Strategy to control catheter encrustation with citrated drinks: a randomized crossover study

The role of the district nurse in managing blocked urinary catheters

This article will investigate the district nurse's role in managing urinary catheter blockages, looking at why people require long-term catheterisation and the causes of blockages and then reviewing treatment methods. Current practice will be critically analysed and compared to the most up to date research and literature to inform district nurses of best evidence-based practice in the hopes of improving service user outcomes and quality of life and reducing the impact this problem has upon district nursing services with regards to time and resources.

Does alkalinised urine reduce the rate of encrustation in patients with ureteric stents? A randomised controlled study

PURPOSE

Stent encrustation is not uncommonly encountered with a high number of ureteric stents. The exact pathophysiology is not well understood. Therefore, we investigated the relationship between the use of sodium citrate and likelihood of stent encrustation.

METHODS

This prospective, randomised, intervention study was conducted between October 2018 and October 2019 in a tertiary hospital. Overall, 115 patients with ureteral stents that were inserted after lithotripsy surgeries were recruited. The study subjects were randomised into two groups: one group was administered sodium citrate (Utix sachets) three times per day until stent removal (intervention group), and the second group was not administered Utix sachets (control group). Stents were removed after 1 month and inspected under macroscopic visualisation from the proximal to distal end for any crystallisation; a second inspection was done with a 60 × magnification lens. Any crystallisation observed was considered to be encrustation.

RESULTS

Patients who had Utix sachets post-insertion of a ureteric stent constituted 50.4% of the study cohort. The rate of encrustation in the control group was 52.6%. In the intervention group, the rate of encrustation was 46.6%. The difference was not statistically significant with the chi-squared test (p value, 0.514).

CONCLUSION

Alkaline citrate medications had no significant effect on stent encrustation rate. More studies are needed to elucidate different agents and their roles in reducing stent encrustation as it incurs high morbidity.

The therapeutic importance of acid-base balance

Baking soda and vinegar have been used as home remedies for generations and today we are only a mouse-click away from claims that baking soda, lemon juice, and apple cider vinegar are miracles cures for everything from cancer to COVID-19. Despite these specious claims, the therapeutic value of controlling acid-base balance is indisputable and is the basis of Food and Drug Administration-approved treatments for constipation, epilepsy, metabolic acidosis, and peptic ulcers. In this narrative review, we present evidence in support of the current and potential therapeutic value of countering local and systemic acid-base imbalances, several of which do in fact involve the administration of baking soda (sodium bicarbonate). Furthermore, we discuss the side effects of pharmaceuticals on acid-base balance as well as the influence of acid-base status on the pharmacokinetic properties of drugs. Our review considers all major organ systems as well as information relevant to several clinical specialties such as anesthesiology, infectious disease, oncology, dentistry, and surgery.

Supporting patients with long-term catheterisation to reduce risk of catheter-associated urinary tract infection

More than 90 000 of the UK adult population are estimated to have a urinary catheter, with 24% likely to develop symptoms of catheter-associated urinary tract infection (CAUTI). The consequences of having a CAUTI are reduced quality of life, risk of hospitalisation and increased mortality. The authors undertook a literature review of primary research studies to identify how nurses could support patients to maintain effective catheter care to reduce the risk of CAUTI. Four themes emerged: education, knowledge, empowerment and communication. The authors therefore conclude that consistent knowledge, clear communication and treating patients as partners in the decision-making process can help build trust and allow empower patients. This will enable patients to make safe and healthy decisions about their catheter, particularly with regard to personal hygiene and optimal fluid intake, to reducing the risk of CAUTI.

Bacterial biofilm formation on indwelling urethral catheters

Urethral catheters are the most commonly deployed medical devices and used to manage a wide range of conditions in both hospital and community care settings. The use of long-term catheterization, where the catheter remains in place for a period >28 days remains common, and the care of these patients is often undermined by the acquisition of infections and formation of biofilms on catheter surfaces. Particular problems arise from colonization with urease-producing species such as Proteus mirabilis, which form unusual crystalline biofilms that encrust catheter surfaces and block urine flow. Encrustation and blockage often lead to a range of serious clinical complications and emergency hospital referrals in long-term catheterized patients. Here we review current understanding of bacterial biofilm formation on urethral catheters, with a focus on crystalline biofilm formation by P. mirabilis, as well as approaches that may be used to control biofilm formation on these devices. SIGNIFICANCE AND IMPACT OF THE STUDY: Urinary catheters are the most commonly used medical devices in many healthcare systems, but their use predisposes to infection and provide ideal conditions for bacterial biofilm formation. Patients managed by long-term urethral catheterization are particularly vulnerable to biofilm-related infections, with crystalline biofilm formation by urease producing species frequently leading to catheter blockage and other serious clinical complications. This review considers current knowledge regarding biofilm formation on urethral catheters, and possible strategies for their control.

Review of Catheter-Associated Urinary Tract Infections and In Vitro Urinary Tract Models

Catheter-associated urinary tract infections (CAUTIs) are one of the most common nosocomial infections and can lead to numerous medical complications from the mild catheter encrustation and bladder stones to the severe septicaemia, endotoxic shock, and pyelonephritis. Catheters are one of the most commonly used medical devices in the world and can be characterised as either indwelling (ID) or intermittent catheters (IC). The primary challenges in the use of IDs are biofilm formation and encrustation. ICs are increasingly seen as a solution to the complications caused by IDs as ICs pose no risk of biofilm formation due to their short time in the body and a lower risk of bladder stone formation. Research on IDs has focused on the use of antimicrobial and antibiofilm compounds, while research on ICs has focused on preventing bacteria entering the urinary tract or coming into contact with the catheter. There is an urgent need for in vitro urinary tract models to facilitate faster research and development for CAUTI prevention. There are currently three urinary tract models that test IDs; however, there is only a single very limited model for testing ICs. There is currently no standardised urinary tract model to test the efficacies of ICs.

Exploring relationships of catheter-associated urinary tract infection and blockage in people with long-term indwelling urinary catheters

AIMS AND OBJECTIVES

To describe and explore relationships among catheter problems in long-term indwelling urinary catheter users, including excess healthcare use for treating catheter problems.

BACKGROUND

Long-term urinary catheter users experience repeated problems with catheter-related urinary tract infection and blockage of the device, yet little has been reported of the patterns and relationships among relevant catheter variables.

DESIGN

Secondary data analysis was conducted from a sample in a randomised clinical trial, using data from the entire sample of 202 persons over 12 months' participation.

METHODS

Descriptive statistics were used to characterise the sample over time. Zero-inflated negative binomial models were employed for logistic regressions to evaluate predictor variables of the presence/absence and frequencies of catheter-related urinary tract infection and blockage.

RESULTS

Catheter-related urinary tract infection was marginally associated with catheter blockage. Problems reported at least once per person in the 12 months were as follows: catheter-related urinary tract infection 57%, blockage 34%, accidental dislodgment 28%, sediment 87%, leakage (bypassing) 67%, bladder spasms 59%, kinks/twists 42% and catheter pain 49%. Regression analysis demonstrated that bladder spasms were significantly related to catheter-related urinary tract infection and sediment amount, and catheter leakages were marginally significantly and positively related to catheter-related urinary tract infection. Frequencies of higher levels of sediment and catheter leakage were significantly associated with higher levels of blockage, and being female was associated with fewer blockages. Persons who need help with eating (more disabled) were also more likely to have blockages.

CONCLUSIONS

Catheter-related urinary tract infection and blockage appear to be related and both are associated with additional healthcare expenditures. More research is needed to better understand how to prevent adverse catheter outcomes and patterns of problems in subgroups.

RELEVANCE TO CLINICAL PRACTICE

Nurses can develop care management strategies to identify catheter blockage prior to its occurrence by tracking the amount of sediment and frequency of leakage. Bladder spasms could be an early warning of catheter-related urinary tract infection.

Proteus mirabilis and Urinary Tract Infections

Proteus mirabilis is a Gram-negative bacterium and is well known for its ability to robustly swarm across surfaces in a striking bulls'-eye pattern. Clinically, this organism is most frequently a pathogen of the urinary tract, particularly in patients undergoing long-term catheterization. This review covers P. mirabilis with a focus on urinary tract infections (UTI), including disease models, vaccine development efforts, and clinical perspectives. Flagella-mediated motility, both swimming and swarming, is a central facet of this organism. The regulation of this complex process and its contribution to virulence is discussed, along with the type VI-secretion system-dependent intra-strain competition, which occurs during swarming. P. mirabilis uses a diverse set of virulence factors to access and colonize the host urinary tract, including urease and stone formation, fimbriae and other adhesins, iron and zinc acquisition, proteases and toxins, biofilm formation, and regulation of pathogenesis. While significant advances in this field have been made, challenges remain to combatting complicated UTI and deciphering P. mirabilis pathogenesis.

Testing a Model of Self-Management of Fluid Intake in Community-Residing Long-term Indwelling Urinary Catheter Users

BACKGROUND

Urinary tract infection and blockage are serious and recurrent challenges for people with long-term indwelling catheters, and these catheter problems cause worry and anxiety when they disrupt normal daily activities.

OBJECTIVE

The goal was to determine whether urinary catheter-related self-management behaviors focusing on fluid intake would mediate fluid intake-related self-efficacy toward decreasing catheter-associated urinary tract infection (CAUTI) and/or catheter blockage.

METHODS

The sample involved data collected from 180 adult community-living, long-term indwelling urinary catheter users. The authors tested a model of fluid intake self-management related to fluid intake self-efficacy for key outcomes of CAUTI and blockage. To account for the large number of zeros in both outcomes, a zero-inflated negative binomial (ZINB) structural equation model was tested.

RESULTS

Structurally, fluid intake self-efficacy was positively associated with fluid intake self-management, suggesting that higher fluid intake self-efficacy predicts more (higher) fluid intake self-management; however, fluid intake self-management was not associated with either the frequency of CAUTIs or the presence or absence of CAUTI. Fluid intake self-efficacy was positively related to fluid intake self-management, and fluid intake self-management predicted less frequency of catheter blockage, but neither fluid intake self-efficacy nor fluid intake self-management predicted the presence or absence of blockage.

DISCUSSION

Further research is needed to better understand determinants of CAUTI in long-term catheter users and factors which might influence or prevent its occurrence. Increased confidence (self-efficacy) and self-management behaviors to promote fluid intake could be of value to long-term urinary catheter users to decrease catheter blockage.

Impact of the lack of community urinary catheter care services on the Emergency Department

OBJECTIVES

To conduct an audit of patients presenting with long-term urinary catheter (LTC)-associated problems to our Emergency Department (ED) and to assess the availability of community nursing support for their LTC. We also estimated the cost implication to the health service and the potential solutions to this issue, as although catheter care is provided by community nurses, LTC problems are common presentations to the ED and are often significant burdens to the services.

PATIENTS AND METHODS

A study was carried out of all patients presenting to the ED with a urinary catheter problem, specifically studying LTCs and the reason for presentation, district nurses' involvement, and the intervention received.

RESULTS

In all, 78 patients with a urinary catheter problem presented to the ED over a 69-day period, of whom 59 (68%) had a LTC. In all, 33 patients (42%) attended during normal working hours between 0900 and 1700 h. The mean (range) age was 74 (42-93) years and the duration the LTC had been in situ was 11 (1-120) months. The most common reasons for attendance were blocked catheter (37 patients, 47%) and catheter-bypass (18, 23%). Only 28 patients (36%) were known to district nursing services, and 14% were referred by a district nurse. Most of the remaining patients self-referred to the ED. No patient had any documented contact with their general practitioner. In addition, 64 patients (82%) had their catheter issues addressed adequately by ED nurses or doctors, without any urology involvement.

CONCLUSIONS

The high morbidity of LTCs causes a considerable demand on ED services, and has heavy cost implications to the health system. Most patients had minimal community nurse support, and their catheter problems were easily dealt with by ED nurses and doctors.

Urinary catheters: history, current status, adverse events and research agenda

For more than 3500 years, urinary catheters have been used to drain the bladder when it fails to empty. For people with impaired bladder function and for whom the method is feasible, clean intermittent self-catheterization is the optimal procedure. For those who require an indwelling catheter, whether short- or long-term, the self-retaining Foley catheter is invariably used, as it has been since its introduction nearly 80 years ago, despite the fact that this catheter can cause bacterial colonization, recurrent and chronic infections, bladder stones and septicaemia, damage to the kidneys, the bladder and the urethra, and contribute to the development of antibiotic resistance. In terms of medical, social and economic resources, the burden of urinary retention and incontinence, aggravated by the use of the Foley catheter, is huge. In the UK, the harm resulting from the use of the Foley catheter costs the National Health Service between £1.0-2.5 billion and accounts for ∼2100 deaths per year. Therefore, there is an urgent need for the development of an alternative indwelling catheter system. The research agenda is for the new catheter to be easy and safe to insert, either urethrally or suprapubically, to be retained reliably in the bladder and to be withdrawn easily and safely when necessary, to mimic natural physiology by filling at low pressure and emptying completely without damage to the bladder, and to have control mechanisms appropriate for all users.

Self-management intervention for long-term indwelling urinary catheter users: randomized clinical trial

BACKGROUND

People using long-term indwelling urinary catheters experience multiple recurrent catheter problems. Self-management approaches are needed to avoid catheter-related problems.

OBJECTIVES

The aim was to determine effectiveness of a self-management intervention in prevention of adverse outcomes (catheter-related urinary tract infection, blockage, and accidental dislodgement). Healthcare treatment associated with the adverse outcomes and catheter-related quality of life was also studied.

METHODS

A randomized clinical trial was conducted. The intervention involved learning catheter-related self-monitoring and self-management skills during home visits by a study nurse (twice during the first month and at 4 months-with a phone call at 2 months). The control group received usual care. Data were collected during an initial face-to-face home interview followed by bimonthly phone interviews. A total of 202 adult long-term urinary catheter users participated. Participants were randomized to treatment or control groups following collection of baseline data. Generalized estimating equations were used for the analysis of treatment effect.

RESULTS

In the intervention group, there was a significant decrease in reported blockage in the first 6 months (p = .02), but the effect did not persist. There were no significant effects for catheter-related urinary tract infection or dislodgment. Comparison of baseline rates of adverse outcomes with subsequent periods suggested that both groups improved over 12 months.

DISCUSSION

A simple-to-use catheter problems calendar and the bimonthly interviews might have functioned as a modest self-monitoring intervention for persons in both groups. A simplified intervention using a self-monitoring calendar is suggested-with optimal and consistent fluid intake likely to add value.

Defining and advancing education and conservative therapies of underactive bladder

In contrast to other forms of voiding dysfunction, underactive bladder (UAB) has traditionally received little research or educational attention. This is changing as our understanding of the underlying mechanisms of detrusor dysfunction and other forms of underactive bladder improves. In addition, the impact of UAB on patient symptoms, general and health-related quality of life, and caregiver burden are becoming more recognized. However, there remains a paucity of data on the subject, and an extensive need for additional research and education on the topic. This paper explores the current state of knowledge about UAB with an emphasis on education regarding the condition and conservative methods of assessment and treatment. Recommendations for future work in this area are considered.

Perceived value of a urinary catheter self-management program in the home

A long-term indwelling urinary catheter intervention was tested in a randomized trial that is described in this article. The perceived value of the intervention to the catheter users, one of the study's specific aims, was assessed at the end of their 12-month participation and is reported here. Study participants' responses, our findings, and implications for home healthcare are discussed.

Clinical complications of urinary catheters caused by crystalline biofilms: something needs to be done

This review is largely based on a previous paper published in the journal Spinal Cord. The care of many patients undergoing long-term bladder catheterization is complicated by encrustation and blockage of their Foley catheters. This problem stems from infection by urease-producing bacteria, particularly Proteus mirabilis. These organisms colonize the catheter forming an extensive biofilm; they also generate ammonia from urea, thus elevating the pH of urine. As the pH rises, crystals of calcium and magnesium phosphates precipitate in the urine and in the catheter biofilm. The continued development of this crystalline biofilm blocks the flow of urine through the catheter. Urine then either leaks along the outside of the catheter and the patient becomes incontinent or is retained causing painful distension of the bladder and reflux of urine to the kidneys. The process of crystal deposition can also initiate stone formation. Most patients suffering from recurrent catheter encrustation develop bladder stones. P. mirabilis establishes stable residence in these stones and is extremely difficult to eliminate from the catheterized urinary tract by antibiotic therapy. If blocked catheters are not identified and changed, serious symptomatic episodes of pyelonephritis, septicaemia and endotoxic shock can result. All types of Foley catheters including silver- or nitrofurazone-coated devices are vulnerable to this problem. In this review, the ways in which biofilm formation on Foley catheters is initiated by P. mirabilis will be described. The implications of understanding these mechanisms for the development of an encrustation-resistant catheter will be discussed. Finally, the way forward for the prevention and control of this problem will be considered.

The management of bladder lithiasis in the modern era of endourology

The recent evolution in the management of vesical lithiasis is a result of the major advancements of modern endourology. The ideal method for achieving stone clearance, however, remains an issue of debate and evidence-based recommendations are lacking. Contemporary literature focuses on management options, such as extracorporeal shockwave lithotripsy, transurethral, percutaneous and minimally-invasive surgery, as well as state-of-the-art energy sources. Issues of particular interest include the results of comparative studies, the management of lithiasis in the paediatric population and the recent challenge of the traditional dogma that dictated BPH surgery for the management of vesical lithiasis secondary to bladder outlet obstruction.

Dietary therapy for patients with hypocitraturic nephrolithiasis

Citrate is an inhibitor of urinary stone formation. Clinical and in vitro data suggest that increasing urine citrate levels will decrease the precipitation of calcium stones. Historically, low urinary citrate has been treated with oral potassium citrate or sodium citrate supplementation, but recent studies have shown the potential of dietary interventions to raise urine citrate levels. Dietary therapy with commercial or homemade beverages is attractive to patients who would prefer nonpharmacological intervention. To date, several drinks have shown promise but no single beverage has been found to consistently raise urine citrate levels in a reproducible fashion. Further research is necessary to develop the ideal dietary therapy for hypocitraturic calcium nephrolithiasis.