but the (catheter) is just another piece of technology that (nurses) have to keep track of. It just gets forgotten about.

A good solution is to use external condom catheters more often, according to Siegel. (Theyre not used often enough) because theres always issues when placing them on, she says. You really need to be trained pretty well to get them on and get them to stay on. (Its) a great way to keep track of input and output of patients.

A Reminder System

A proper reminder system is an effective way to show which patients have catheters and for how long theyve had them. The system can be electronic, verbal, or on paper, and should be tailored to individual facilities, Siegel says. If we routinely say that, (for example) the catheter was put in on Feb. 20 and then we monitored it after that and say, Well, can we take it out, and talk about it in the morning report, then everybody would be aware. But I think a lot of times its put in, nobody puts the date, and nobody remembers when the catheter was inserted.

Theyve done chart reviews where patients have come to units with catheters and no one is even aware that they were put in the emergency room, she adds. We wouldnt be this blasé about IVs or other invasive things but (catheters) have become so routine that we are becoming blasé.

When determining whether a doctor, nurse, or other team member should spearhead a reminder system, the level of care should be strongly considered, according to Siegel. In acute care, of course the doctor should be aware but many times its the nurses who are the primary care givers, so my focus would really be on the registered nurses, the licensed practical nurses, Siegel says. Since most facilities are switching to an electronic medical records system, an electronic reminder system is likely best.

In long-term care youd have to get everyone involved because the nursing assistants are the ones doing hands-on care every day, she adds. In home care youd even want to get the families involved because many times a family can pick up on signs or symptoms that patients are having an infection. Theyre going to be looking at whether the urine is getting darker or cloudy, is the patient a little more confused? These are all things you want the family to be aware of, so you should do some teaching with them. There are patients who need long term catheters were never going to get away from that, so to me, youd want as many people educated as possible, to monitor the symptoms.

The Female Factor

One in nine American women have had at least one UTI and up to 60 percent of all women will develop a UTI at some time in their lives, Tsai says. Certain instances, of course, are catheter-related.

Changes after menopause, due to biologic factors, put older women at particular risk for primary and recurring UTIs, Tsai adds. Twenty 25 percent of women older than 65 have UTIs.

Causes for this increase, according to Tsai, include: Estrogen loss, which impairs immune function in the vagina, and results in E. coli adhering to vaginal cells; thinning urinary tract walls with weakening mucous membranes reduce the ability to resist bacteria; and decreased bladder elasticity which can prevent complete emptying Women often receive catheters during the labor process, and the insertion process is basically identical to standard catheter insertions, Darouiche says.

However, in that situation it would be very prudent to optimize what we can do to prevent catheter related UTI because the last complication you want to have is a catheter-related UTI that results in infection of epidural catheters which in turn can result in serious consequences including spinal cord compression and potential paralysis, he says.

Darouiche does not think there is particular protocol that is implemented to deal differently with bladder catheters in pregnant women with epidural catheters versus those who are not pregnant and do not have epidural catheters.

The way I look at it is this: I think we should attempt to prevent catheter related UTI in all patients regardless of their underlying disease and potential for developing infection in other bodily sites, he says. So in terms of implementation of basic infection control measures, they should be rather similar.

UTIs and the Elderly

In a study conducted at Summa Health System in Akron, Ohio, to which Margaret Tsai contributed, it was indicated that the strong association between indwelling urinary catheters (IUC) use and UTIs may be partly explained by the high prevalence of preexisting UTI prior to IUC placement. Further prospective studies are needed to clarify the true risk versus benefit ratio for IUC use in acutely ill elderly patients.

The use of indwelling urinary catheters (IUCs) is thought to be the most significant risk factor for developing nosocomial urinary tract infections (UTIs), the study continues. However, it is unclear how many elderly patients have preexisting bacteriuria prior to IUC placement.

Seventy three percent of patients who received an IUC were more than 65 years old. During the study period, 277 elderly patients received an IUC prior to admission.¹

Of these, 28 percent were diagnosed with a UTI during their hospitalization. Sixty nine percent of those diagnosed with a UTI by discharge either had the UTI diagnosed in the ED or had bacteriuria greater than 105 organisms/ ml prior to IUC placement, according to the study. Of the 24 elderly patients who developed a catheter-associated UTI, 11 of the IUCs were placed inappropriately. Thus, four percent of elderly patients with no indication of UTI on admission who received an inappropriate IUC in the ED had a primary or secondary diagnosis of UTI by discharge.

Device Details

Even effective inventions can be improved, but for the most part, the catheters and associated devices on the market are sufficient, Siegel says.

Theres not really a lot of new research as far as products to help fight UTIs, but if people follow the evidence-based guidelines that have been published and that are quite available from different organizations, then people should be able to manage catheters pretty well, Siegel adds.

According to a study from the Veterans Affairs Medical Center, in Houston, Texas, one securing device, the StatLock, may lead to a reduction of UTIs. The study was based on adult patients with spinal cord injury or dysfunction because of multiple sclerosis (who) were randomized to have their indwelling bladder catheters secured in place by using the StatLock device as opposed to the group that used preexisting methods such as CathSecure, tape and Velcro. Patients were monitored for the development of symptomatic UTI during an eight-week period.

Of 127 patients, 118 (60 in the experimental group and 58 in the control group) were evaluable. The two groups of evaluable patients were comparable in terms of clinical characteristics and risk factors for infection, the study continues. Symptomatic UTI was diagnosed in 8 of 60 (13.3 percent) patients in the experimental group versus 14 of 58 (24.1 percent) patients in the control group.² Although the trial size precluded the demonstration of statistically significant differences, the finding of a 45 percent reduction in the rate of symptomatic UTI in patients who received the StatLock securing device is clinically relevant and prompts further investigations, the researchers concluded.

Another device-related subject worthy of further study and that is a recent topic of debate, according to Tsai, (Is) the use of silver alloy coated urinary catheters and urinary catheters impregnated with the antibiotic combination of minocycline and rifampin.

Some studies report silicone urethral catheters coated with hydrogel and silver salts decreases the risk of developing bacteriuria versus standard latex urethral catheters (Foley catheters), she says. These catheters are coated with silver alloy (which are coated on both internal and external surfaces of the catheter), but not silver oxide (which are coated on the external catheter surface only).³ However, studies since the meta-analysis have shown mixed results on the benefits of silver alloy-coated urinary catheters and antimicrobial impregnated catheters, she adds.

Aseptic Technique

Even if a healthcare worker is using the best devices available, those tools are possibly lethal without proper sanitary care. This point cannot be overestimated, Siegel believes.

Really, with catheters, people are supposed to be washing their hands before they go near a catheter and then immediately after, which we know isnt occurring, she says. Infection control nurses are looking at that problem hospital-wide and nationwide in all levels of care because people just walk out of rooms and forget to wash their hands. We put hand gels in hallways and in peoples rooms but its a conscience effort to really make yourself remember to wash your hands. Its the simplest solution and the best solution to prevent nosocomial infections.

Even with short-term catheters theres always a risk but as long as the catheters are monitored and are being used in an aseptic manner, most patients tolerate them very well, Siegel says.

Catheters are starting to be replaced more often which is largely good but this change does call for more handwashing, etc.

We used to routinely change catheters every month in homecare and now weve decided that for some patients it may need to be much more frequent and for other patients less frequent, Siegel says. We have to really look at their habits. That monthly guide of changing catheters is really changing and becoming much more individualized.

Perineal care is a vital part of the equation, for bacteria from that area can contribute to UTIs.

We used to do a whole (perineal care) procedure when I was a new nurse, Siegel says. We had a really fancy catheter procedure, but what studies have found is that really soap and water is the best thing. You dont have to be really fancy, and you really want to be washing the patient after every bowel movement. Yes, perineal care is important.

Catheterized patients who develop diarrhea are nine times more likely to develop UTIs than are patients without diarrhea, according to Tsai. The shortness of the urethra, which is 1.5 inches in women compared to 8 inches in men (is the part of the problem), she says. Bacteria from fecal matter can be easily transferred to the vagina or the urethra.

In addition to keeping catheters and surrounding bodily areas clean, basic hydration and a vitamin C regimen are also advisable to ward off urinary tract infections, Siegel suggests.

I think we have everything we need to manage catheters at this point based upon the evidence that we have right now, Siegel says. Could things change tomorrow? Sure. New research could come out that could blow all of this out of the water.

References:

1. Hazelett SE. The association between indwelling urinary catheter use in the elderly and urinary tract infection in acute care. PubMed Central. Oct. 2006.

2. Darouiche RO. Impact of StatLock securing device on symptomatic catheter-related urinary tract infection: a prospective, randomized, multicenter clinical trial. Am J Infect Control. Nov. 2006.

3. Saint S, Elmore JG, et. al. The efficacy of silver alloy-coated urinary catheters in preventing urinary tract infection: a metaanalysis. Am J Med. 1998;105:236-241.

4. Saint S. Clinical and economic consequences of nosocomial catheter-related bacteriuria. Am J Infect Control. 2000;28:68- 75.

5. Foxman B. Epidemiology of urinary tract infections: incidence, morbidity, and economic costs.Dis Mon. Feb. 2003;49(2):53-70.