It has been estimated that 1 in 4 patients receive an indwelling urinary catheter during the course of acute-care hospital stays.  In most cases, nurses are responsible for the insertion of these catheters as well as the subsequent monitoring, and management of patients with these devices.  As most nurses are aware, the most common complication of indwelling urinary catheters is the development of urinary tract infections (UTIs).  UTIs account for 40% of all nosocomial infections and indwelling catheters are implicated in 80% of these UTI cases.  When UTIs develop the length of typical hospital stays are extended by 2 days, healthcare expenditures elevate, and overall health outcomes worsen.  For these reasons a review of the evidence-based management of indwelling urinary catheters is both timely and important.  Included in this article are several evidence-based practices for preventing indwelling urinary catheter related infections. 

       There are multiple causative correlations between urinary catheter use and UTIs.  Firstly, local immunity is decreased by the mechanical irritation of catheters to the urinary mucosa.  Secondly, catheters provide additional surfaces on which bacteria proliferate.  Bacteria are introduced during catheter insertion, by raising the collection bag above the catheter lumen, or through cross-contamination. 

        When inserting a new catheter, staff should use the smallest diameter catheter reasonable - 14 FR or 16 FR are best as larger ones increase risk of trauma, UTIs, leakage, and urinary obstruction.  To reduce the amount of urine pooling below the level of the lumen, 10 cc balloons are recommended.  Since saline water can crystallize around the balloon, sterile water is better for inflation.  The use of generous amounts of sterile lubricant is also necessary to decrease rates of trauma to the urethra.  Trauma can be further minimized by stabilizing the catheter in a dependant position either on patients’ inner or upper thighs. 

        Women are at a notably increased risk for UTIs due to the shorter length of their urethras as well as increased rates of urethral contamination by E.coli (the microorganism responsible for 80% of UTIs) from stool after wiping.  It is especially important that women are always cleansed, and instructed to cleanse themselves, from front to back (urethral meatus to anus).  Contrary to popular belief, use of bactericidal agents on the urinary meatus itself does not decrease the risk of UTI acquisition. 

Nurses should also encourage ongoing hydration to reduce urinary stasis and flush the urinary tract.  The drainage bag should be emptied at least every 8 hours and staff should ensure that drainage bags are cleaned daily with 1:10 bleach or vinegar solutions.

         In order to avoid cross-contamination, staff should always wear gloves and use proper hand washing when handling catheters.  Additionally, caregivers are advised to separate and label urine collection containers so that emptying spouts do not touch contaminated containers.  They should also try to avoid touching the spout to the container when emptying the drainage bag.  If a patient has multiple drainage bags, the bags should be isolated on opposite sides of the bed.  When possible, attempts should be made to limit the number of patients with catheters to one per room. 

          While research has produced mixed findings, there is clinical evidence to suggest that raising urine acidity, which can be accomplished by drinking cranberry juice, may reduce bacterial colonization.  There is certainly no harm in encouraging patients to up their intake of cranberry juice.  As with the any liquid, it can augment the proper functioning of the urinary tract. 

While it is probably impossible to eliminate the risk of infection in the setting of indwelling urinary catheters, discussions about urinary hygiene and the “whys” behind our best practices may help patients assume increased responsibility for preventing future UTIs whether or not an indwelling urinary catheter is in place.
 

References:

Newman, Diane K (2007). The Indwelling Urinary Catheter Principles for Best Practice. 

Journal of Wound, Ostomy, and Continence Nursing,34(6), 655-661.  

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