Prevention and Management of Catheter- Associated UTIs

PRINTER-FRIENDLY VERSION AT IDSE.NET
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Prevention and
Management
of CatheterAssociated UTIs
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DIANE K. NEWMAN, RNC, MSN, CRNP, FAAN
Co-Director
Penn Center for Continence and Pelvic Health
University of Pennsylvania Health System
Division of Urology
Philadelphia, Pennsylvania
T
he urinary tract is the most common
1
site of nosocomial infections and
urinary tract infections (UTIs)
account for approximately 40% of all
hospital-acquired infections (HAIs) in the
United States.2 More than 80% of HAIs
are associated with an indwelling urinary
catheter (IUC).3 Referred to as catheter-
associated UTIs (CA-UTI), these infections
can cause substantial morbidity in both men
safety issue. Urinary catheters often are
placed unnecessarily, remain in place without
physician awareness, and are not removed as
soon as possible when no longer needed.4
I N D E P E N D E N T LY D E V E L O P E D B Y M C M A H O N P U B L I S H I N G
An IUC (often referred to as a “Foley”) is a
commonly used medical device that allows for
continuous urine drainage in patients with bladder dysfunction. IUCs are used in both men and
women in all care settings. They are used in the
acute care setting more than any other medical
device. At least 15% to 25% of patients may have
a urinary catheter inserted sometime during
their hospital stay, with most used on a shortterm basis (<30 days). The prevalence of CAUTIs is greater in high-acuity patient units, as
is evident by the high rate of IUC use in critical
care and intensive care units.
Inappropriate IUC use has been equated to a
“one-point restraint,” and as a form of restraint,
catheters are associated with functional impairment, discomfort, nosocomial infection, pressure ulcers, and death.5 Patients have reported
that IUCs are uncomfortable, painful, and restrict
activities of daily living.6 IUCs have been associated with a greater risk for death in hospitalized
older patients—4 times as great during hospitalization and 2 times as great within 90 days after
discharge.7 Extended IUC use in older patients
sustaining hip fracture who are discharged to
skilled nursing facilities with a catheter in place
also has been associated with poor outcomes
d.
and women and are a preventable patient
Prevalence of CA-UTI
INFECTIOUS DISEASE SPECIAL EDITION • 2010
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as IUC placement puts these these individuals at higher
risk for rehospitalization for CA-UTI and sepsis.8
IUCs are associated with many adverse events; the
most frequent being CA-UTIs. Approximately 560,000
cases of CA-UTIs are reported yearly to the Centers for
Disease Control and Prevention (CDC). Although frequently asymptomatic, between 20% and 30% of individuals with catheter-associated bacteriuria will develop
symptoms of CA-UTI, secondary to long-term catheter use (>30 days). IUCs have specific indications that
recently have been defined by the Healthcare Infection
Control Practices Advisory Committee (HICPAC) and
are listed in Table 1.9,10 Table 2 cites examples of inappropriate IUC use, as provided by HICPAC.9,10 Longer duration of IUC should be avoided as it provides access for
bacteria and ultimately may result in a CA-UTI. Finally,
another reason to avoid use of an IUC is cost. The cost
of treating a single episode of a CA-UTI can range from
$980 to $2,900, depending on the presence of associated bacteremia.11
this policy, CMS hopes to provide hospitals with the
incentive to prevent hospital-acquired conditions by
not reimbursing for their occurrence and treatment.
Hospitals are now at risk for financial losses (nonpayment for additional costs) if CA-UTIs occur. So, in addition to improving patient care and safety, hospitals now
have a financial incentive to minimize the use of IUCs.
Causes of CA-UTIs
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A UTI is an inflammatory response to colonization of
the urinary tract from a bacterial or fungal pathogen.15
A CA-UTI is classified as a complicated UTI if the presence of a foreign body in the urinary tract not only predisposes the patient to UTI, but also alters the body’s
ability to eradicate bacteria from the lower urinary tract.
It is the most severe and common catheter-associated
complication because it can lead to urosepsis and septicemia and most often is associated with long-term
catheter use. CA-UTIs may occur at least twice a year
in patients with long-term IUC and usually require hospitalization. CA-UTI is more likely to occur in women
because of decreased estrogen hormone in the genitalia and the shorter length of the female urethra; as well
as the urethra’s close proximity to the anus providing
bacteria a shorter distance to travel.11
The bacteria causing CA-UTI gain access to the urinary
tract either extraluminally or intraluminally.16 Approximately 66% of CA-UTIs are attributed to bacteria gaining access via the catheter–urethral lumen interface, and
the remaining 34% are attributed to intraluminal migration associated with manipulation of the catheter and
urinary drainage system.17 Extraluminal contamination
may occur during insertion from contamination of the
catheter from any source. Extraluminal contamination
also is thought to occur when microorganisms ascend
Nonpayment for CA-UTIs
Changes by the Centers for Medicare & Medicaid
Services (CMS) have reshaped reimbursement for inpatient prospective payment for acute care hospitals.
CMS holds acute care hospitals accountable for failing to avert preventable harm resulting from medical
care and will withhold additional payments to hospitals
for “serious preventable events.”12-14 As part of the Hospital-Acquired Conditions Initiative (known as the “nopay rule”), CMS has placed a high priority on reducing
CA-UTIs because they are viewed as unacceptable harm
resulting from medical care. CMS can deny payment for
8 costly and sometimes deadly preventable hospitalacquired conditions, one of which is CA-UTIs. Through
Table 1. Recommended Indications for Use of an IUC
Acute urinary retention or bladder outlet obstruction
Need for accurate measurements of urinary output in critically ill patients
Perioperative use for selected surgical procedures: urologic surgery or other surgery on contiguous
structures of the genitourinary tract
Anticipated prolonged duration of surgery (if inserted, remove in postanesthesia care unit)
Large-volume infusions or diuretics during surgery
Need for intraoperative monitoring of urinary output
Prolonged immobilization (eg, potentially unstable thoracic or lumbar spine, multiple traumatic
injuries such as pelvic fractures)
To improve comfort for end-of-life care
IUC, indwelling urinary catheter
Adapted from references 9 and 10.
14
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d.
To assist in healing of open sacral or perineal wounds in incontinent patients
Table 2. Examples of Inappropriate
Uses of an IUC
As a substitute for nursing care of the patient
with incontinence
As a means of obtaining urine for culture or
other diagnostic tests when the patient can
voluntarily void
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For prolonged postoperative duration without appropriate indications (eg, structural repair
of urethra or contiguous structures, prolonged
effect of epidural anesthesia)
Bacteriuria and Infecting Organisms
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Approximately 50% of hospitalized patients catheterized longer than 7 to 10 days develop bacteria or
fungus in the urine (called bacteriuria). A large number
and a variety of types of organisms are present in the
periurethral area, in the distal part of the urethra, and
they may be introduced into the bladder at the time of
catheter insertion. Other factors that increase the risk
for bacteriuria include the presence of residual urine in
the bladder resulting from inadequate bladder drainage (urine stasis promotes bacterial growth), ischemic
damage to the bladder mucosa through overdistention, mechanical irritation from the presence of a catheter, and biofilm formation on the catheter intraluminal
surface.
Most patients with bacteriuria are asymptomatic and
although they should not be treated, many receive inappropriate antimicrobials. A 2009 article by Cope et al,
reviewed all urine culture results of predominately male
patients at a Veterans Affairs medical center during
a 3-month period and noted that of the 164 episodes
of catheter-associated asymptomatic bacteriuria, 68%
(n=111) were managed appropriately (no treatment),
whereas 32% (n=53) were treated with antibiotics (inappropriate treatment).21
However, between 20% and 30% of individuals with
catheter-associated bacteriuria will develop symptoms
of a CA-UTI. Most CA-UTIs involve multiple organisms
and resistant bacteria from catheter-associated biofilms.
These include Enterobacteriaceae, other than Escherichia coli (eg, Klebsiella, Enterobacter, Proteus, and
Citrobacter), Pseudomonas aeruginosa, enterococci
and staphylococci, and Candida. The infecting organism depends on hospital unit. For example, the predominant microorganisms causing CA-UTI in the intensive
care unit are enteric gram-negative bacilli, enterococci, Candida species, and P. aeruginosa.22 Candiduria is especially common in individuals with prolonged
IUC use who are receiving broad-spectrum systemic
antimicrobial agents.23 However, because of increased
antibiotic use, there has been an increase in antibioticresistant microorganisms, particularly P. aeruginosa and
Candida albicans, 2 organisms frequently involved in
device-associated nosocomial infections.24 A growing problem in hospitals is infection with vancomycinresistant Enterococcus (VRE) and methicillin-resistant
Staphylococcus aureus (MRSA).
IUC, indwelling urinary catheter
Adapted from references 9 and 10.
from the perineum along the surface of the catheter
and occurs most often in women. Fecal strains contaminate the perineum and urethral meatus, are harbored in
the labia, and subsequently ascend to the bladder along
the external surface, thereby causing bacteriuria, catheter biofilm formation, and encrustation.18 Intraluminal
contamination occurs by ascent of bacteria from a contaminated catheter, drainage tube, or urine drainage
bag.19 Microorganisms can migrate up the catheter into
the bladder within 1 to 3 days.20
There are 3 main catheter-associated entry points for
bacteria: 1) the urethral meatus, with introduction of bacteria occurring on insertion of the catheter; 2) the junction of the catheter-bag connection, especially when a
break in the closed catheter system occurs; and 3) the
drainage port of the collection bag (Figure). All of these
mechanisms involved in the pathogenesis of colonization and infection of the urinary tract combine to make
CA-UTI very difficult to prevent in patients with an IUC
in place for longer than 2 weeks.
Catheter
Drainage Tubing
Junction
Urethral
MeatusCatheter
Junction
Catheter-Associated Biofilms
d.
Catheters are a good medium for bacterial growth
because once they gain access to the urinary tract, bacteria produce various adhesions, including hairlike fimbriae that allow them to firmly attach to the catheter
wall. These attached bacteria upregulate their expression of certain genes, resulting in altered phenotypes
that ultimately lead to biofilms (living layers of organisms).19,25-28 Urine contains protein that adheres to and
primes the catheter surface. Microorganisms bind to
this protein layer and thus attach to the surface. Such
Drainage Bag
Outlet Tube
Figure. IUC bacteria entry.
IUC, indwelling urinary catheter
I N D E P E N D E N T LY D E V E L O P E D B Y M C M A H O N P U B L I S H I N G
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bacteria are different from free-living planktonic bacteria (bacteria that float in urine). Initially, IUC biofilms
may be composed of single organisms, but can lead
to multiorganism biofilms because the presence of the
biofilm inhibits antimicrobial activity.29
Biofilm provides a sustained reservoir for microorganisms that, after detachment, can infect the patient.
These biofilms cause further problems if the bacteria (eg, P. mirabilis) produce the enzyme urease.24 The
urine then becomes alkaline, causing the production of
ammonium ions, followed by crystallization of calcium
and magnesium phosphate within the urine. These crystals then are incorporated into the biofilm, resulting in
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encrustation and blockage of the catheter over a period
of time.
Several features of biofilms have important implications for the development of antimicrobial resistance in
organisms growing within the biofilm. The complex structures of the biofilm promote bacterial proliferation and
protect bacteria from destruction by cleaners, antiseptics, antibiotics, and the host’s immune system. Bacteria
within a biofilm exhibit a greater ability to communicate
and exchange genetic information than do free-floating
(planktonic) bacteria. This communication is hypothesized
to promote antibiotic resistance and spread of the biofilm
to other surfaces of the catheter and urinary epithelium.
Table 3. Best Practices for Management of IUCs and Prevention of CA-UTIs
Conduct daily assessment of the need for IUC, implement quality-improvement programs to reduce
the risk for CA-UTIs and educate physician and nursing staff on indications for IUC
Proper technique (aseptic) and equipment during catheter insertion
Minimize urethral trauma during catheter insertion by using generous amounts of sterile lubricant and holding
the penis in a near vertical position when catheterizing a male patient
Wash hands before and after handling of the catheter site or apparatus as up to 15% of UTIs occur
in clusters as a result of cross-infection. Always wear gloves when handling any part of the catheter system
Ensure an unobstructed urine flow by preventing any kinks or loops from occurring in the catheter and tubing,
which might restrict flow of urine
Secure the catheter by anchoring it to the upper thigh in women or to the upper thigh or lower
abdomen in men, to prevent excessive tension on the catheter, which can lead to urethral trauma and tears
Avoid rigorous, frequent cleansing of the catheter entry site (urethral meatus or suprapubic) and do not
use antiseptics for routine cleansing; wash the catheter entry site daily with soap and water or after bowel
contamination
Empty the drainage bag at least every 4 to 6 hours or when urine in the drainage bag reaches 400 mL
to avoid migration of bacteria up the lumen of the catheter system. Empty bag prior to transporting patient
Separate graduated containers for each patient and each patient drain. With multiple drainage devices for one
patient, keep drainage devices on opposite sides of the bed and keep drainage devices in semiprivate rooms
on opposite sides of the room
Consider changing the catheter before obtaining a specimen for culture as cultures obtained through the
old catheter may be inaccurate
Routine urine should not be performed in the absence of infection because all chronically catheterized individuals have bacteria and the organisms change frequently (about 1-2 times per month). Urine cultures should
only be obtained if the patient demonstrates clinical symptoms of a UTI. Consider changing the entire catheter
and system if infection or obstruction occurs or before treating a CA-UTIs with antibiotics
Encourage adequate fluid intake (approximately 30 mL/kg per day with a 1,500 mL/day minimum or as indicated based on the patient’s medical condition)
d.
Do not clamp the catheter or drainage tube
Do not give the asymptomatic patient antibiotics and antimicrobials as a UTI prevention strategy
Do not perform bladder or catheter irrigation unless medically necessary (eg, tissue/blood clots obstructing
drainage). If catheter patency is questioned or occlusion is suspected, scan the bladder to assess urine volume
CA-UTIs, catheter-associated urinary tract infections; IUC, indwelling urinary catheter; UTI, urinary tract infection
Adapted from references 9, 14, 34-36.
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I N D E P E N D E N T LY D E V E L O P E D B Y M C M A H O N P U B L I S H I N G
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A 2010 article by Stickler and Feneley noted that
P. mirabilis was the main cause of crystalline biofilms
that encrust and block IUCs, and that elimination of
this organism by antibiotics as soon as it appears could
reduce associated complications.30 However, as the
presence of the biofilm inhibits antimicrobial activity,
organisms within the biofilm cannot be eradicated by
antimicrobial therapy alone.29 The urinary biofilm provides a protective environment for the microorganisms,
which allows evasion of the activity of antimicrobial
agents. The biofilm also allows for microbial attachment
to catheter surfaces in a manner that does not allow for
removal with gentle rinsing, such as irrigation.20,31 Biofilms can begin to develop within the first 24 hours after
catheter insertion and have reportedly grown so thick
in some circumstances as to block a catheter lumen.26
The presence of urinary catheter biofilms has important implications for antimicrobial resistance, diagnosis of UTIs, and prevention and treatment of CA-UTIs. In
those patients who need an IUC for long-term bladder
management, prevention of associated complications
relies on adherence to catheter care practices that are
outlined in Table 3.9,14,34-36
unexplained fever may be the only symptoms of CA-UTI
in elderly patients. Similarly, diagnosing catheter-related
infection in patients with spinal cord injury may be especially challenging from the standpoint of history and
physical examination because of frequent lack of localizing symptoms.32 Often, the only symptoms of CA-UTI
in these patients are fever, diaphoresis, abdominal discomfort, or increased muscle spasticity.33
A New Focus on Strategies for Prevention
Of CA-UTIs
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The 2009 HICPAC Guideline for Prevention of Catheter-Associated Urinary Tract Infections has estimated
that between 17% and 69% of hospital-acquired CA-UTIs
may be prevented by implementation of an evidencebased prevention program.9 Evidence suggests that certain interventions can reduce the incidence of CA-UTI
in patients managed by short-term IUC. These include
staff education about catheter management, combined
with regular monitoring of CA-UTI incidence, a hospitalwide program to ensure catheterization only when indicated, and prompt removal of the IUC. These practices
are outlined in Table 3 and the strategies discussed here
should be adopted to prevent CA-UTIs.9,14,34-36
Signs and Symptoms of a CA-UTI
In patients with long-term IUC, symptoms are caused
by an inflammatory response of the epithelium of the
urinary tract to invasion and colonization by bacteria,
but usually are nonspecific. Clinical manifestations of
UTI (pain, urinary urgency, dysuria, fever, and leukocytosis) are uncommon even when bacteria or yeast is
present, and are no more prevalent with positive urine
culture results than with negative results. Confusion or
REDUCE DEVICE DAYS
A 2008 national survey reported by Saint, Kowalski,
Kaufman, Hofer, Kauffman, Olmsted et al, noted that many
hospitals were not paying attention to IUC use.37 Less than
50% of hospitals responding to the survey monitored
whether patients had an IUC in place, and less than
25% knew the duration of catheterization (referred to
as “Foley” days). The longer the IUC remains in place,
Table 4. Bladder Bundlea Practices and Measures
Measures
Nurse-initiated IUC discontinuation protocol
Prevalence rate of IUC utilization (number of IUC-days/
total number of patient-days during a period of time)
Institute IUC reminder and removal prompts
Review indications for insertion (Table 1)
Determine urine volume in the bladder using
portable ultrasound bladder monitoring (eg,
BladderScan®)
Prevalence rate of unnecessary IUC utilization (number
of unnecessary urinary catheter-days/total number of
patient-days during a period of time)
Ensure catheter insertion care and maintenance
Rate of discontinuation of unnecessary IUCs (number of
unnecessary catheters discontinued/number of IUC evaluated for which no indication was found)
d.
Practices
Consider alternatives to IUC
IUC, indwelling urinary catheter
a
Bundle is a set of evidence-based practices that are generally mean to be implemented together.
Adapted from reference 47.
I N D E P E N D E N T LY D E V E L O P E D B Y M C M A H O N P U B L I S H I N G
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the greater the risk for development of a CA-UTI, so
the cornerstone of a prevention program is to remove
the IUC as soon as possible. The most important strategy for prevention of CA-UTIs is to avoid insertion of
a catheter; however, if a catheter must be used, duration of catheterization should be limited to the shortest
time possible. Given that the rate of infection is closely
related to the duration of catheterization, the high frequency of inappropriate catheterization, and the finding
that physicians often are unaware of catheter presence,
it is apparent that an automatic urinary catheter “stop
order” or other reminder would be appropriate. Such
an innovative, systemwide administrative intervention, similar to an antibiotic stop order, ideally would
remind physicians and nurses that a patient has an IUC
in place, which in turn might help reduce inappropriate
catheterization.38,39
deter the reinsertion of a catheter. Bladder monitoring
should include the use of noninvasive techniques such
as portable ultrasound bladder volume technology (eg,
BladderScan) to detect postvoid residual (PVR) urine
amounts as high PVR or unnecessary catheterizations
can lead to a UTI. Catheters should not be used as a
substitute for nursing care in the incontinent patient.
They should not be inserted to obtain urine specimen
for culture or other diagnostic tests in a patient who
voids, nor should they be used postoperatively without
appropriate indications.
Approximately 15% of CA-UTIs have been linked
to poor aseptic techniques when cleansing the urinary meatus area and inserting and maintaining the
catheters. However, studies have shown that vigorous
twice-daily meatal cleansing does not seem to reduce
rates of urinary infections. Infection control-based IUC
practices may enhance patient safety and decrease
catheter-related costs, therefore, knowledge of and
education on proper hand hygiene practices is appropriate. Hand washing is the best way to prevent spread
of most nosocomial infections. Rates of hand washing
among health care providers usually range from 20%
to 50% per patient encounter, although some studies
have reported hand-washing rates as high as 81%.48 Viable pathogens (eg, Acinetobacter spp., Clostridium difficile, Klebsiella spp., MRSA, Pseudomonas spp., VRE,
and yeasts including Candida) often are found on the
hands of health care providers. Alcohol-based handwashing solutions generally are considered to be more
effective and are believed to have higher compliance
rates than soap and water.49
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STAFF HYGIENE
DEVELOP APPROPRIATE INFRASTRUCTURE
AND SURVEILLANCE
GUIDELINES
FOR
CATHETER USE
Hospitals should provide and implement written
guidelines for catheter use, insertion, and maintenance.
It is necessary to develop a protocol that describes
steps to take following catheter removal in order to
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I N D E P E N D E N T LY D E V E L O P E D B Y M C M A H O N P U B L I S H I N G
CATHETER CARE PRACTICES
The recommended practices for IUC care are detailed
Table 3 and include the following categories:
aseptic catheter-insertion procedures;
care of the drainage bag;
maintenance of catheter patency;
perineal care;
catheter irrigation;
fluid and hydration;
hand washing and glove use; and
patient, physician, and nursing staff education.
In order to prevent CA-UTIs, a “closed” system
should be used and the catheter should be removed as
soon as possible. A systematic review suggested that
use of sealed (eg, taped or presealed) drainage systems
contribute to preventing bacteriuria.50 The basic components of a closed system include the catheter, a preconnected collecting tube with an attached sampling
port, and a vented bag with a port for drainage. In general, the use of oral antibiotics and urinary acidifying
agents, antimicrobial bladder irrigations, antimicrobial
drainage bag solutions, and topical meatal antiseptics
have been studied. It has been shown that bacteriuria
and UTI can be suppressed temporarily, but resistant
in
•
•
•
•
•
•
•
•
d.
The next strategy that hospitals should employ to
prevent CA-UTIs is an appropriate infrastructure that
includes some type of surveillance. Strong surveillance
programs can control CA-UTIs and implementing appropriate “best-practice” protocols for catheter management can decrease prevalence of hospital-acquired UTIs.
Multiple references in the literature deal with hospitalwide surveillance programs that have been successful in
reducing hospital-acquired UTIs.35,39-45 Hospitals need to
understand resources as well as current practices and
problems so a plan can be developed for monitoring
IUC use and preventing CA-UTIs.
A 2008 article by Fakih, et al reported on the effect
of nurse-led multidisciplinary rounds on 10 medicalsurgical units looking at the unnecessary use of IUCs.46
The group reviewed patient records to determine
appropriate indication for IUC use. If indication for IUC
placement was unfounded, the patient’s nurse was
asked to contact the physician to request discontinuation. In this study, more than two-thirds of IUC placements did not have a clear indication. These authors
found this simple monitoring intervention enabled a
10% reduction in unnecessary catheter placement. In
2010, Meddings et al conducted a systematic review
and meta-analysis of the effectiveness of reminder
systems to reduce CA-UTI and found that IUC reminders and stop orders decreased the rate of CA-UTIs by
50%.38 In 2009, Saint and colleagues implemented a
“bladder bundle” that focused on preventing CA-UTIs
by optimizing the use of IUCs with emphasis on daily
assessment and removal as soon as possible. Saint’s
bladder bundle practices and measures are described
in Table 4.47
flora eventually appear. All staff caring for patients with
IUCs in place should be taught methods that may prevent cross-contamination of bacteria.
AVOID REPEAT CATHETERIZATIONS
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Bladder monitoring should not be performed with
repeat catheterizations, rather noninvasive technology (eg, portable bladder volume ultrasound) to avoid
unnecessary catheterizations and to prevent UTIs is recommended. Portable bladder volume ultrasound has
been used for more than 2 decades to measure urinary
retention and has been advocated by some to reduce
the need for catheterization.51 Portable bladder volume
ultrasound accurately measures urine volume. Additionally, these “scanners” have been found to reduce the
number of intermittent catheterizations and to perhaps
even decrease the risk for UTIs.52
of their patients have indwelling urinary catheters? Am J Med.
2000;109(6):476-480.
5. Saint S, Lipsky BA, Goold SD. Indwelling urinary catheters:
A one-point restraint? Ann Intern Med. 2002;137(2):125-127.
6. Saint S, Lipsky BA, Baker PD, McDonald LL, Ossenkop K.
Urinary catheters: what type do men and their nurses prefer?
J Am Geriatr Soc. 1999;47(12):1453-1457.
7. Holroyd-Leduc JM, Sen S, Bertenthal D, et al. The relationship
of indwelling urinary catheters to death, length of hospital stay,
functional decline, and nursing home admission in hospitalized
older medical patients. J Am Geriatric Soc. 2007;55(2):227-233.
8. Wald H, Epstein A, Kramer A. Extended use of indwelling urinary
catheters in postoperative hip fracture patients. Med Care.
2005;43(10):1009-1017.
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rv
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9. Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA; Healthcare Infection Control Practices Advisory Committee. Guideline for
prevention of catheter-associated urinary tract infections 2009.
Infect Control Hosp Epidemiol. 2010;31(4):319-326.
Alternative Methods of Bladder Management
There are several alternatives to management of
patients with bladder dysfunction that cause fewer complications than use of IUC. These include urinals, external
catheters in men, absorbent products for urinary incontinence, and intermittent catheterization for urinary
retention.16,53 Urinals and absorbent products contain
urine leakage in patients with incontinence. External
devices are secured to the skin with adhesive or straps
and are connected to a tube and collecting bag. They
primarily are used in men with urinary incontinence.
Intermittent catheterization is the insertion of a catheter
into the bladder to allow for drainage. The catheter is
removed after drainage. This type of catheterization is
used in patients with urinary retention as it minimizes
episodes of overdistention of bladder and frequent,
regular bladder emptying prevents UTI. There is no limit
to the number of times a patient can be intermittently
catheterized safely.
Conclusions
IUCs are a significant source of hospital infections.
The best prevention is to avoid insertion of an IUC at
all costs, but if needed, the duration of catheterization
should be limited. Nursing and physician staff can be
instrumental in preventing a CA-UTI with the implementation of hospital-wide surveillance programs and
appropriate catheter care protocols developed from
evidence-based practices. Health care providers need
to be aware of the current guidelines on the use of IUCs
to ensure patient safety and best practices.
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