Some observations on catheter care

J. chron. Dis. Vol. 15. pp. 675-682. Pergamon

Press Ltd. Printed in Great Britain

SOME OBSERVATIONS ON CATHETER CARE JULIAN ANSELL. Division

of Urology,

Department

M.D.

of Surgery, University of Washington School of Medicine, Seattle, Washington (Received

20 February

1962)

FOR YEARS urologists have been dedicated to the elimination of the catheter as a means of urinary drainage. Their success in removing this urinary prosthesis is epitomized in CREEVY’Sremarkable achievement of 0.6 per cent mortality in a series of 1000 cases of prostatectomy [l]. DEBENHAMand WARD in Great Britain [2] have gone so far as to attempt prostatectomy suns catheter although their mortality and infection figures are no improvement on those of others for the same procedure with catheter drainage. It is somewhat embarrassing then for an urologist to have to come to the defense of the urinary catheter when he and his predecessors have worked so hard to effect its safe removal from patients. However, because misleading charges have been cast at the catheter in the recent past [3], one whose practice involves the temporary use of this device is moved to defend the proper care of the catheter and to castigate those whose abuse has given it a poor reputation. This paper is divided into three parts. The first deals with single catheterization: the second is concerned with the problem of the indwelling catheter, and finally the closed drainage system of catheter care employed on the Urology Service at the University of Washington Hospital will be discussed. Single diagnostic catheterization. Clean-voided midstream specimens should be used for diagnostic urine cultures wherever feasible [4]. SANFORD’Srevival of the colony count originally suggested by MARPLE [5] as a means of differentiating contaminants from pathogens has been most useful. However, there are situations in which diagnostic or therapeutic catheterization is unavoidable and PRYLES et ~2. [6] and JACKSON and GRIEBLE [7] suggest that the incidence of infection during a carefully carried out catheterization, while definite, is very low. This is also borne out by the series of 200 single catheterizations carried out in a local institution by TURCK et al. [8] in which no contamination resulted. In this respect it may be well to cite the work of PRYLES [6] who followed closely a group of children subsequent to catheterization. All were free from urinary tract infection within a period of Thus, while organisms were introduced into 4-6 months following catheterization. the urine of the children during catherization and in apparently significant quantities, long-term infection was not a complication. While properly collected clean-voided specimens may be used in most instances for making the diagnosis of bacteriuria in children, catheterization, when properly done, should not be withheld for fear of While all physicians should be alert to the producing urinary tract infection. 675

676

JULIANANSELL

importance of catheterization in occasionally initiating infection, catheterization must remain a necessary procedure in the diagnosis and management of urinary tract infections in certain cases, notably the following : (1) where there is urinary retention; (2) where repeated study of clean voided specimens yield borderline or doubtful results; (3) where the patient is so acutely ill that there is need for immediate antimicrobial therapy, and no time for multiple specimens to be obtained; (4) where the patient is unable or unwilling to co-operate [9]. Zndwelling catheters. It has been demonstrated on several occasions [lO-141 that with an open drainage system bacterial invasion of the urine occurs within 48-72 hours. It is extremely important to identify the route along which this bacterial contamination occurs because identification of the route may lead to successful preventive measures. The possibility of contamination by careless introduction of the catheter has long been recognized. As long ago as 1940, EMMET wrote: “The preoperative care of the patient with urinary obstruction does not always begin in the hospital. It begins with the first visit of the physician when he may be summoned in an emergency to relieve a patient from the severe pain of an overdistended bladder. Upon the type of treatment employed at this time may depend the outcome of the condition. Poorly done or uncleanly catheterization with its subsequent infection may cost the patient his life, or at least institute a severe and disabling infection that can leave the patient with a poor surgical result even though the operation is most skilfully performed.” [15]. He emphasizes the need for the gentle slow passage of soft, small caliber catheters, to which we would add the suggestion that beforehand the urethra be well lubricated with lo-15 ml of water-soluble lubricating jelly. He also advocates the use of opiates for sedation before catheterization in the patient in severe discomfort with retention. With prolonged drainage he advocated a semi-closed collecting system and irrigation by means of a closed system with a ‘Y’ drainage tube. In 1951, WEYRAUCHand BASSETT [16] suggested that major bacterial contamination of the urine started in the open bedside collection device for the urine. They suggested that the bacteria from the air and fomites in the ward contaminated the open bottle in which the stagnant urine provided an excellent culture medium. In mock systems, they showed that bacteria migrated up the collection tubing into the bladder. They showed that motile bacteria could be prevented from migrating up the collection tubing by a flow rate of approximately 50 ml an hour. A urine output of 3000 ml a day would easily provide such a flow rate in clinical circumstances if catheters were allowed to drain continuously. They performed no clinical studies to confirm these findings but suggested the use of 10% formalin in collecting bottles to prevent bacterial growth. PYRAHet aE. in 1955 [17] virtually eliminated an epidemic of Pseudomonas urinary tract infections in patients undergoing prostatectomy by the adoption of rigid aseptic techniques in the passage of catheters coupled with the institution of the semi-closed system advocated by EMMET. (The system is semi-closed in that an unfiltered.air vent is provided for the collecting bottle.) Simultaneously they cut the incidence of urinary infections by all organisms from 100 to 25 per cent. KASS and SCHNEIDERMAN in 1957 {18] attempted to show that the route of entry of bacteria into the urinary tract was alongside the catheter per urethra into the bladder. They placed Serratia marcescens on the skin of the thighs and penis of

Some Observations on Catheter Care

671

three comatose individuals and concluded from the appearance of Serratia in the urine 48-72 hours later that they had arrived there via the urethral exudate alongside the catheter. They do not discuss the type of drainage system used or precautions taken to prevent contamination of the catheter lumen, nor do they mention whether or not the organism was subsequently found on the bed clothing, bed frame, walls or floor. While it is possible that bacteria enter the urinary tract along this route, we believe subsequent discussion will demonstrate that this is an unlikely pathway for major contamination. ORSKOV [12, 131 noted that nosocomial spread was a common method for spread of urinary tract infections. He found one strain of Klebsiella in the urine of patients on one ward, while in another ward of the same institution a different strain of the same organism was cultured from the urine of patients with indwelling catheters. Subsequently he cultured the same organism from bed pans and urinals in use on the ward. The organism was present in feces of only one of a small number of patients, but cultures from towels, door handles, chairs, bottle necks and ‘clean’ urinals all grew the strain of Klebsiella found in the urine. Cultures from hands and forearms of personnel employed to clean urinals grew Klebsiella of the type isolated from patients’ urine. Sterilized catheters, packaged and ready for use. did not give positive cultures. DUTTONand RALSTON[lo] also accumulated evidence that cross infection was the most important consideration in the development of MILLER, GILLESPIE, LINTON, urinary tract infections in catheterized patients. SLADEand MITCHELL [19] demonstrated that multiple breaks in asepsis during the They showed that for preuse of the catheter were involved in contamination. vention of infection closed drainage was absolutely essential. By means of a nicely contrived arrangement of consecutive steps in asepsis, which they were able to repeat in reverse order, they found that contamination per urethra alongside the catheter was sot an important route of infection. They re-emphasized the importance of proper sterilization of instruments and suggested decontamination of the urethra with l/2000 solution of chlorhexidine in glycerine. GIBBON’Swork [20] on paraplegics is of interest with regard to the importance of catheter size and of breaks which occur in separating the catheter from the drainage tubing. He was able by use of a special catheter and very careful catheterization technique to maintain sterile urine up to six weeks in paraplegics with indwelling catheters. He emphasized that the use of his special plastic catheter which reached all the way to the collection bottle without a break was vital because the lumen was larger for a given size than in comparable latex or self-retaining catheters. Also he felt that the plastic walls accumulated less debris, therefore necessitating fewer changes of the catheter. He also advocated closed drainage systems. DESAUTELS [21] has advocated the use of a catheter dressing soaked with Zephiran solution to prevent contamination alongside the catheter. The use of antibiotics to protect patients with inlying catheters is of debatable value. Their use after the catheter has been withdrawn seems worthwhile. CLARKE [22], in a retrospective analysis of patients who had had catheter drainage, found only 7 per cent infected some months after drainage had been eliminated. He emphasized the importance of post-operative follow-up and the use of antibiotics SEXTON[23] studied a series of after catheter drainage has been discontinued. patients requiring indwelling catheters following gynecological procedures. Half

678

JULIANANSELL

were treated with sulfisoxazole, 1 gram q.i.d., during the period of drainage and the rest served as controls. In a three year follow-up of 312 cases the incidence of persistent infection in both groups was 4-6 per cent; symptoms of infection immediately after drainage were reduced from 23 per cent in the controls to 3 per cent in the treated group. He does not indicate what type of drainage system was employed. PETERSDORF [24] has demonstrated that antibiotics are detrimental when prolonged drainage is required. To summarize the experience of others we may state that in order to avoid infection when indwelling catheters are used the following points must be observed : 1. Meticulous aseptic and gentle atraumatic technique in passage of the catheter. 2. The use of the smallest catheter sufficient to do the job.

-5TRAlGH-F

IPITERMITTENT

CLOSED

DlWNAGE

IRRIGATION

1 Buckle draInage tube between fingers. 2. Release clamp on Irrigation bottle. SALINE

Tlghten 4 Release 3.

SALINE

FLOWS

INTO

BLADDER.

clamp on irrigation drainage tube. FLOWS

FROM

BLADDER

bottle. 1NTO

BOTTLE.

FIG. 1.

Some Observations

3.

on Catheter

Care

679

Bacteriologically sealed drainage systems with antiseptic in the collecting bottle to prevent growth of any possible contaminant. 4. Continuous egress of urine should be allowed and high fluid intake encouraged. 5. If irrigation is required, a closed system is best. 6. Prophylactic use of antibiotics may be of value when brief (up to three days) drainage is anticipated. Prophylactic measures for prolonged drainage (over 14 days) are probably detrimental [24]. Closed drainage system in use at the University of Washington Hospital. It was with these factors in mind that the system of drainage in use at the University of Washington Hospital was designed (Fig. 1). The drainage system consists of a glass connector in one end of four feet of latex tubing, the other end of the tubing being attached to one of a pair of straight, airtight, glass connectors in a 2-hole 6-cork stopper. The unattached glass connector in the 2-hole stopper is bacteriologically sealed with a cotton plug. The final element is a one-gallon, narrow-necked jug. The tubing, connector and stopcock are assembled and sterilized in one package and the jug is capped with paper and sterilized separately by autoclaving. At the time of catheterization the jug is uncapped and 30 ml of 10% formalin is placed in the jug. The stopper is placed in the jug and the latex tubing is attached to the indwelling catheter by means of the glass connector (Fig. 1). When a need for frequent irrigation arises, an additional glass ‘Y’ is provided in the tubing with an attachment for a sterile drip bottle. If hand irrigation is necessary, it is carried out according to the directions shown in Fig. 2. Under no circumstances is the tubing disconnected for any other reason than irrigation or the daily replacement. Cystoscopic instruments are sterilized at the end of each day with ethylene oxide in a gas sterilizing apparatus under pressure of 7-l 5 lb/in2 and at temperatures of 120”-140” Fahrenheit. If resterilization is required between cases, the instruments are soaked for 20 min in UrolocideR (a quaternary ammonium compound obtainable from American Cystoscope Makers, Pelham Manor, New York). In order to test the efficacy of this system all patients requiring indwelling catheters on the Urology Service at the University of Washington Hospital during the 18 month period from April 1, 1960, to October 1, 1961, were studied, by means of quantitative bacteriological techniques; 85 patients had indwelling catheters during that time. From this group only those whose precatheterization cultures were sterile were selected for study. This eliminated 45 patients who had significantly positive Of the remaining 40 patients, nine did not have cultures prior to catheterization. a follow-up urine culture after the catheter had been removed and one patient did not have a pre-operative urine culture. Of 30 patients left for inclusion in the study, 23 were males and 7 were females. Types of catheter drainage employed were as follows: 23 patients had urethral catheter drainage only; one patient had urethral catheter and nephrostomy; one had urethral, suprapubic, ureteral and nephrostomy drainage; two had suprapubic drainage, urethral and ureterostomy drainage: two had urethral and suprapubic drainage; and one patient had urethral and ureteral catheter drainage. Duration of drainage varied between 2 days and 270 days with an average of 16 days and a median of 4 days (Table 1). The diagnoses for these patients were: benign prostatic hypertrophy, 11; carcinoma of the prostate, 3; carcinoma of the bladder, 3; calculous disease, 8; congenital bladder defects, 4; and hypertension of

680

JULIAN ANSELL

A

\,

Straightcb4n.q

FIG. 2.

TABLE 1.

DURATION OF CATHETERSTAY

Days

2

3

4

6

7

8

9

15

30

31

270

Patients

4

10

2

1

3

4

2

1

1

1

1

renal origin, 1. A note about the patient with an indwelling suprapubic catheter for This boy was in the hospital for but 15 of the 270 days 270 days seems in order. While at home the catheter drained continuously into one of two plastic of drainage. leg bags (DispozabagR-C. R. Bard, Summit, New Jersey) while the other bag was The soaked in germicide. At night the catheter was attached to straight drainage. catheter was changed every six weeks and new drainage bags were purchased at the rate of one a month on average. The child attended school regularly during this period. He emptied the leg bags as necessary from the spout in the bottom. Four of the five urine cultures made during drainage showed no growth. It seems unlikely that contamination did not occur at some time during this prolonged period of

Some Observations

on Catheter

681

Care

drainage. Freedom from infection may be related in part to the absence of virulent nosocomial urinary pathogens from the home environment. Colony counts of the post-catheterization cultures are given in Table 2. All of these post-drainage cultures were obtained at least seven days after cessation of therapy. Organisms cultured were as follows: Staphylococcus albus (coagulase TABLE 2. COLONY

Colony Number

count per ml of urine of cultures

coumso~

POST-CATHETERIZATION CULTURES

0

10

103

10.3

104

16

1

7

4

1

105 0

106 1

negative), 5; Esch. coli, 4; Enterococcus, 2; Pseudomonas aeruginosa, 1; Bacterium anitratum, 1. The single count of 1-l x 10” colonies per ml consisted of Bacterium anitratum. Subsequent cultures in that patient were sterile, so that this organism was probably a contaminant. Utilizing the criterion that a colony count of 10’ organisms is synonymous with significant bacteriuria, one patient or 3 per cent of the entire group was infected following the use of the indwelling catheter. This was a 9-yearold girl with congenital vesical dysfunction who had bilateral indwelling ureteral catheters for five days and a suprapubic catheter for eight days, and whose urine had a colony count of 1 x lo6 Esch. coli per ml after the suprapubic tube had been removed. It is our assumption that the infection which occurred in this girl was the result of a break in technique. Following a course of appropriate antibiotics her urine cultures became sterile. Several patients received antibiotics for part or all of the time that they had indwelling catheters. However, the role of these agents in prevention of infection under these circumstances requires further investigation. Our results agree with those of GILLESPIE et al. [l l] indicating that the entrance of bacteria into the urine alongside the catheter is not a major source of contamination if large catheters which traumatize the urethra are not used for prolonged periods of time. The data also support the idea that it is possible by meticulous aseptic techniques to cut contamination to a minimum and to prevent urinary tract infection by way of the indwelling catheter.

REFERENCES prostatic resection, J. Ural. 65, 876, 1951. 1. CREEVY. C. D.: Mortality of transurethral 3. DEBENHAM,L. S. and WARD, A. E.: Retropubic prostatectomy using a no-catheter technique, Brir. .l. Ural. 32, 178. 1960. 3. EEESON,P. B. : The case against the catheter, Amer. .I. Med. 24, 1, 1958. 4. SANFORD, J. P., FAVOUR, C. B., MAO. F. H. and HARRISON, J. H.: Evaluation of the ‘Positive’ urine cultures: An approach to differentiation of significant bacteria from contaminants, Amer. J. Med. 20, 88, 1956. 5. MARPLE, C. D.: Frequency and character of urinary tract infections in an unselected group of women, Ann. intern. Med. 14,2220, 1941. 6. PRYLES, C. V., LUDERS. D. and ALKAN, M. K.: A comparative study of bacterial cultures and colony counts in paired specimens of urine obtained by catheter versus voiding from normal infants with urinary tract infection, Pediatrics 27. 17. 1961. I. JACKSON,G. G. and GRI~BLE, H. G. : Pathogenesis of’ renal infection, Ann. intern. Med. 100,692,

1957.

682

8. 9. 10. 1 I. 11. 13. 14. 15. 16. 17. i;8. 19. 20. 21. 12. 1-3. 14.

25.

16.

JULIAN ANSELL

PETERSDORF,R. G. and TURCK, M. : Personal communication. PRYLES, C. V.: The diagnosis of urinary tract infection, Pediatrics 26, 441, 1960. DLJTTON, A. A. C. and RALSTON, M.: Urinary tract infection in a male urological ward, Lancet 1, 115, 1957. GILLESPIE, W. A., LINTON, K. B., MILLER, A. and SLADE, N. : The diagnosis, epidemiology and control of urinary infection in urology and gynaecology, J. clin. Pat/z, 13, 187, 1960. ORSKOV, I.: Nosocomial infections with Klebsiella in lesions of the urinary tract. Acfa path. microbial. stand. Suppl. 93, 2.59, 1951. O~seov, 1.: Nosocomial infections with Klebsiella in lesions of the urinary tract. II. Acta. path. microbial. scand. 35, 194, 1954. SHACKMAN,R. and MESSENT, D.: Effect of indwelling catheter on bacteriology of male urethra and bladder, Brit. med. J. 2. 1009, 1954. EMVIMET, J. L.: Preoperative and postoperative care in transurethral prostatectomy. Surg. Clirl. N. Amer. 20, 1061 1940. WEYRAUCH,H. M. and BASSETT, J. B.: Ascending infection in artificial urinary tract, experimental study. Stanf. med. BzdL 9, 75, 1951. PYRAH, L. N., GOLDIE, W., PARSONS. F. M. and RAPER. F. P.: Control of Pseudomonas pyocyanea infection on a urology ward, Lancet 2. 314, 1955. XAS&. E. H. and SCHNEIDERMAN,L. J.: Entry of bacteria into the urinary tracts of patients with inlying catheters. N. Engl. .I. Med. 256, 556, 1957. MILLER, A., GILLESPIE. W. A., LINTON, K. B., SLADE, N. and MITCHELL, J. P.: Postoperative infection in urology, Lancet 2, 608, 1958. GIBBON, N.: A new type of catheter for urethral drainage of the bladder, Brit. J. Ural. 30, 1, 1958. -~ESAUTELS.R. E. : Aseptic management of catheter drainage, N. Engl. J. Med. 263, 189, 196!l CLARKE, B. G. and JORESS, S.: Quantitative bacteriuria after use of indwelling catheters. Incidence in genito-urinary surgery, J. Amer. med. Ass. 174, 1593, 1960. SEXTON, G. L., Jr. : Urinary tract infection following use of an indwelling catheter. Obstet. and Gynec. 17,739, 1961. PETERSDORF.R. G., CURTIN, J. A., HOEPRICH, P. D., PEELER, R. N. and BENNETT,I. L.. Jr.: A study of antibiotic prophylaxis in unconscious patients, N. Engl. 1. Med. 257, 1001, 1957. KASS, E. H.: Bacteriuria and diagnosis of infections of the urinary tract. Ann. intern. Med 100, 709, 1957. DAVIS. J. H.. ROSENBLUM.J. M.. QUILLIGAN,E. J. and PERSKY, L.: An evaluation of post-catheterization prophylactic chemotherapy. J. Ural. 82, 613, 1959.