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Thread: Frequent infections with SP catheter?

  1. #1
    Senior Member zillazangel's Avatar
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    Frequent infections with SP catheter?

    Chad had a SP catheter put in around late January because I broke my foot and could not stand to cath him. It was an idea we'd tossed around for awhile, but my broken appendage forced the issue. Since then, it has been a total godsend for me because round the clock cathing with no help (plus a job, a kid and a house to run) was just not feasible.

    However, since he got it, he has had infection after infection after infection and I'm wondering what the heckola is up, and what the heckola to do about it. I know that a urine dip is useless because he is always colonized with the SP; so far we are basing our diagnosis of a UTI if all of the following occur: cloudy/gunky + fever + pain/uncomfortable abdomen + stinky. His uro gave him Septra several times and while they did not culture it, the Septra did the trick within a few doses, back to crystal clear and no fever, etc. Of course he finishes the entire 10 day course.

    Then he will turn around and bang, get another UTI (again, based on symptoms described above). Take another course, all fine for a week, two, then another. ]

    As this is becoming a near constant, which makes Chad either miserable or on Septra all the time, I am wondering what we can do. I have tried irrigating to see if I can flush out the sediment (I've read alot about whether to irrigate or not and while the evidence suggests not to routinely, I tried it twice just to see if it helped ... hard to tell). I change the SP every 3 weeks, I wash the stoma every day with soap/water, keep it dry otherwise, keep the hair trimmed short 3 inches around the stoma, taking Vit c, drinking LOTS of water (at least 3 liters a day minimum, with nothing else, no juice, no alcohol, no caffeine/soda/coffee) .... all with no result, in fact, the UTI frequency appears to be increasing.

    I am doing something wrong in his care? Is there something else we should try? I could take it in to be cultured but it sure seems to respond to Septra quite dramatically in terms of symptoms, so I'm not sure if we need to do that (and if I do, how do I get a sample for testing via a SP cath? stick in an intermittent after clamping the SP??)

    Thanks for any wisdom. I've scoured this site looking for answers and have found tons of useful information but nothing addressing our particular problem directly. Advice highly welcomed, thanks so much.
    Wife of Chad (C4/5 since 1988), mom of a great teenager

  2. #2
    Senior Member wheeliecoach's Avatar
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    Did you try cranberry pills? My fiance had issues with UTIs all of the time and then we put him on cranberry pills and now he does not get them as frequently. He just got one now...but that was after a year had passed since his last one.
    "Unless someone like you cares a whole awful lot nothing's going to get better. It's not." - Dr. Seuss

  3. #3
    Senior Member McDuff's Avatar
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    Uti's will usually "respond" to most antibiotics, this does not mean that it kills it.

    Might just be that the Septra is holding it at bay and it comes back with a vengeance afterwards. Get it cultured.
    "a T10, who'd Rather be ridin'; than rollin'"

  4. #4
    Hi,

    I agree with McDuff above in that the only way you can definitely target the correct bug is to get a urine culture and treat according to the sensitivities shown on the culture. Also, for recurrent or complicated UTI, the treatment is usually longer, 14 days.

    Can't guarantee this will totally erase all infections, but should help.

    Unfortunately, you are seeing first-hand the difference in infection rate between an indwelling catheter and IC. In my experience, indwelling cath users have more infections and that is why clinicians try hard to avoid indwellings whenever possible.

    That said, I see why you had to go to this method in the first place but perhaps this is temporary and he could resume IC's in the future?
    One has to make choices with consideration to lifestyle and available resources.

    AAD

  5. #5
    Quote Originally Posted by zillazangel
    Chad had a SP catheter put in around late January because I broke my foot and could not stand to cath him. It was an idea we'd tossed around for awhile, but my broken appendage forced the issue. Since then, it has been a total godsend for me because round the clock cathing with no help (plus a job, a kid and a house to run) was just not feasible.

    However, since he got it, he has had infection after infection after infection and I'm wondering what the heckola is up, and what the heckola to do about it. I know that a urine dip is useless because he is always colonized with the SP; so far we are basing our diagnosis of a UTI if all of the following occur: cloudy/gunky + fever + pain/uncomfortable abdomen + stinky. His uro gave him Septra several times and while they did not culture it, the Septra did the trick within a few doses, back to crystal clear and no fever, etc. Of course he finishes the entire 10 day course.

    Then he will turn around and bang, get another UTI (again, based on symptoms described above). Take another course, all fine for a week, two, then another. ]

    As this is becoming a near constant, which makes Chad either miserable or on Septra all the time, I am wondering what we can do. I have tried irrigating to see if I can flush out the sediment (I've read alot about whether to irrigate or not and while the evidence suggests not to routinely, I tried it twice just to see if it helped ... hard to tell). I change the SP every 3 weeks, I wash the stoma every day with soap/water, keep it dry otherwise, keep the hair trimmed short 3 inches around the stoma, taking Vit c, drinking LOTS of water (at least 3 liters a day minimum, with nothing else, no juice, no alcohol, no caffeine/soda/coffee) .... all with no result, in fact, the UTI frequency appears to be increasing.

    I am doing something wrong in his care? Is there something else we should try? I could take it in to be cultured but it sure seems to respond to Septra quite dramatically in terms of symptoms, so I'm not sure if we need to do that (and if I do, how do I get a sample for testing via a SP cath? stick in an intermittent after clamping the SP??)

    Thanks for any wisdom. I've scoured this site looking for answers and have found tons of useful information but nothing addressing our particular problem directly. Advice highly welcomed, thanks so much.
    Ami,

    I have known many people who have had indwelling suprapubic catheters for many years and who have very few or no urinary tract infections (as opposed to a much higher incidence of urinary tract infections in people who have indwelling urethral foley catheters). Unfortunately, I don't think that there has been a prospectively randomized clinical trial to compare suprapubic with intermittent catheterization. In most studies, suprapubic is lumped in alongside urethral indwelling catheters (Tsan, et al., 2008). However, a few studies have suggested that the incidence of urinary tract infections associated with suprapubic catheterization is similar to that of clean intermittent catheterization. For example, Escalarin de Ruz, et al. (2000) reported risk of 0.34 for suprapubic compared to 2.72 for urethral indwelling catheters and 0.41 for clean intermittent catheterization. The risk is expressed in episodes of infection per 100 patient-days. Likewise, Warren (1997) has suggested that suprapubic catheterization has a lower incidence of infection than urethral catheterization.

    You seem to be doing things correctly. Here are some questions that come to mind. I am wondering if perhaps the daily washing of the stoma with soap is contributing to the infections. Some people just use baby wipes to clean the area around the stoma. Are you sure that the urine bag is always below the stoma so that there is no possibility of reflux? Is Chad still taking anti-yeast medication? Sometimes such medications and the prevention of "good" yeast populations may predispose to bacterial infections. Changing the catheter every 3 weeks may be too often. Are the infections usually occurring after you have changed the catheters? Usually, people change suprapubic catheters every 4-12 weeks. Every time you change, you run the risk of introducing infection. Finally, what is his urine output? Increasing the output helps reduce infections. http://www.incontact.org/publication...catheters.html

    While searching for information on this subject, I came across a Cochrane analysis of clinical trials suggesting that silver-alloy catheters have lower infection rates than regular catheters (Schumm & Lam, 2008). I also came across several papers that reviewed patients who have bladder cancer and have found that a significant number of such patients have suprapubic catheters, suggesting that suprapubic catheters. For example, West, et al. (1999) reported that 19% of people who have developed bladder cancer had suprapubic catheters. However, it is important not to blame suprapubic catheters for causing the bladder infection. Since suprapubic catheters are becoming more popular for managing all sorts of bladder problems, it is not surprising that a significant fraction of people who have bladder carcinoma have been managed by suprapubic catheters.

    I hope that the above is helpful.

    Wise.

    1. Tsan L, Davis C, Langberg R, Hojlo C, Pierce J, Miller M, Gaynes R, Gibert C, Montgomery O, Bradley S, Richards C, Danko L and Roselle G (2008). Prevalence of nursing home-associated infections in the Department of Veterans Affairs nursing home care units. Am J Infect Control. 36: 173-9. Office of Medical Inspector, Department of Veterans Affairs Central Office, Washington, DC 20402, USA. linda.tsan@va.gov. BACKGROUND: The Department of Veterans Affairs (VA) is the largest single provider of long-term care in the United States. The prevalence of nursing home-associated infections (NHAIs) among residents of VA nursing home care units (NHCUs) is not known. METHODS: A Web-based point prevalence survey of NHAIs using modified Centers for Disease Control and Prevention definitions for health care-associated infections was conducted in the VA's 133 NHCUs on November 9, 2005. RESULTS: From a total population of 11,475 NHCU residents, 591 had at least 1 NHAI for a point prevalence rate of 5.2%. Urinary tract infection, asymptomatic bacteriuria, pneumonia, skin infection, gastroenteritis, and soft tissue infection were most prevalent, constituting 72% of all NHAIs. A total of 2817 residents (24.5%) had 1 or more indwelling device. Of these 2817 residents with an indwelling device(s), 309 (11.0%) had 1 or more NHAI. In contrast, the prevalence of NHAIs in residents without an indwelling device was 3.3%. Indwelling urinary catheter, percutaneous gastrostomy tube, intravenous peripheral line, peripherally inserted central catheter, and suprapubic urinary catheter were most common, accounting for 79.3% of all devices used. CONCLUSION: There are effective infection surveillance and control programs in VA NHCUs with a point prevalence of NHAIs of 5.2%.

    2. Esclarin De Ruz A, Garcia Leoni E and Herruzo Cabrera R (2000). Epidemiology and risk factors for urinary tract infection in patients with spinal cord injury. J Urol. 164: 1285-9. Departments of Physical Medicine and Rehabilitation, and Medicine, Hospital Nacional de Paraplejicos, Toledo and Department of Preventive Medicine, Universidad Autonoma de Madrid, Madrid, Spain. PURPOSE: To our knowledge risk factors for urinary tract infection associated with various drainage methods in patients with spinal cord injury have never been evaluated overall in the acute period. We identified the incidence and risk factors associated with urinary tract infection in spinal cord injured patients. MATERIALS AND METHODS: We prospectively followed 128 patients at our spinal cord injury reference hospital for 38 months and obtained certain data, including demographic characteristics, associated factors, methods of urinary drainage, bladder type, urological complications and predisposing factors of each infection episode. Logistic regression modeling was done to analyze variables and identify risk factors that predicted urinary tract infection. RESULTS: Of 128 patients 100 (78%) were male with a mean age plus or minus standard deviation of 32 +/- 14.52 years. All patients had a nonfatal condition by McCabe and Jackson guidelines, and 47% presented with associated factors. The incidence of urinary tract infection was expressed as number episodes per 100 patients daily or person-days. The overall incidence of urinary tract infection was 0.68, while for male indwelling, clean intermittent, condom and female suprapubic catheterization, and normal voiding the rate was 2.72, 0.41, 0.36, 0. 34 and 0.06, respectively. The risk factors associated with urinary tract infection were invasive procedures without antibiotic prophylaxis, cervical injury and chronic catheterization (odds ratio 2.62, 3 and 4, respectively). Risk factors associated with repeat infection were a functional independence measure score of less than 74 and vesicoureteral reflux (odds ratio 10 and 23, respectively). CONCLUSIONS: Spinal cord injured patients with complete dependence and vesicoureteral reflux are at highest risk for urinary tract infection.

    3. Schumm K and Lam TB (2008). Types of urethral catheters for management of short-term voiding problems in hospitalised adults. Cochrane Database Syst Rev. CD004013. University of Aberdeen, Academic Urology Unit/CHaRT, Health Sciences Building, Foresterhill, Aberdeen, UK, AB25 2ZB. k.schumm@abdn.ac.uk. BACKGROUND: Urinary tract infection (UTI) is the most common hospital acquired infection. The major associated cause is indwelling urinary catheters. Currently there are many types of catheters available. A variety of specialised urethral catheters have been designed to reduce the risk of infection. These include antiseptic impregnated catheters and antibiotic impregnated catheters. Other issues that should be considered when choosing a catheter are ease of use, comfort and cost. OBJECTIVES: The primary objective of this review was to determine the effect of type of indwelling urethral catheter on the risk of urinary tract infection in adults who undergo short-term urinary catheterisation. SEARCH STRATEGY: We searched the Specialised Trials Register of the Cochrane Incontinence Group (searched 11 September 2007). We also examined the bibliographies of relevant articles and contacted catheter manufacturer representatives for trials. SELECTION CRITERIA: All randomised and quasi randomised trials comparing types of indwelling urinary catheters for short-term catheterisation in hospitalised adults. Short-term catheterisation was defined as up to and including fourteen days, or other temporary short-term use as defined by the trialists (for example less than 21 days with data time points at 7 day intervals). DATA COLLECTION AND ANALYSIS: Data were extracted by one reviewer and independently verified by a second reviewer. Disagreements were resolved by discussion. Data were processed as described in the Cochrane Handbook. Where data in trials were not fully reported, clarification was sought directly from the trialists (secondary sources were used to confirm results of one trial). MAIN RESULTS: Twenty three trials met the inclusion criteria involving 5236 hospitalised adults in 22 parallel group trials and 27,878 adults in one large cluster-randomised cross-over trial.The antiseptic catheters were either impregnated with silver oxide or silver alloy. Silver oxide catheters were not associated with a statistically significant reduction in bacteriuria in short-term catheterised hospitalised adults but the confidence intervals were wide (RR 0.89, 95% CI 0.68 to 1.15) and these catheters are no longer available. Silver alloy catheters were found to significantly reduce the incidence of asymptomatic bacteriuria (RR 0.54, 95% CI 0.43 to 0.67) in hospitalised adults catheterised for less than one week. At greater than one week of catheterisation the risk of asymptomatic bacteriuria was still reduced with the use of silver alloy catheters (RR 0.64, 95% CI 0.51 to 0.80). The randomised cross-over trial of silver alloy catheters versus standard catheters was excluded from the pooled results because data were not available prior to crossover. The results of this trial indicated benefit from the silver alloy catheters and included an economic analysis that indicated cost savings of between 3.3 per cent and 35.5 per cent.Antibiotic impregnated catheters were compared to standard catheters and found to lower the rate of asymptomatic bacteriuria in the antibiotic group at less than one week of catheterisation for both minocycline and rifampicin (RR 0.36, 95% CI 0.18 to 0.73), and nitrofurazone (RR 0.52, 95% CI 0.34 to 0.78). However, at greater than one week the results were not statistically significant. One of 56 men in the antibiotic impregnated group had a symptomatic UTI compared with 6 of 68 who had standard catheters (RR 0.20, 95% CI 0.03 to 1.63).Three trials compared two different types of standard catheters (defined as catheters that are not impregnated with antiseptics or antibiotics) to investigate infection. Individual trials were too small to show whether or not one type of standard catheter reduced the risk of catheter related urinary tract infection compared to another type of standard catheter. AUTHORS' CONCLUSIONS: The results suggest that the use of silver alloy indwelling catheters for catheterising hospitalised adults short-term reduces the risk of catheter acquired urinary tract infection. Further economic evaluation is required to confirm that the reduction of infection compensates for the increased cost of silver alloy catheters.Catheters impregnated with antibiotics are also beneficial in reducing bacteriuria in hospitalised adults catheterised for less than one week but the data were too few to draw conclusions about those catheterised for longer. There was not enough evidence to suggest whether or not any standard catheter was better than another in terms of reducing the risk of urinary tract infection in hospitalised adults catheterised short-term. Siliconised catheters may be less likely to cause urethral side effects in men; however, this result should be interpreted with some caution as the trials were small and the outcome definitions and specific catheters compared varied.

    4. Warren JW (1997). Catheter-associated urinary tract infections. Infect Dis Clin North Am. 11: 609-22. Department of Medicine, University of Maryland School of Medicine, Baltimore, USA. Millions of urethral catheters are used each year. This device subverts several host defenses to allow bacterial entry at the rate of 3% to 10% incidence per day, and its presence encourages the organism's persistent residence in the urinary tract. Most catheter-associated bacteriurias are asymptomatic. The complications in short-term catheterized patients include fever, acute pyelonephritis, bacteremia, and death; patients with long-term catheters in place are at risk for these complications and catheter obstruction, urinary tract stones, local periurinary infections, chronic renal inflammation, chronic pyelonephritis, and, over years, bladder cancer. The closed catheter system has been a magnificant step forward in the prevention of catheter-associated bacteriuria. Indeed, only two catheter principles are universally recommended: keep the closed catheter system closed and remove the catheter as soon as possible. Most modifications of the closed catheter system have not improved markedly on its ability to postpone bacteriuria. On first inspection, systemic antibiotics seem to be an exception to this rule, but their use results in infection of the bladder with resistant organisms, including candida. This and the effect of side effects on the patient and emergence of resistant bacteria in the medical unit have led most authorities to conclude that antibiotics are not useful for prevention of bacteriuria, nor for treatment of bacteriuria in the asymptomatic catheterized patient. For symptomatic patients, usually with fever or signs of sepsis, treatment of bacteriuria with appropriate systemic antibiotics and removal or replacement of the urethral catheter are indicated. Gloves, hand washing, and segregation of catheterized patients can minimize nosocomial clusters. Because clinicians can only postpone bacteriuria, and once it occurs, clinicians seem unable to prevent its complications, methodologies other than urethral catheters should be used for urine drainage assistance whenever possible. These options include condom, intermittent, suprapubic, and intraurethral catheterization for appropriate patients. The few data available suggest that each one of these catheterization options yields a lower incidence of bacteriuria-and its consequent complications-than urethral catheterization.

    5. West DA, Cummings JM, Longo WE, Virgo KS, Johnson FE and Parra RO (1999). Role of chronic catheterization in the development of bladder cancer in patients with spinal cord injury. Urology. 53: 292-7. Department of Surgery, St. Louis University School of Medicine, and the John Cochran Veterans Affairs Medical Center, Missouri, USA. OBJECTIVES: Patients with spinal cord injury (SCI) and chronic indwelling catheters are known to be at increased risk of bladder malignancy. "Decatheterization" by clean intermittent catheterization, external condom catheterization, or spontaneous voiding is thought to reduce the risk by decreasing the chronic mucosal irritation and rate of infection. We examined two Department of Veterans Affairs (DVA) data bases to test this theory. METHODS: A population-based retrospective analysis of invasive treatments for carcinoma of the bladder in all DVA hospitals was conducted using computerized inpatient files from fiscal years 1988 to 1992. RESULTS: One hundred thirty patients with bladder malignancy were identified from a pool of 33,565 patients with SCI (0.39%). All 130 patients underwent either radical cystectomy (n = 63, 48%) or transurethral resection of bladder tumor (n = 67, 52%). The 30-day perioperative mortality and overall 5-year survival rates were 2 (1.5%) and 49 (38%) of 130, respectively. Of the 130 patients analyzed, 42 (32%) had adequate data available regarding tumor pathologic findings and method of bladder management for analysis. The average age at diagnosis was 57.3 years. The histologic finding was transitional cell carcinoma in 23 (55%), squamous cell carcinoma in 14 (33%), and adenocarcinoma in 4 (10%) of 42. Bladder management was an indwelling urethral catheter in 18 (43%), suprapubic catheter in 8 (19%), clean intermittent catheterization in 8 (19%), and condom catheter in 6 (14%) of 42 patients. Squamous cell carcinoma was more common in patients with indwelling urethral catheters and suprapubic tubes (11 of 26, 42%) than in those using clean intermittent catheterization, condom catheterization, or spontaneous voiding (3 of 16, 19%). CONCLUSIONS: Bladder cancer was diagnosed in approximately 0.39% of this large SCI population during a 5-year period. Most cancers (55%) were transitional cell carcinomas. Squamous cell carcinoma was more common in patients with SCI and indwelling catheters than those without chronic catheterization. These data continue to suggest that avoidance of indwelling catheters, when feasible, is the preferred method of bladder management in patients with SCI.

  6. #6
    Senior Member Zeus's Avatar
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    Ami,

    I change my SPC every 5 weeks - in Australia, 4-6 weeks seems to be the norm. Beyond 6 weeks sediment builds up in the catheter and blockages become more prevalent.

    I've had about 4 UTIs in 2.5 years of my SPC, only ever indicated by smell. If I'm on antibiotics for, say, 10 days, I'll change my catheter at 8 days into the treatment. My fear is that bacteria 'attached' to the catheter survives the antibiotics and re-infects me afterwards.

    That's about all I can think of - beyond washing less around the stoma.

    Chris.
    Have you ever seen a human heart? It looks like a fist wrapped in blood! Larry in 'Closer', a play by Partick Marber

  7. #7
    Senior Member zillazangel's Avatar
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    Thanks to everyone for the helpful responses. One question is how can I take a sample for culturing? Do I clamp it then use an intermittent cath to get a sample? I think that is clearly the next step. I've been doing more frequent changes because the catheter gets all gunked up, as you mention Chris, but perhaps I am doing more harm than good. Wise, thank you, the articles are indeed helpful, some of them I'd read from your previous posts re: SP vs IC. These studies and others ultimately swayed me into believing this was a healthy and reasonable alternative to IC.

    Its been frustrating because the SP has improved my quality of life dramatically - I never got more than 5-6 hours of sleep at a stretch ever for many years. That takes an incredible toll and it really is cumulative. Now I can sleep and he also has SO much more indepedence as he is not tethered to me 24/7 (he has always been very worried about needing to be cathed and no one being there). But his QoL is going down. I am looking for that win-win situation!

    Thanks, any others responses welcome, and I'll update after we get a sample taken in.
    Wife of Chad (C4/5 since 1988), mom of a great teenager

  8. #8
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    To get a sample, you can get it when you change his SP tube using the new catheter then hook up to the drainage system. If put on antibiotics, we always change the catheter and drainage system after about 3 days to prevent re-infection. Jim has had the SP for 7 years, has had 3 infections, routinely changed cath's monthly for the first 5 years, now about every two weeks due to sediment. We opted to do this instead of irrigation or instillations. Besides the cost of catheter change as compared to daily instillations, it is really more time efficient. The stoma site is not treated any differently, just bathed at shower time and left open. I am religious about cleaning bags well and always look at that as the culprit first, then changing technique. Deb

    Edited to add: no bladder meds taken routinely

  9. #9
    Here is another method for getting urine sample if you have a needle and syringe and you have changed the catheter within last 7 days.

    Put on gloves
    Wipe sampling port(not the port you fill with water to fill the balloon) with alcohol swab for 30 seconds contact time.Using a sterile syringe and needle (if necessary) insert needle at 45 degree angle and aspirate the required amount of
    urine from the access port (approx 30cc) then withdraw needle and insert urine into the culture tube/container.


    AAD


  10. #10
    Quote Originally Posted by Zeus
    Ami,

    I change my SPC every 5 weeks - in Australia, 4-6 weeks seems to be the norm. Beyond 6 weeks sediment builds up in the catheter and blockages become more prevalent.

    I've had about 4 UTIs in 2.5 years of my SPC, only ever indicated by smell. If I'm on antibiotics for, say, 10 days, I'll change my catheter at 8 days into the treatment. My fear is that bacteria 'attached' to the catheter survives the antibiotics and re-infects me afterwards.

    That's about all I can think of - beyond washing less around the stoma.

    Chris.
    I use the same logic when I take antibiotics for a UTI. Get rid of that "infected" catheter. I change my SPC the 1st of every month, just keep it simple.

    Also, I make a point to drink at least 2 quarts of water every night...along with drinking as much as possible during the other day, Usually tea or sugar-free kool aid. I'll drink a Mt Dew now and then as a treat. haha

    Good luck! the SPC was one of the best decision Ive made for me.
    Brian

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