Transmission of urinary bacterial strains between patients with indwelling catheters--nursing in the same room and in separate rooms compared

Despite lack of supporting scientific data it has been suggested that patients with an indwelling urinary catheter (IUC) should be nursed in separate rooms to reduce the risk of cross-infection. We conducted a one-month case-control study of nursing home patients with an IUC and bacteriuria, 20 nursed together pairwise and 20 in separate rooms, by weekly urine cultures and typing of the bacterial isolates. The transmission rate of urinary strains between patients was three times higher within rooms (5/9 possible transmissions) than between rooms (9/53 possible transmissions, P = 0.02). The study thus supported nursing IUC patients in separate rooms.

[Analysis of primary management of bladder malfunction in traumatic paraplegic patients]

Intermittent catheterisation is the demanded therapy of bladder paralysis during the spinal shock. We investigated the realisation of this concept. In 1994 after first treatment in other hospitals 97 patients were treated in the Thuringian Spinal Cord Centre Sülzhayn. The primary treatment of the paralysed bladder was: indwelling catheter: 44 patients (45.4%), suprapubic catheter: 30 patients (30.9%). Only 15 patients (15.5%) were catheterized intermittently. No urological treatment was carried out in seven cases.

CONCLUSION

The primary treatment of bladder analysis in spinal cord injured patients has to be improved.

[Current strategies in patients with urinary diversion, I: the lower urinary tract]

Urethral catheterization, intermittent self-catheterization and suprapubic catheters are reliable methods to drain the urine in the lower urinary tract. Only a strict indication for indwelling catheters can minimize the complications and negative side effects. All physicians, especially pediatricians, surgeons, neurologists and internists should be familiar with the problems of catheter drainage by using a strictly aseptic technique.

Comparison of 1 and 3 days' transurethral Foley catheterization after retropubic incontinence surgery

This prospective study was done to see if reducing transurethral Foley catheterization from 3 days to 1 would lead to fewer urinary tract infections without an increase in voiding problems. Ninety-one women undergoing retropubic surgery for stress urinary incontinence (Burch or Marshall-Marchetti-Krantz) were randomized to either 1 or 3 days' catheterization. Antibiotics were not used. Infection was diagnosed in 9 (20.0%) patients in the 1-day group and in 16 (34.8%) in the 3-day group. Delayed voiding occurred in 13 (28.9%) and 10 (21.7%) patients, respectively, and 5 (11.1%) and 3 (6.5%), respectively, received a new catheter. The differences do not reach statistical significance. Therefore, catheter time may safely be reduced to 1 day. This may lead to fewer infections but also somewhat more voiding problems. If a transurethral catheter is to be used, on balance the two regimens are equivalent.

Antiseptic catheter gel and urinary tract infection after short-term postoperative catheterization in women

This paper compares the rates of postoperative urinary tract infection (UTI) when an antiseptic lubricating gel was used at catheter insertion in 132 women and not used in 387 women. 519 consecutive patients admitted for elective gynaecological surgery were studied prospectively. Antibiotics were not used. Mean catheterization time was 1.4 days (range 1-3). Postoperative UTI occurred in 17.4% and 18.3% of the patients, respectively (p = 0.95). Therefore, using antiseptic anaesthetic gel at catheter insertion does not appear to reduce the risk of UTI associated with short-term transurethral catheterization after gynecological surgery.

Perioperative bladder management after primary total hip arthroplasty

A retrospective review of 95 consecutive primary total hip arthroplasty patients was performed to assess the clinical outcome of two postoperative bladder management protocols. The first 49 patients (group 1) were treated with a pro re nata straight catheterization protocol. The next 46 patients (group 2) were treated with an indwelling catheterization protocol. There were no differences between the groups with respect to sex or age. The patients in group 2 had significantly lower incidences of urinary retention (P < .0005) and bladder distention (P < .0005) than those in group 1. Preoperative systemic diseases and urologic symptoms did not correlate with the occurrence of postoperative urinary retention or bladder distention. There were no infections in group 1. In group 2, one patient (2%) had bacteriuria and one patient (2%) had a urinary tract infection (P > .1). This trend of increased contamination in the catheterization group may be related to a mean catheterization duration of 72 hours.

Clean intermittent catheterization: safe, cost-effective bladder management for male residents of VA nursing homes

OBJECTIVES

To compare the safety and cost of clean versus sterile intermittent bladder catheterization in male nursing home residents. To provide evidence to support the hypothesis that intermittent catheterization is a valid, alternative method of bladder management in male residents of long-term care in whom urinary retention is a documented problem.

DESIGN

Randomized clinical trial.

SETTING

Three long-term care sites having predominantly male populations.

PARTICIPANTS

Eighty male veterans, residents of three long-term care facilities, ranging in age from 36 to 96 years with a mean age of 72.

INTERVENTIONS

Standardized procedures for clean and sterile intermittent catheterization (IC) were implemented by staff nurses at each site. Patients were randomized into clean and sterile IC groups. Nursing time and catheterization equipment usage were recorded using bar code readers. Clinical data were collected from the medical chart. Treatment of urinary tract infection was prescribed by the medical personnel responsible for each individual resident.

MEASUREMENTS

We compared the number of treatment episodes for symptomatic bacteriuria between groups randomized to receive either clean or sterile intermittent catheterization. Laboratory analysis of blood and urine was done on predetermined days. Control variables were research site and patient history of urinary tract infection within the last 6 months. A cost comparison of nursing time and equipment usage for the two catheterization techniques was also performed.

RESULTS

No significant differences were found between clean and sterile groups with regard to number of treatment episodes, time to first infection, type of organism cultured, or cost of antibiotic treatment. The cost of sterile technique was considerably higher both in terms of nursing time and supplies.

CONCLUSIONS

Findings from this study demonstrate that clean technique intermittent catheterization is a safe and cost-effective bladder management technique with male, nursing home residents, despite the frailty of this high risk population. An annual savings of approximately $1460 per patient in nursing time and catheterization supplies could be anticipated if a patient were catheterized an average of four times per day substituting clean IC technique for sterile IC technique.

Antimicrobial prophylaxis in management of urinary tract stones by extracorporeal shock-wave lithotripsy: is it necessary?

OBJECTIVES

In a prospective randomized study, we evaluated the incidence of urinary tract infections following extracorporeal shock-wave lithotripsy (ESWL) and the necessity of prophylactic antibiotic administration in patients treated with this modality.

METHODS

A total of 360 consecutive patients with renal and ureteric stones who had sterile urine before ESWL treatment and did not have any increased risk of infection received either a single dose of 400 mg of ofloxacin or no prophylaxis. Patients were followed by simple urine analysis and urine cultures together, with clinical evaluations.

RESULTS

Only 3 patients (0.8%) had positive urine cultures at 1 week after ESWL. Two of these patients were in the antibiotic prophylaxis group.

CONCLUSIONS

The incidence of urinary tract infections after ESWL is extremely low, provided that patients have sterile urine before ESWL, and prophylactic antibiotics are not required.

A large randomized clinical trial of a silver-impregnated urinary catheter: lack of efficacy and staphylococcal superinfection

PURPOSE

The antibacterial activity of silver-containing compounds has recently been employed in constructing medical devices, such as vascular and urinary catheters, that may be effective in blocking infection. The present study was designed to evaluate the efficacy of a silver oxide-coated urinary catheter.

PATIENTS AND METHODS

A total of 1,309 hospitalized patients who required placement of an indwelling urinary catheter for 24 hours or longer were randomly assigned to receive either a silicone catheter coated externally with 5% silver oxide or a standard silicone elastomer-coated latex catheter. Daily catheter-urine specimens were collected aseptically and catheter-care violations were monitored daily for the duration of the catheterization.

RESULTS

Bacteriuria developed in 85 of 745 patients (11.4%) in the silver-coated catheter group and in 73 of 564 patients (12.9%) in the control group (P = 0.45). In women who did not receive antibiotics, the rates were 29.3% and 30.4%, respectively (P = 0.98). In men who did not receive antibiotics, the rate of bacteriuria was significantly higher with the silver-coated catheter (29.4% compared to 8.3%, respectively, P = 0.02). Staphylococcal species were isolated more often from the silver-coated catheter group than from the control group (25% versus 8% of all isolates, respectively, P = 0.002).

CONCLUSIONS

This study, the largest ever reported evaluating any silver-impregnated device, has not only failed to demonstrate the efficacy of silver in prevention of catheter-associated bacteriuria, as suggested in prior studies, but it has also shown a significantly increased incidence of bacteriuria in male patients and a significantly increased occurrence of staphylococcal bacteriuria. These results suggest the need for caution and for similar large-scale trials before silver-containing compounds are widely used for preventing device-associated infections, both in vascular and urinary catheters.

Socio-biological associations of bacteriuria in pregnancy

The prevalence and socio-biological relations of bacteriuria in Trinidadian pregnant women were investigated. The prevalence of bacteriuria was found to be 16.7% and it was more common in the 30-39 year age group, among parous women, among Negroes, and in patients with a low family income and overcrowded living conditions. Symptoms were present in 19% of bacteriuric patients and almost one-third gave a past history of urinary tract infection. Only 10% had been previously exposed to sexually transmitted diseases such as syphilis, gonorrhea and herpetic genital infections. Because of the serious consequences to mother and foetus, we advocate quantitative urine cultures for all antenatal patients, especially those coming from disadvantaged socio-economic conditions.

Trimethoprim-sulfamethoxazole prophylaxis against urinary tract infection in the chronic spinal cord injury patient

Suppressive therapy with antibiotics has long been thought to decrease the number of complications from the neuropathic bladder in spinal cord injury patients, but it may also induce resistance to antibiotics which subsequently causes difficulties in treating symptomatic urinary tract infections. Forty-three chronic spinal cord injury patients were randomized to continue to receive daily trimethoprim-sulfamethoxazole (TMP-SMX) urinary tract prophylaxis versus discontinuing antibiotic prophylaxis. Patients were all at least 6 months after spinal cord injury. Patients were followed for a minimum of 3 months, with weekly catheter urine cultures. The difference in the colonization rate at onset and after 3 months (percent of cultures with asymptomatic bacteriuria) between the control and prophylaxis group was not statistically significant (P > 0.1). There was a significant decrease in the percentage of TMP-SMX resistant asymptomatic bacteriuria in the control group, 78.8%, compared to 94.1% in the suppressive group (P < 0.05). There was no significant difference in the number of symptomatic urinary tract infections following the withdrawal of suppressive therapy between the control group, 0.035/week, and the prophylaxis group, 0.043/week (P > 0.5). There was a larger percentage of TMP-SMX resistant symptomatic urinary tract infections in the treated group, 42.5% versus 37.5% in the control group, but the difference was not significant (P > 0.5). Irrespective of the method of bladder management, suppressive therapy with TMP-SMX did not reduce the incidence of symptomatic bacteriuria and did increase the percentage of cultures resistant to TMP-SMX in asymptomatic patients.

Clinical effects of preoperative oestradiol treatment before vaginal repair operation. A double-blind, randomized trial

The objective of the study was to assess the effects of low-dose vaginal treatment with oestradiol before vaginal operation. In a double-blind randomized study including 43 postmenopausal women scheduled for vaginal repair operation for genital descensus, it was found that 7 patients suffered from concomitant urinary stress incontinence. Vagifem (25 micrograms oestradiol) or placebo was administered as vaginal pessaries daily, 3 weeks prior to surgery and the clinical effects evaluated. One month postoperatively the prevalence of bacteriuria (> 100,000 CFU/ml urine) was significantly lower when using oestradiol than in the placebo group. At follow-up 3 years later 40 women (93%) answered the questionnaires. None received hormone replacement therapy. Nineteen percent in the preoperative oestradiol group and 11% in the preoperative placebo group had had more than two episodes of cystitis treated with antibiotics. This difference is not statistically significant (p > 0.05). Recurrent cystitis was not correlated to bacteriuria postoperatively. Seventy-nine percent of the women with genital prolapse but only 29% of the women with concomitant urinary stress incontinence were cured (p < 0.05). Neither preoperative oestradiol treatment nor body weight had any influence on relapse. Preoperative low-dose vaginal oestradiol treatment may reduce the incidence of bacteriuria in the immediate postoperative period but no long-lasting effects on recurrent cystitis or relapse were seen. Longer-lasting hormone replacement therapy may be necessary to achieve lasting effects.

Lomefloxacin prophylaxis in visual laser ablation of the prostate

OBJECTIVES

Visual laser ablation of the prostate (VLAP) is a relatively new option for relief of urinary outlet obstruction secondary to benign prostatic hyperplasia. There is currently no consensus regarding the optimum use of antibiotic prophylaxis in VLAP. This study was designed to evaluate two dosage regimens of a new difluoroquinolone, lomefloxacin, for prevention of postoperative bacteriuria following VLAP.

METHODS

Sixty men with benign prostatic hyperplasia who were scheduled for VLAP were enrolled in an open-label, randomized trial comparing groups receiving no antimicrobial prophylaxis (n = 20), a single preoperative oral dose of 400 mg lomefloxacin (n = 20), or a single preoperative oral dose of 400 mg lomefloxacin followed by 400 mg daily for 3 days (n = 20). The VLAP procedures were performed using 60 watts of energy from a neodymium:yttrium-aluminum-garnet (Nd:YAG) laser delivered via a Bard Urolase fiber or Laser Sonic fiber.

RESULTS

Ten of 20 patients (50%) in the no prophylaxis group developed bacteriuria (defined as growth of 10(4) or more colony-forming units/mL) during the 14 days following surgery, whereas 2 of 20 patients (10%) in the single-dose group and 1 of 20 in the multiple-dose group (5%) developed bacteriuria during the follow-up period. Both dosage regimens were well tolerated.

CONCLUSIONS

Lomefloxacin was successful in preventing postoperative bacteriuria in 90% (single dose) to 95% (multiple doses) of patients undergoing VLAP. There was no clinically significant difference between the two dosage regimens.

Screening for bacteriuria in Malaysian school children

Urinary tract infection is the most common of bacterial infections. Screening children for asymptomatic bacteriuria to prevent pyelonephritis and renal scarring is widely recommended. In Malaysia no such attempt has been made to establish the prevalence of asymptomatic bacteriuria. Bacteriuria was screened among 44,816 healthy school children from three different districts in Kelantan. There were 23,132 boys and 21,684 girls. The prevalence of bacteriuria was 0.12% after second screening. Higher prevalence was seen in other reports.

Catheter-associated bacteriuria in long-term care facilities

Catheter-associated bacteriuria is the most common infection acquired in long-term care facilities. Complications include fever, acute pyelonephritis, bacteremia, catheter obstruction, urinary stones, chronic interstitial nephritis, renal failure, and death. The closed-catheter system has been the only innovation in this traditional method of care that has led to prevention of bacteriuria. Antimicrobial agents rarely are indicated to prevent or treat bacteriuria in long-term catheterized patients, except for those with symptomatic infection. Alternative devices are available and often may be preferable to the indwelling urethral catheter. These patients and their reservoirs of bacteriuric organisms are sources of nosocomial outbreaks. Such outbreaks can be prevented and controlled with attention to catheter hygiene, prevention of patient-to-patient transmission on the hands of caregivers, and possibly use of antimicrobials to diminish bacterial concentrations in the urine.

Prevention and treatment of urinary catheter-related infections in older patients

The elderly population is more likely to have urinary catheters used than younger populations. Most patients with short term indwelling catheters (those in place less than 30 days) will be residents of acute care institutions. The frequency of catheter-acquired bacteriuria is greater with longer durations of catheterisation, female gender, failure to maintain a closed drainage system, and in patients not receiving systemic antimicrobials. Systemic antimicrobials given within 48 hours of catheter removal decrease the incidence of urinary infection, but are not currently recommended because of concerns with antimicrobial resistance. Interventions such as topical meatal antimicrobials, disinfectants added to the urinary drainage bag, antimicrobial coatings for catheters, and antimicrobial irrigation have not been shown to decrease the incidence of infection. Asymptomatic bacteriuria should not be treated while the catheter remains in place. However, catheter-acquired bacteriuria should probably be treated following catheter removal. Long term indwelling catheters are most frequently used in elderly individuals resident in long term care institutions. These individuals are always bacteriuric, usually with a complex polymicrobial flora. There are no clinical benefits of treatment of asymptomatic bacteriuria in such persons. In fact, treatment will promote the emergence of resistant organisms. The optimal management of symptomatic infection has not been defined.