Catheter-associated urinary tract infections

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Abstract

Nosocomial urinary tract infection (UTI) is the most common infection acquired in both hospitals and nursing homes and is usually associated with catheterization. This infection would be even more common but for the use of the closed catheter system. Most modifications have not improved on the closed catheter itself. Even with meticulous care, this system will not prevent bacteriuria. After bacteriuria develops, the ability to limit its complications is minimal. Once a catheter is put in place, the clinician must keep two concepts in mind: keep the catheter system closed in order to postpone the onset of bacteriuria, and remove the catheter as soon as possible. If the catheter can be removed before bacteriuria develops, postponement becomes prevention.

Introduction

The urethral catheter is one of the most venerable of medical devices, having been used for urine retention on an intermittent or indwelling basis for centuries. In the 1920s, Foley introduced a catheter which could be held in place with an intra-bladder balloon. In the first several decades of use, Foley catheters were attached to collecting tubes which drained into buckets placed on the floor beside the bed, the so-called ‘open-catheter system’. Bacteriuria occurred by the end of 4 days. The 1950s saw the progressive development of ‘closed’ catheter systems. Plastic collection bags fused to the distal end of the tubes began to be used in the 1960s. This arrangement allows drainage through a tube into a receptacle so that the urine is always contained within a lumen protected from the contaminated environment. The onset of bacteriuria is now more than 30 days in closed catheter systems. Although no well-designed controlled trials comparing open with closed catheters have been performed, reports have been sufficiently positive so that the closed system has become the standard for patients requiring indwelling urethral catheters.

Section snippets

Pathogenesis

Insertion of a catheter may carry urethral organisms into the bladder. The catheter may be disconnected from the collection tube and bacteriuria has been associated with such interruptions. The drainage tube of the collection bag must be opened periodically to drain accumulated urine. If the lumen of the drainage tube is contaminated with bacteria, organisms may enter the drainage bag and ascend the collection tube and catheter. Even with meticulous attention to maintenance of the closed

Prevention of catheterization

The last several decades have seen major advances in understanding complications of catheterization which prompted attention to the use of alternatives such as patient training, biofeedback, medications, surgery, and using special clothes and bed-clothes. Additionally, several devices have been explored as options to the urethral catheter.

For men with urinary incontinence, condoms applied about the penis that empty through a collection tube into a drainage bag have been widely used. Although

Treatment of complications

For the patient who develops fever and/or signs of bacteremia, the clinician should rule out sources outside the urinary tract, catheter obstruction, and, especially among men, periurethral infection. Urine and blood cultures should be performed. Many clinicians would empirically treat such patients with parenteral antibiotics to treat possible bacteremia from a bacteriuric species. Because of the likelihood of bacteria sequestered in a biofilm on the catheter surface, a reasonable decision may

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