Water or antiseptic for periurethral cleaning before urinary catheterization: a randomized controlled trial

Pharmaceutical Incompatibility of Lubricating Gel Formulation Reduces Antibacterial Activity of Chlorhexidine Gluconate: In Vitro Study in Northern Thailand

Chlorhexidine gluconate (CHG) is a cationic disinfectant. The positive charge of CHG molecules binds to phospholipid's negative charge in bacterial cell walls, causing membrane disruption. The in vitro kinetic physical, chemical and biological incompatibilities of nine lubricating gels with 1% w/v CHG were investigated. Five containing anionic thickener, two containing nonionic thickener, and two containing cationic thickener were collected from hospitals in northern Thailand. All the anionic and nonionic lubricating gels significantly reduced (p < 0.05) the CHG amount after 5 min of exposure time from 12.54% to 54.99%, respectively. In contrast, the amount of CHG exposed with cationic lubricating gels was maintained. Antibacterial activity was significantly reduced to a 1.17-4.33 log10 reduction for Staphylococcus aureus ATCC25923 and a 1.07-3.52 log10 reduction for Escherichia coli ATCC25922 after 5 min exposure to all anionic and nonionic lubricating gels. In contrast, the two cationic lubricating gels maintained the antibacterial activity of the CHG solution (5.69 ± 0.14 and 5.45 ± 0.17 log10 reduction). The results suggest that anionic and nonionic thickeners in lubricating gel formulations may neutralize the positive charge and reduce the antibacterial activity of CHG, reducing its effectiveness as a disinfectant.

Effectiveness of meatal cleaning in the prevention of catheter-associated urinary tract infections and bacteriuria: an updated systematic review and meta-analysis

OBJECTIVE

A systematic review on meatal cleaning prior to urinary catheterisation and post catheterisation and reduces the risk catheter-associated urinary tract infections (CAUTIs) and bacteriuria was published in 2017, with further studies undertaken since this time. The objective of this paper is to present an updated systematic review on the effectiveness of antiseptic cleaning of the meatal area for the prevention of CAUTIs and bacteriuria in patients who receive a urinary catheter.

DESIGN

Systematic review.

DATA SOURCES

Electronic databases Cochrane Library, PubMed, Embase, The Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline and Academic Search Complete were searched from 1 January 2016 and 29 February 2020.

ELIGIBILITY CRITERIA

Randomised controlled trials (RCTs) and quasi-experimental studies evaluating the use of antiseptic, antibacterial or non-medicated agents for cleaning the meatal, periurethral or perineal areas before indwelling catheter insertion or intermittent catheterisation or during routine meatal care.

DATA EXTRACTION AND SYNTHESIS

Data were extracted using the Cochrane Collaboration's data collection form for RCTs and non-RCTs. Data were extracted by one researcher and then checked for accuracy by a second researcher.

RESULTS

A total of 18 studies were included. Some potential benefit of using antiseptics, compared with non-antiseptics for meatal cleaning to prevent bacteriuria and or CAUTI was identified (OR 0.84, 95% CI 0.69 to 1.02; p=0.071). Antiseptics (chlorhexidine or povidine-iodine) may be of value for meatal cleaning on the incidence of CAUTI, compared with comparator agents (saline, soap or antimicrobial cloths) (OR=0.65, 95% CI 0.42 to 0.99; p=0.047).

CONCLUSION

There is emerging evidence of the role of some specific antiseptics (chlorhexidine) prior to urinary catheterisation, in reducing CAUTIs, and some potential benefit to the role of antiseptics more generally in reducing bacteriuria.

PROSPERO REGISTRATION NUMBER

CRD42015023741.

A comparison of the efficacy of normal saline and Savlon solutions in periurethral cleaning to reduce catheter-associated bacteriuria: A randomized control trial

OBJECTIVE

Catheter-associated urinary tract infection (CAUTI) is a common nosocomial infection. However, there has been no randomized control trial (RCT) comparing the efficacy of periurethral cleaning solutions for reducing CAUTI. This study aimed to compare the efficacy of normal saline solution (NSS) and Savlon solution.

METHODS

A non-inferiority cross-over RCT was conducted to compare the 2 solutions by the incidence of significant bacteriuria (SB) on day 5 after Foley catheterization. Patients admitted to a tertiary referral hospital from June 2018 to August 2019 participated in the study. The acceptable prespecified non-inferiority margin was 10%.

RESULTS

There were 265 and 275 patients in the NSS and Savlon groups, respectively. The incidence of CAUTI was 2.65/1000 catheter-days, and the median duration of catheterization was 5 days (IQR 4, 7). There was no significant difference between the incidence of SB in the NSS and Savlon groups, as indicated by the adjusted difference of 0.6 (95% CI: -3.1-4.2).

CONCLUSION

This study was the first RCT in patients from multiple hospital units to compare the efficacy of the 2 solutions in the periurethral cleaning process. The study demonstrated non-inferiority of NSS to Savlon solution.

THAI CLINICAL TRIALS REGISTRY STUDY ID

TCTR20180518001.

Foley catheters functionalised with a synergistic combination of antibiotics and silver nanoparticles resist biofilm formation

Foley catheters are inevitable in health care unit. Pathogens colonise and form biofilm on catheter causing catheter-associated urinary tract infection. Therefore, the authors aimed to functionalise catheter to resist biofilm formation. The authors impregnated urinary catheters with a synergistic combination of antibiotics and silver nanoparticles (SNPs) to evaluate antibiofilm efficacy in vitro and in vivo. SNPs were synthesised using Spirulina platensis. Synergy between the SNPs and antibiotics was determined by the checker-board method. In vivo efficacy of the functionalised catheters was assessed in mice. Liver and kidney function tests of mice were performed. The in vitro anti-adherence activity of the functionalised catheters was evaluated after 2 years. Nanoparticle sizes were 42-75 nm. Synergistic activity was observed among SNPs (2 µg/ml), amikacin (6.25 µg/ml), and nitrofurantoin (31.25 µg/ml). In mice, catheters functionalised with combinations of antibiotics and SNPs exhibited no colonisation until Day 14. Blood, liver, and kidney tests were normal. After 2 years, catheters functionalised with antibiotics exhibited 25% inhibition of bacterial adhesion, and catheters functionalised with the nanoparticle-antibiotic combination exhibited 90% inhibition. Impregnation of urinary catheters with a synergistic combination of antibiotics and SNPs is an efficient and promising method for preventing biofilm formation.

Does periurethral cleaning with water prior to indwelling urinary catheterization increase the risk of urinary tract infections? A systematic review and meta-analysis

OBJECTIVE

To determine whether periurethral cleaning with water before indwelling urinary catheterization increases the risk of urinary tract infections (UTIs) compared with studies using anti-infective agents.

METHODS

A literature search via MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials through October 2017 and a manual search of references for additional relevant studies. Trials studying clean intermittent catheterization were excluded. Data were extracted independently by 2 reviewers. Disagreements were resolved through discussion. Results of randomized controlled trials were pooled using random effects models. Both individual and pooled risk estimates were reported using risk ratios (RRs) and 95% confidence intervals (CIs).

RESULTS

From 121 identified articles, 5 studies involving 824 patients were included in the review (822 patients included in meta-analysis). No statistical significance in the incidence of UTIs existed between the water group and antiseptics group (RR, 1.07; 95% CI, 0.77-1.49; P = .89; I² = 0%). Available data comparing water with povidone-iodine or chlorhexidine gluconate demonstrated no significant difference between the incidence of UTIs (RR, 1.10; 95% CI, 0.66-1.83; P = .79; I² = 0%; and RR, 1.05; 95% CI, 0.68-1.62; P = .72; I² = 0%; respectively).

CONCLUSIONS

Based on current data, water is as safe as other topical antiseptics for periurethral cleansing before indwelling urinary catheter insertion.

Comparison of the preventive effect of urethral cleaning versus disinfection for catheter-associated urinary tract infections in adults: A network meta-analysis

BACKGROUND

Catheter-associated urinary tract infections (CAUTIs) are the main cause of infectious complications in patients with indwelling urinary catheters (IDCs). However, the best cleaning methods for the prevention of CAUTIs have not been evaluated clearly in previous studies.

METHODS

An electronic database search was performed, from inception to December 2017. Randomized controlled trials and quasi-experimental trials using different methods of urethral cleaning versus disinfection to prevent CAUTIs were considered. The study selection and data collection were performed independently by two reviewers. The risk of bias assessment was performed using the Cochrane risk of bias scale. The primary outcome was the incidence rates of CAUTIs. A network meta-analysis was conducted to compare the effect among the different methods of urethral cleaning versus disinfection to prevent CAUTIs.

RESULTS

Thirty-three studies (6490 patients) with seven different methods of urethral cleaning versus disinfection were eligible for inclusion, and the data were summarized in the network meta-analysis. No evidence of heterogeneity (P>0.05) was observed among the studies. The network meta-analysis showed that there was no difference in the incidence of CAUTIs when comparing the different urethral cleaning methods versus disinfection (P>0.05 for all). However, chlorhexidine ranked first in the results of the Bayesian analysis and is recommended for preventing CAUTIs.

CONCLUSIONS

Current evidence suggests that there are no significant differences among different urethral cleaning versus disinfection methods with regard to CAUTI incidence rates.

Urinary Catheter-Associated Infections

Catheter-associated urinary tract infection remains one of the most prevalent, yet preventable, health care-associated infections. General prevention strategies include strict adherence to hand hygiene and antimicrobial stewardship. Duration of urinary catheterization is the most important modifiable risk factor. Targeted prevention strategies include limiting urinary catheter use; physician reminder systems, nurse-initiated discontinuation protocols, and automatic stop orders have successfully decreased catheter duration. Alternatives should be considered. If catheterization is necessary, proper aseptic practices for insertion and maintenance and closed catheter collection systems are essential for prevention. The use of bladder bundles and collaboratives aids in the effective implementation of prevention measures.

Urinary tract infection control in intensive care patients

This retrospective study tried to find the potential approach for reducing the urinary tract infection (UTI) in intensive care patients (ICPs) among adult population.In total, 96 eligible ICP cases were included. Of these, 48 cases received 10% povidone-iodine and were assigned to the intervention group, while the other 48 cases underwent sterile water, and were assigned to the control group for the prevention of catheter-associated UTI before indwelling urinary catheter insertion in ICP. The primary outcome was the occurrence of an UTI after the indwelling catheter. The secondary outcome was the identification of pathogenic species. The outcomes were assessed after catheter removed.After catheter removal, the occurrence of an UTI did not differ significantly between the 2 groups (P = .34). In addition, no significant differences regarding the pathogenic species were detected between the 2 groups (Escherichia coli, P = .73; Candida albicans, P = .57; Enterococcus, P = .65; Proteus mirabilis, P = .50; Citrobacter, P = .50; Klebsiella pneumoniae, P = .57).The use of 10% povidone-iodine may not help reducing UTI in ICP.

Telenursing Intervention for Clean Intermittent Urinary Catheterization Patients: A Pilot Study

Telenursing is a promising strategy to make nursing care feasible in different health situations, mainly to help patients with chronic illnesses. The aim in this study was to test the feasibility (acceptability and usability) of a telenursing intervention in care delivery to patients using clean intermittent urinary catheterization. This descriptive study focused on an intervention involving urology outpatients. The telenursing intervention was implemented synchronously by audio calls and chat and asynchronously by e-mail as part of a pilot study. The contact between nurse and patient was undertaken through an active search or on spontaneous demand, in which the patient contacted the nurse when necessary. During the 5 weeks of study, 21 telenursing care sessions took place, including 13 (61.9%) on spontaneous demand and eight (38.1%) on active demand. With regard to the technological resource used, 13 telenursing sessions (61.9%) took place by telephone call and eight (30.1%) by e-mail. The pilot study demonstrated the potential of the telenursing intervention to achieve important results, and as a complement to the patients' traditional health treatment. In addition, it revealed various barriers that need to be overcome for this type of care to take place effectively.

Telenursing manual for providing care to patients using clean intermittent urinary catheterization

Abstract Objective: To develop and evaluate apparent and content validity of a telenursing manual to support nurses in the care delivery of patients using clean intermittent urinary catheterization. Methods: Methodological study addressing the development and validation of a telenursing manual. The expert group who validated the telenursing manual was composed of 11 nurses. An inter-rater level of agreement of 70% was considered for each aspect of the instrument. Results: The following levels of agreement were obtained for each aspect: Language 97%, Content 97.7% and Objectives, Relevance, Functionality and Usability 100% each. Conclusion: The manual is available for access and represents an important initiative for the field of telenursing in Brazil, assisting nurses in the telecare provided to patients using clean intermittent urinary catheterization.

Varna tehnika dolgotrajne intermitentne samokatetrizacije

Uvod: Intermitentna samokatetrizacija je prednostna metoda praznjenja sečnega mehurja pri pacientih z zastojem urina. Medicinska sestra običajno pacienta nauči čiste ali aseptične tehnike samokatetrizacije. Namen prispevka je s pregledom literature ugotoviti, ali obstaja optimalna tehnika intermitentne samokatetrizacije, ki bi jo medicinske sestre priporočale pacientom. Metode: Uporabljen je bil sistematični pregled literature v bazah podatkov: CINAHL, Medline, ProQuest, COBIB.SI in Cochrane Library. Vključena je bila literatura od prve omembe samokatetrizacije leta 1972 do leta 2016. S selekcijo prvotnih 350 virov smo glede na njihovo skladnost z namenom raziskave izbrali 67 enot literature. Rezultati: Osemnajst referenc, izbranih z orodjem CASP, je bilo objavljenih med letoma 1992 in 2015: šest randomiziranih kliničnih in pet kohortnih raziskav ter šest sistematičnih pregledov literature in ena kritika. Ključne spremenljivke analize zbranih podatkov so bile sterilnost katetra, vrsta vlažilnega gela in higiena periuretralnega področja. Diskusija in zaključek: Nobena tehnika intermitentne samokatetrizacije se ne izkaže kot optimalna. Ob upoštevanju značilnosti in sposobnosti pacienta je za slovenske razmere najboljša uporaba sterilnega materiala za enkratno uporabo (katetra in vlažilnega gela), higiena periuretralnega področja s sterilno solucijo in tamponi ter tehnika nedotikanja.

Clean intermittent self-catheterisation: working with patients

Clean intermittent self-catheterisation is carried out when the bladder cannot be emptied adequately by voiding. Because learning how to self-catheterise can be daunting, it is essential that the nurse has the time, knowledge and skills necessary support the patient during the learning phase, so that he or she can develop confidence and master the technique. Causes for urinary retention are considered and step-by-step instructions are given for both female and male patients, including problems that may be encountered and how these can be overcome. Examples of catheters and other aids available are suggested, with reference to particular features they may have, to overcome difficulties or to assist patients with particular needs. Issues including infection, frequency of catheterisation and fluid intake are also discussed.

Chlorhexidine: an unrecognised cause of anaphylaxis

Chlorhexidine is a highly effective antiseptic and disinfectant. In the past 20 years there has been a substantial increase in the number of chlorhexidine containing products used in healthcare. Anaphylaxis to chlorhexidine was first reported in 1984 and was almost always seen in men. However, in the last 4 years we have observed a surge in confirmed cases of anaphylaxis to chlorhexidine, with increasing numbers of female patients recently diagnosed. Yet, awareness of chlorhexidine as a cause of anaphylaxis is low because it is not a drug but a 'hidden' allergen, for example as a coating on medical devices such as central lines and urinary catheters. Patients will often have more than one allergic/anaphylactic reaction before the diagnosis is suspected. We have observed that there is poor recognition of an initial allergic reaction to chlorhexidine, which is well described. This, alongside poor labelling of chlorhexidine containing products, has resulted in further inadvertent exposure resulting in severe anaphylaxis. Prompt referral to a specialist allergy centre ensures appropriate investigations, diagnosis and management. Increasing awareness of the potential risk of life-threatening anaphylaxis associated with chlorhexidine use is vital, particularly in perioperative procedures. Healthcare workers are fundamental in avoiding and preventing further reactions to chlorhexidine containing products in patients diagnosed with anaphylaxis to chlorhexidine.

Intermittent self-catheterisation in women: reducing the risk of UTIs

Intermittent self-catheterisation (ISC) is the insertion and removal of a catheter to drain the bladder and is a safe and effective way to preserve renal function. It can be used as a one-off intervention to drain urine post-operatively or to measure residual urine volumes if a bladder scanner is unavailable. ISC can also be used as a long-term option to manage bladder dysfunction, and for some provides an excellent option to maintain independence and improve quality of life. Urinary tract infections are a common complication for women undertaking ISC. This article explores the prevention of urinary tract infections in women undertaking long-term ISC for the management of bladder dysfunction.

[Effectiveness of cleaning or disinfecting the urinary meatus before urinary catheterization: a systematic review]

The urinary tract infections associated with catheterization are very common in hospital and home care contexts. Currently there are several recommendations for its prevention, however, when approaching the kind of solute used in the urinary meatus prior to catheterization doubts continue to persist. Thus this study aimed at determining the effectiveness of cleaning the urinary meatus with water or saline comparing to its sterilization through a systematic review and meta-analysis. In order to do so, the principles proposed by the Cochrane Handbook were followed, a critical analysis was conducted by two researchers and the statistical analysis was performed with the use of STATA 11.1. We concluded that the cleaning or disinfection of the urinary canal prior to bladder catheterization is not statistically significant (OR=1.07, CI 95%=0.68-1.68, p=0.779) and that there is some evidence that the use of water/saline reduces rates of UTI (urinary tract infection).

Integrative review: evidences on the practice of intermittent/indwelling urinary catheterization

OBJECTIVE

to seek the best evidence available in the literature concerning the knowledge produced and related to the techniques of intermittent and indwelling urinary catheterization, so as to place the nursing care given to patients submitted to urinary catheterization on a scientific foundation and to prevent urinary tract infections.

METHOD

the literature search was undertaken in the Pubmed and Cochrane databases for the development of the integrative review. The sample was of 34 articles. These were analyzed by two independent researchers using an instrument adapted for ascertaining the level of evidence and the grade of recommendation, in addition to the use of the Jadad scale.

RESULTS

the evidence available related to the nursing care for patients submitted to urinary catheterization is: the infection rate in the urinary tract does not alter whether the perineum is cleaned with sterile water or not, or with the use of povidone-iodine solution or chlorhexidine; or using clean or sterile technique. The use of an intermittent catheter with clean technique results in low rates of complications or infections compared to the use of an indwelling catheter. The removal of the catheter in up to 24 hours after surgery and the use of an antimicrobial-impregnated or hydrophilic-coated catheter reduce urinary tract infection .

CONCLUSIONS

there are controversies in relation to periurethral cleansing technique, the type of material the catheter is made of, and some procedures for the maintenance and removal of the catheter. This review's results represent an updating of the nurse's conducts and decision-making for the prevention of urinary tract infections in urinary catheterization.

epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England

National evidence-based guidelines for preventing healthcare-associated infections (HCAI) in National Health Service (NHS) hospitals in England were originally commissioned by the Department of Health and developed during 1998-2000 by a nurse-led multi-professional team of researchers and specialist clinicians. Following extensive consultation, they were first published in January 2001(1) and updated in 2007.(2) A cardinal feature of evidence-based guidelines is that they are subject to timely review in order that new research evidence and technological advances can be identified, appraised and, if shown to be effective for the prevention of HCAI, incorporated into amended guidelines. Periodically updating the evidence base and guideline recommendations is essential in order to maintain their validity and authority. The Department of Health commissioned a review of new evidence and we have updated the evidence base for making infection prevention and control recommendations. A critical assessment of the updated evidence indicated that the epic2 guidelines published in 2007 remain robust, relevant and appropriate, but some guideline recommendations required adjustments to enhance clarity and a number of new recommendations were required. These have been clearly identified in the text. In addition, the synopses of evidence underpinning the guideline recommendations have been updated. These guidelines (epic3) provide comprehensive recommendations for preventing HCAI in hospital and other acute care settings based on the best currently available evidence. National evidence-based guidelines are broad principles of best practice that need to be integrated into local practice guidelines and audited to reduce variation in practice and maintain patient safety. Clinically effective infection prevention and control practice is an essential feature of patient protection. By incorporating these guidelines into routine daily clinical practice, patient safety can be enhanced and the risk of patients acquiring an infection during episodes of health care in NHS hospitals in England can be minimised.

Cateter urinário: mitos e rituais presentes no preparo do paciente

OBJETIVO: Este estudo buscou identificar e descrever mitos e rituais no preparo do paciente para a inserção do cateter urinário. MÉTODOS: Trata-se de um estudo observacional, exploratório e descritivo, realizado em nove hospitais de um município do interior paulista. Seguidos os preceitos éticos, os dados foram coletados por entrevista, junto ao enfermeiro designado pela instituição, utilizando-se um instrumento semiestruturado. Dentre as 13 instituições do município, nove participaram do estudo. RESULTADOS: Todos os hospitais possuíam o procedimento de cateterismo urinário padronizado e implantado. Durante o preparo do paciente, 5 (55,5%) não fizeram referência à orientação, privacidade e humanização. Todas adotam procedimentos divergentes para higiene e antissepsia do meato uretral, com presença de mitos e rituais que se sobressaem às evidências científicas e destacam o modelo funcionalista nos procedimentos realizados pela equipe de enfermagem. CONCLUSÃO: Há necessidade de reavaliar a intervenção de cateterismo urinário, com discussões interdisciplinares, dando ênfase à utilização de princípios científicos.

Reducing catheter-associated urinary tract infection in the critical care unit

Changes in reimbursement policies have focused attention on the use of indwelling catheters in the critical care unit as well as their role in hospital-acquired urinary tract infections. Implementation of an evidence-based prevention program can significantly reduce both the prevalence of indwelling catheterization and the incidence of hospital-acquired catheter-associated urinary tract infection. This article describes the epidemiology and pathophysiology of catheter-associated urinary tract infection, and outlines essential elements of an evidence-based prevention program for the critical care unit.

Urinary tract infections

Catheter-associated urinary tract infections (CAUTIs) account for approximately 40% of all health care-associated infections. Despite studies showing benefit of interventions for prevention of CAUTI, adoption of these practices has not occurred in many healthcare facilities in the United States. As urinary catheters account for the majority of healthcare-associated UTIs, the most important interventions are directed at avoiding placement of urinary catheters and promoting early removal when appropriate. Alternatives to indwelling catheters such as intermittent catheterization and condom catheters should be considered. If indwelling catheterization is appropriate, proper aseptic practices for catheter insertion and maintenance and use of a closed catheter collection system are essential for preventing CAUTI. The use of antimicrobial catheters also may be considered when the rates of CAUTI remain persistently high despite adherence to other evidence-based practices, or in patients deemed to be at high risk for CAUTI or its complications. Attention toward prevention of CAUTI will likely increase as Center for Medicare and Medicaid Services and other third-party payers no longer reimburse for hospital-acquired UTI.

A systematic review of the management of short-term indwelling urethral catheters to prevent urinary tract infections

BACKGROUND

Indwelling urinary catheterisation is a relatively common procedure in hospital settings, associated with potential risk of infection. Around 80% of urinary tract infections (UTIs) are associated with urinary catheters and the risk of infection increases in patients who are acutely ill. The objective of this review was to present the best available critically appraised evidence related to preventing infections associated with the use of short-term indwelling urethral catheters. This review is an update of a previous review published in 2004.

REVIEW METHODS

The review considered randomised controlled trials that included adult patients with short-term indwelling urinary catheters. The main interventions related to catheterisation techniques, meatal care, catheter composition, bladder irrigation, drainage systems, care delivery practices and education programs. The primary outcome of interest was the difference in the rates of UTIs between the intervention group and control group. This review was limited to short-term urethral catheters, so studies that evaluated long-term or suprapubic catheters were excluded.

SEARCH STRATEGY

The search included both published and unpublished studies with an initial limited search of MEDLINE and CINAHL databases undertaken to identify key words contained in the title or abstract, and index terms used to describe relevant interventions. A second extensive search used all identified key words and index terms. The third step included a search of the reference lists and bibliographies of relevant articles.

METHODOLOGICAL QUALITY

The methodological quality of the included papers was assessed using a checklist developed by the Joanna Briggs Institute. Two independent reviewers conducted critical appraisal and data extraction and any disagreements that arose were addressed through mutual discussion.

RESULTS

The review found six new studies in relation to catheter composition and delivery care practices interventions. Studies from previous review have been reported on in the results, discussion and conclusion sections. No one type of catheter was found to be better than another in terms of reducing the risk of bacteriuria in hospitalised adults. The incidence of catheter associated bacteriuria and funguria (CABF) was lower in adult trauma patients when nitrofurazone-impregnated catheters were used. Nitrofurazone-coated and silver alloy-coated catheters reduced the development of asymptomatic bacteriuria during short-term (< 30 days) use when compared with latex or silicon control catheters. Studies that compared immediate versus delayed catheter removal following operations found that early removal of catheter after operation was safe and that there was a tendency for increased infection with longer duration of catheterisation. Stop (prewritten) orders for urinary catheters resulted in a significant reduction in duration of inappropriate catheterisation days.There was no significant difference in infection rate using either sterile surgical or non-sterile insertion technique. The use of water for cleansing prior to catheter insertion was recommended. There was no additional benefit from specific meatal care other than standard daily personal hygiene and removal of debris. Infection rates were similar for both latex and silicone catheters. Comparisons between silver and Teflon coating clearly favoured the silver alloy coating.The use of a complex closed drainage system in the intensive care environment did not confer any additional benefit. Studies comparing types of junction seals and use of junction seals either prior to or following catheterisation found no clear benefit from using either preconnected sealed systems or sealed systems with the addition of silver releasing devices. Neither the addition of chlorhexidine nor hydrogen peroxide to the drainage bag was found to be effective at reducing UTI rates. The findings indicated there was a higher incidence of bacteriuria associated with Foley catheters compared with intermittent catheterisation (P < 0.025). A single RCT examined the effect on UTI rates of routine bag changes against no routine bag change. Routine bag changes were not advantageous in reducing the risk of infection.

CONCLUSIONS

Current RCT evidence suggests the use of a surgical sterile catheterisation technique is not required, and that tap water is sufficient for cleaning genitalia. Following insertion, daily hygiene around the meatal area is as effective as catheter toilets; and catheters impregnated with silver may reduce the incidence of catheter associated bacteriuria. Sealed (e.g. taped, presealed) drainage systems should not be relied upon as the sole mechanism for prevention of bacteriuria. The addition of antibacterial solutions to drainage bags and the routine change of drainage bags had no effect on catheter associated infection.Identified evidence consistently supported early removal of catheter after operations. New evidence was also identified to support the use of "stop orders" for urinary catheters in reducing prolonged unnecessary catheterisation. However, most of the recommendations arising from this review were based on single studies, often with limited numbers of participants.

IMPLICATIONS FOR PRACTICE

The following are some of the recommendations based on the best available clinical evidence.Use of stop order approach to physicians by nurses can be recommended to reduce prolonged unnecessary catheterisations.

IMPLICATIONS FOR RESEARCH

Most of the recommendations arising from this review were based on single studies, often with limited numbers of participants. There is an urgent need to replicate these studies in other clinical settings.Further high quality RCTs with adequate allocation concealment and blinding are required with a focus on examining current techniques and methods in catheterisation and management. In addition, there are cost implications associated with new technologies for indwelling urethral catheter management that have not yet been adequately addressed.

Periurethral cleaning prior to urinary catheterization in children: sterile water versus 10% povidone-iodine

OBJECTIVE

To compare urinary infection rate in children cleaned with sterile water versus a 10% povidone-iodine before bladder catheterization.

METHODS

Prospective randomized controlled study of children requiring bladder catheterization in the emergency department whose parents consented to the study were randomly assigned to either of 2 groups, in which sterile water (the "sterile water" group) or 10% povidone-iodine (the "10% povidone-iodine" group) was to be used for peri-urethral cleansing prior to catheterization.

RESULTS

The sterile water group had 92 patients and the povidone-iodine group had 94. Most children (87%) were under 12 months of age. Urine cultures were positive in 16% of children in the povidone-iodine group and in 18% in the water group. There was no significant difference in signs and symptoms between the 2 groups. There was no significant association between solution preparation and cultures on univariate regression analysis.

CONCLUSIONS

Cleaning the periurethral area of children with sterile water prior to catheterization is not inferior to cleaning with povidone-iodine.

Chlorhexidine - Pharmacology and Clinical Applications

chlorhexidine is a widely used skin antisepsis preparation and is an ingredient in toothpaste and mouthwash. It is an especially effective antiseptic when combined with alcohol. Its antimicrobial effects persist because it is binds strongly to proteins in the skin and mucosa, making it an effective antiseptic ingredient for handwashing, skin preparation for surgery and the placement of intravascular access. Catheters impregnated with chlorhexidine and antimicrobial agents can reduce the incidence of catheter-related bloodstream infections. Contact dermatitis related to chlorhexidine is not common in health care workers. The incidence of contact dermatitis to chlorhexidine in atopic patients is approximately 2.5 to 5.4%. Acute hypersensitivity reactions to chlorhexidine are often not recognised and therefore may be underreported. This review discusses the pharmacology, microbiology, clinical applications and adverse effects of chlorhexidine.

Water versus antiseptic periurethral cleansing before catheterization among home care patients: a randomized controlled trial

BACKGROUND

There is a lack of research studies on periurethral cleansing before catheterization among home care patients. The purpose of this study was to compare the risk of acquiring symptomatic urinary tract infections through the conventional practice of using 0.05% chlorhexidine gluconate (CHG) versus sterile water for periurethral cleansing before insertion of an indwelling urinary catheter.

METHODS

A randomized controlled trial was used, and subjects were randomly allocated to either the sterile water group or the 0.05% CHG group. Urine specimens for culture were collected 4 times for each subject within 2 weeks.

RESULTS

Seventy-four urine samples were collected in 20 subjects (sterile water group, 8; 0.05% CHG group, 12). There was no significant difference in colonization count between the 2 groups. In addition, none of the subjects in the 2 groups developed symptomatic bacteriuria.

CONCLUSION

Using sterile water to clean the periurethral area before catheterization among home care patients will not increase the risk for urinary tract infections.

ANTIMICROBIAL ACTIVITY OF CEFAZOLIN-IMPREGNATED MESH GRAFTS

BACKGROUND

The aim of this study is the preparation and characterization of cefazolin-impregnated meshes (Surgipro; Tyco Healthcare USSC, Norwalk, CT, USA) to be used as antimicrobial devices.

METHODS

During the impregnation, poly(DL-lactide-co-glycolide) solution with cephazolin in dichloromethane was used as coating material. In vitro release experiment was carried out first; later cefazolin-impregnated meshes were evaluated for the characteristics of antimicrobial efficacy and in the last part of the study native and cefazolin-impregnated meshes were implanted in the rats. Cefazolin content was proposed as the effective parameter to control the cefazolin release rate and it was concluded that the higher amounts of initial cefazolin content caused higher release rates. In all cases (or with different cefazolin content for each mesh), the release rates were very rapid in the first 24 h and in the following periods rather slow release rates were obtained.

RESULTS

Antimicrobial activity was increased in the case of cefazolin-impregnated form and this efficiency was also increased by the higher amount of cefazolin in certain mesh pieces. Similar antimicrobial activities were observed in the in vitro studies.

CONCLUSION

In this study, almost all of the cefazolin-impregnated mesh grafts showed very high antimicrobial activity compared with the bare mesh (or mesh without cefazolin).

epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England

National evidence-based guidelines for preventing healthcare-associated infections (HCAI) in National Health Service (NHS) hospitals in England were commissioned by the Department of Health (DH) and developed during 1998-2000 by a nurse-led multi-professional team of researchers and specialist clinicians. Following extensive consultation, they were published in January 2001. These guidelines describe the precautions healthcare workers should take in three areas: standard principles for preventing HCAI, which include hospital environmental hygiene, hand hygiene, the use of personal protective equipment, and the safe use and disposal of sharps; preventing infections associated with the use of short-term indwelling urethral catheters; and preventing infections associated with central venous catheters. The evidence for these guidelines was identified by multiple systematic reviews of experimental and non-experimental research and expert opinion as reflected in systematically identified professional, national and international guidelines, which were formally assessed by a validated appraisal process. In 2003, we developed complementary national guidelines for preventing HCAI in primary and community care on behalf of the National Collaborating Centre for Nursing and Supportive Care (National Institute for Healthand Clinical Excellence). A cardinal feature of evidence-based guidelines is that they are subject to timely review in order that new research evidence and technological advances can be identified, appraised and, if shown to be effective in preventing HCAI, incorporated into amended guidelines. Periodically updating the evidence base and guideline recommendations is essential in order to maintain their validity and authority. Consequently, the DH commissioned a review of new evidence published following the last systematic reviews. We have now updated the evidence base for making infection prevention and control recommendations. A critical assessment of the updated evidence indicated that the original epic guidelines published in 2001 remain robust, relevant and appropriate but that adjustments need to be made to some guideline recommendations following a synopsis of the evidence underpinning the guidelines. These updated national guidelines (epic2) provide comprehensive recommendations for preventing HCAI in hospitals and other acute care settings based on the best currently available evidence. Because this is not always the best possible evidence, we have included a suggested agenda for further research in each section of the guidelines. National evidence-based guidelines are broad principles of best practice which need to be integrated into local practice guidelines. To monitor implementation, we have suggested key audit criteria for each section of recommendations. Clinically effective infection prevention and control practice is an essential feature of protecting patients. By incorporating these guidelines into routine daily clinical practice, patient safety can be enhanced and the risk of patients acquiring an infection during episodes of healthcare in NHS hospitals in England can be minimised.

Decreasing Urinary Tract Infections Through Staff Development, Outcomes, and Nursing Process

For patients with indwelling catheters, even with current standards of care and evidence-based practice, urinary tract infections continue to be a problem. Data were gathered on urinary catheter usage in a large, rural acute care hospital, and outcomes profiles were developed (including mortality, morbidity, length of stay, and costs). An innovative poster and video approach focusing on alternatives to urinary catheterization, early discontinuance of catheters, and proper insertion and care techniques were used to educate nursing staff and improve outcomes.

Infección urinaria asociada a catéteres urinarios en la comunidad

The prevalence of urinary catheterization in the community ranges from 0.02% to 0.07%. Despite the generalized use of closed systems, the risk of bacteriuria in patients with urethral catheters is 3%-10% per day and its presence is universal when the device remains in place for 30 days or longer. Although most of these episodes of bacteriuria are asymptomatic, up to 30% of them lead to clinical symptoms and complications, including severe sepsis and death. The microorganisms infecting the urine of catheterized patients frequently belong to species less susceptible to antibiotics and form biofilms on both the device's surfaces and probably also on the urothelium. Biofilm formation greatly hampers eradication of the involved flora by antibiotics, probably favors the development of resistance and, in some instances, constitutes the substrate on which crystal precipitates are deposited, eventually resulting in blockage of the catheter lumen. Due to the scarce number of controlled studies, there are still many gaps in our knowledge of important issues concerning the clinical management of patients with indwelling urinary catheters in the community. The present study reviews the epidemiology, risk factors, microbiology, pathogenesis, clinical manifestations, diagnosis, prevention and treatment of catheter-related urinary tract infections in the community setting.

Preventing and managing catheter-associated urinary tract infections

Since the Foley catheter was introduced in the 1930s it has become one of the primary sources of hospital acquired infections and long term urinary catheters used in community based patients account for some 4% of community nurses' time. This burden is likely to increase given the projected rise in life expectancy and size of the ageing population. This article considers the current literature around indwelling urinary catheterization and its management with a focus on long term catheterization in the community. The authors discuss contemporary strategies to manage or prevent CAUTI that are based on best practice guidelines. However, it is clear from the dearth of empirical evidence that there is an urgent need to establish well constructed research studies to investigate the prevalence of long term urinary catheterization in the community and the prevention and management of CAUTI.

Incidence of catheter-associated urinary tract infection among dogs in a small animal intensive care unit

OBJECTIVE

To determine incidence of and possible risk factors for catheter-associated urinary tract infection (UTI) among dogs hospitalized in an intensive care unit and compare results of bacterial culture of urine samples with results of bacterial culture of catheter tips.

DESIGN

Prospective study.

ANIMALS

39 dogs.

PROCEDURE

A standard protocol for aseptic catheter placement and maintenance was used. Urine samples were obtained daily and submitted for bacterial culture. When possible, the urinary catheter tip was collected aseptically at the time of catheter removal and submitted for bacterial culture. Bacteria that were obtained were identified and tested for antimicrobial susceptibility.

RESULTS

4 of the 39 (10.3%) dogs developed a UTI. The probability of remaining free from UTI after 1 day in the intensive care unit was 94.9%, and the probability of remaining free from UTI after 4 days was 63.3%. Bacteria isolates were generally common urinary tract pathogens and were susceptible to most antimicrobials. Specific risk factors for catheter-associated UTI, beyond a lack of antimicrobial administration, were not identified. Positive predictive value of bacterial culture of urinary catheter tips was only 25%.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggest that placement of an indwelling urinary catheter in dogs is associated with a low risk of catheter-associated UTI during the first 3 days after catheter placement, provided that adequate precautions are taken for aseptic catheter placement and maintenance. Results of bacterial culture of urinary catheter tips should not be used to predict whether dogs developed catheter-associated UTI.

The role of meatal disinfection in preventing catheter-related bacteriuria in an intensive care unit: a pilot study in Turkey

The purpose of this study was to investigate the efficacy of antiseptics meatal care in preventing catheter-related urinary tract infections (UTIs) in patients with an indwelling urinary catheter in the intensive care unit of Osmangazi University Medical School. One hundred patients were divided into four groups (25 per group) and treated with once or twice daily application of chlorhexidine gluconate or povidone-iodine. A control group was also studied (N=30). Urine samples were taken weekly and cultures were evaluated quantitatively. Meatal swabs were obtained on the first, fifth, and 10th day and determinated semiquantitatively. UTI was defined as bacteriuria with 10(5)cfu/L. Cultures showing no growth or mixed growths were stated as negative for UTI. UTI developed in 16 patients on days two, three, four, five and seven (including control group). Dominant micro-organisms in the meatal area were found to be Candida species. In nine cases the causative agents of UTI were Candida species. It was therefore decided that the use of antiseptics to clean the periurethral area provides no benefit in decreasing the rate of bacteriuria.

Management of short-term indwelling urethral catheters to prevent urinary tract infections

BACKGROUND

This systematic review updates a previous review published in 2000. The objective of this review was to present the best available evidence relating to the prevention of catheter-associated urinary tract infections (UTI).

SELECTION CRITERIA

This review considered randomised controlled trials (RCTs) of adult patients with short-term urethral catheters. In the absence of RCTs, other research designs such as non-randomised controlled trials and before and after studies were considered for inclusion. Interventions of interest were those related to the prevention of catheter-related UTI and included: sterile versus non-sterile insertion technique, special coatings to catheters versus standard non-coated catheters, the use of flush solutions, the use of solutions added to urinary drainage bag, maintenance of a closed urinary drainage circuit, the use of antireflux valves, antibiotic creams applied to the external meatus-catheter interface, meatal care regimens, education programs, and changed care delivery practices. This review was limited to short-term urethral catheters, and so studies evaluating long-term or suprapubic catheters were excluded. The primary outcome of interest was the difference in the rates of UTI between experimental intervention and the control.

SEARCH STRATEGY

The search included both published and unpublished studies with an initial limited search of MEDLINE and CINAHL databases undertaken to identify key words contained in the title or abstract, and index terms used to describe relevant interventions. A second extensive search used all identified key words and index terms. The third step included a search of the reference lists and bibliographies of relevant articles. The databases searched included: CINAHL, MEDLINE, Current Contents, Cochrane Library, Expanded Academic Index, and Embase. The Dissertation Abstracts International database was searched for unpublished studies.

ASSESSMENT OF METHODOLOGICAL QUALITY

Methodological quality was assessed using a standardised checklist. Critical appraisal and data extraction were conducted by two independent reviewers; discrepancies were addressed through discussion with a third reviewer as required.

RESULTS

There was no significant difference in infection rate using either sterile surgical or non-sterile insertion technique. The use of water for cleansing prior to catheter insertion was recommended. There was no additional benefit from specific meatal care other than standard daily personal hygiene and removal of debris. Infection rates were similar for both latex and silicone catheters. Comparisons between silver and Teflon coating clearly favoured the silver alloy coating. The use of a complex closed drainage system in the intensive care environment did not confer any additional benefit. Studies comparing types of junction seals and use of junction seals either prior to or following catheterisation found no clear benefit from using either preconnected sealed systems or sealed systems with the addition of silver releasing devices. Neither the addition of chlorhexidine nor hydrogen peroxide to the drainage bag was found to be effective at reducing UTI rates. The findings indicated there was a higher incidence of bacteriuria associated with Foley catheters compared with intermittent catheterisation (P < 0.025). A single RCT examined the effect on UTI rates of routine bag changes against no routine bag change. Routine bag changes were not advantageous in reducing the risk of infection.

CONCLUSIONS

Current RCT evidence suggests the use of a surgical sterile catheterisation technique is not required, and that tap water is sufficient for cleaning genitalia. Following insertion, daily hygiene around the meatal area is as effective as catheter toilets; and catheters impregnated with silver may reduce the incidence of catheter associated bacteriuria. Sealed (e.g. taped, presealed) drainage systems should not be relied upon as the sole mechanism for prevention of bacteriuria. The addition of antibacterial solutions to drainage bags and the routine change of drainage bags had no effect on catheter associated infection. However, most of the recommendations arising from this review were based on single studies, often with limited numbers of participants. There is an urgent need to replicate these studies in other clinical settings.