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Preventing catheter-related bacteriuria


An evidence-based review of the literature on preventing catheter-associated urinary tract infection aims to provide clinicians with an overview of the advances made in the last 20 years [1]. It uses an extensive literature search which should have located most English-language articles published up to 1997.

Background


About a quarter of hospital patients have a urinary catheter some time during their stay, and an average of 5% (range 3-10%) will acquire a urinary tract infection every day. Clearly, then, almost all patients will have an infection after about a month. This can extend hospital stay by about three extra days, and patients with a urinary tract infection are three times more likely to die. The case-fatality rate from urinary tract related bacteraemia is 13%.

Main findings


This review examines so many different aspects that it is all but impossible to summarise for Bandolier , other than recap the main recommendations (Box). There are two major findings. One relates to the use of silver alloy catheters, which have an NNT to prevent one infection of 4.6 (95% confidence interval 3.4 to 6.9), as shown in Bandolier 58 .

Main recommendations

  1. Avoid using a urinary catheter whenever possible. When used, remove as soon as possible.
  2. Always insert a catheter aseptically, use a closed drainage system, and properly maintain the catheter.
  3. Consider systemic antibiotics only during short term (3-14 days) in patients at high risk for complications of catheter-associated bacteriuria.
  4. Consider using a silver alloy catheter in patients at high risk of complications.
  5. Suprapubic catheters may be desirable in patients needing long-term catheterisation.
  6. A condom catheter may be sensible for incontinent men who will not manipulate the device.
  7. Prophylaxis with trimethoprim-sulphamethoxazole should be given to patients undergoing renal transplanation who need a catheter.
  8. Systemic antibiotic prophylaxis should probably be given to men undergoing transurethral resection of the prostate.
  9. No good evidence that bladder irrigation, antibacterial instillation in the drainage bag, rigorous meatal cleaning, and use of meatal lubricants and creams prevent bacteriuria. They should not be used.


The other major finding is that suprapubic catheters give overall lower rates of bacteriuria than do indwelling catheters. For suprapubic catheters, 15% of 227 patients in six trials (four randomised) had bacteriuria, compared with 37% of 208 patients with indwelling catheters. Use of suprapubic catheters rather than indwelling catheters would prevent bacteriuria for one patient in every five so treated (NNT 4.6, confidence interval 3.4 to 7.4).

Comment


This is a super paper, and a 'must-read' for anyone responsible for urinary catheters. It emphasises in strong language the need for thorough hand washing to prevent nosocomial infections. The main recommendations, based on the evidence, are shown in the box.

The other important point that makes this paper worth reading is that it deals with issues relating to catheters in particular clinical situations, like renal transplantation or transurethral resection of the prostate.

Reference:

  1. S Saint, BA Lipsky. Preventing catheter-related bacteriuria. Should we? Can we? How? Archives of Internal Medicine 1999 159: 800-808.

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