Intermittent Catheterization: Clean versus Sterile?

[Wise Young]

A debate has been going on concerning reusing catheters in this forum. Unfortunately, the debate involved personal criticism of members and some of the posts had to be removed. However, in my opinion, the question whether one should re-use catheters for intermittent catheterization is important and should not be discussed without data. So, I decided to restart the discussion with a literature search on the subject.


Intermittent Catheterization: Clean versus Sterile
Wise Young, Ph.D., M.D.
16 October 2007

The History of Urinary Bladder Catheterization

Restrictions of urine flow have been a bain of humankind for many years. When one cannot pee, one dies. Therefore, many civilizations had developed solutions for this problem. Hollow tubes made of natural plant stems were used to evacuate urine or stones from the bladder, to manage urethral strictures, and to instill medicines into the bladder in China. In ancient Greek and then subsequently Roman times, urethral catheters were made of bronze and may be straight and curved. Around 1020 AD, the Persian philosopher Avicenna described uroscopy, to inspect urine and advised physicians to catheterize gently. In 1752, Benjamin Franklin described a flexible silver catheter that he had designed for his older brother.

Modern catheters can probably be dated to 1839, when Charles Goodyear used vulcanized rubber to make a straight red rubber catheter with a side-port near the tip. This device, called the straight catheter, probably has saved more lives than any other medical device in the world. With relatively few and small modifications, this catheter is still very much in use today, including even the red color of the rubber catheter. The modifications of the catheter have been quite subtle but it is surprising how far back the history of urinary catheters goes.

In the 1850's, a French instrument manufacturer by the name of Joseph Charriérre developed a sizing system for catheters that is still being used today and why catheter size is expressed by a number followed by “french”. The smallest size is a third of a mm diameter and increased in multiples of 3. Around 1860, August Mercier developed a bent tip which he called the coudé (french for elbow). In the beginning, catheters were just taped in place. Various doctors had made balloon catheters but these were not widely used until 1936 when Federic E. Foley patented a one-piece latex-self-retaining catheter that bears his name.

In the 1980's, silicone catheters were introduced with much lower friction and could be reused. The silicone catheters have a smoother surface and causes less irritation of the urethra. Rubber catheters had to be used with lubricants. Silicone catheters have one additional advantage. With repeated uses, many people develop allergies to latex or rubber. Silicone catheters avoided this problem. In 1981, Wu, et al. (1981) described a reusable sterilizable catheter with a rubber balloon, ushering in the modern age of reusable catheters. Other materials besides rubber and silicone of course have been used.

Indwelling versus Intermittent Catheterization

In the 1960's, most patients with spinal cord injury and neurogenic bladders used an indwelling catheter, called a foley, to drain urine from the bladder. Indwelling urethral catheters, however, was associated with a high incidence of urinary tract infection. Because the catheter constantly drained urine out, the bladders shrank and it was difficult to expand the volume of the bladder once it shrank. Urinary tract infection was the main cause of death of people with spinal cord injuries. At the time, the only alternative was to use the crede method which involves pressure or tapping of the bladder through the abdomen to stimulate contraction to expel the urine. However, if detrusor-sphincter dysynergia (lack of coordination between bladder contraction and sphincter relaxation) is present, this method causes significant pressure in the bladder with consequent ureteral reflux of urine into the kidney. If the urine is infected, it often cause pyelonephritis. Repeated infections lead to kidney damage.

Early clinical practice recommended strict sterile or aseptic catheterization technique to avoid bacterial infection. The work of Lister had demonstrated the importance of sterility in surgical procedures and sterilization was considered to be a necessary part of catheterization. However, in 1970, jack Lapides introduced the technique of “clean intermittent catheterization”. The concept of a clean but non-sterile technique was controversial because it relied the assumption that bacteria introduced into the bladder will be diluted out by the urine and eliminated by the host defense. Fear of introducing bacteria into the urine dominated medical practice through the 1980's with physicians often prescribing antibiotics at the presence of any bacteriuria (bacteria in the urine) even with no evidence of any systemic infection, such as fever and elevated white blood counts.

The technique of intermittent catheterization revolutionized bladder care for people with spinal cord injury and other causes of the neurogenic bladder. Intermittent catheterization changed solved many of the problems of indwelling urethral catheters or the crede method. In the beginning, the procedure was sterile to avoid infections. The original catheters were made of rubber (or latex) and they tended to generate friction and repeated catheterizations often irritated the urethra and required lubricating jelly during the insertion of the catheter. In the 1980's, new catheter materials made from silicone became available and caused less friction and irritation to the urethra. Due to the expense of catheters, many people reused their catheters after washing them.

Sterile versus Clean

Several studies reported that clean intermittent catheterization (CIC) is just as safe as “sterile” intermittent catheterization. In 1982, Maynard & Diokno (1982) reviewed charts of 65 patients discharged between 1972-1977 and found 54 who used CIC. These 54 patients had an average followup of 3.7 years during which they had the following reported complications: nephrolithiasis (3), cystolithiasis (3), epididymitis (4), urinary tract infection (12). No patient had hydronephrosis or radiographic pyelonephritis. Maynard & Diokno concluded that CIC “appears to be a safe and satisfactory alternative to long-term management of the neurogenic bladder of selected spinal cord injury patients, since the incidence of serious renal complications is low.”

Maynard and Diokno (1984) subsequently reported a prospective study of 50 patients that had CIC randomized to groups that received or did not receive a prophylactic antibacterial preparation. The groups were further divided into subgroups that received definitive antibiotics for bacteriuria or antibiotics given for clinically symptomatic infections. While antibacterial prophylaxis significantly reduced the probabilty of laboratory detected bacteriuria, it did not significantly change the probability of clinical infection although there was a trend towards fewer clinical infections. There was no significant reduction of clinical infections in patients that were treated promptly with antibiotics for bacteriuria without clinical infection.

In 1992, King, et al. compared sterile intermittent catheterization (SIC) and CIC in two groups of 23 patients. The patients were catheterized every six hours and had urine cultures. Bacteriuria (>100,000 organisms/ml) and/or fever of 100˚F were noted. A total of 28 subjects (60.9%) developed bacteriuria but there was no difference between those that received SIC or CIC. Nor were there any difference in fever and clinical infection between the two groups. In 1993, Decter, et al. recommended use of CIC for the pediatric population with spinal cord injury.

Perkash and Giroux (1993) reported a study to 50 patients (36 para and 14 quad) who used CIC and were followed for 3.5 months to 6.5 years (average 22 months). Of the 50 patients, 43 (86%) developed significant bacteriuria (>10,000 colony forming units per ml), at the rate of 364 bacteriuric events per 1000 patient-day. Only 16 of the 43 patients (37%), however, developed clinical symptoms which included fever (8), chills (3), hematuria (3), and flank pain (2). Of the 50 patients, 4 (8%) required rehospitalization for urological problems. One died of questionable sepsis. Transurethral sphincterotomies were done in 15 patients (30%). Four of 7 patients that were having CIC done by others elected to discontinue and use chronic indwelling catheters. Overall, 66% of the patients elected to discontinue CIC. Perkash & Giroux (1993) concluded that CIC “is a successful long-term option to drain bladders in spinal cord injury patients who can perform catheterization independently.

In 1993, a consensus conference in 1993 held by the National Institute on Disability and Rehabilitation Research concluded that “clean intermittent catheterization does not pose a greater risk of infection than sterile self-intermittent catheterization and is much more economic. However, care must be given to proper cleansing of reusable catheters.” Since that time, CIC has become the standard practice for the field and care of people with spinal cord injury.

Modern use of CIC

In 1995, Cardenas, et al. reviewed 179 patients who engaged in four voiding patterns: CIC, indwelling catheter (IND), external collector (EC), and voiding. They found more severe trabeculations of the bladder in patients in the EC group, compared to the CIC or IND groups. In the same year, Chai, et al. (1995) at Michigan concluded that 71% of patients complied with CIC and had lower complication rates than previously reported, concluding that CIC can “provide optimal management of lower urinary tract in spinal cord injured patients.” Gray, et al. (1995) reported that 54% of patients who do CIC experience episodic incontinence. Takeuchi, et al., (1995) observed that patients who have vesicoureteral reflux still needed corrective surgery when treated with CIC, concluding that CIC alone is not effective to control reflux but is a good treatment option when combined with surgery.

Lavallee, et al. (1995) compared various methods, including hydrogen peroxide, vinegar, dishwashing detergent, and tap water to clean catheters that had been contaminated with Pseudomonas aeruginosa and Escherichia coli. They found that rising and drying catheters immediately after use was most effective at reducing bacteria to very near zero. Low-friction catheters are also considered desirable. Waller, et al. (1995) studied 30 patients who used disposable low-friction catheters for 5-9 years, showing that the catheters (after tap water soaking) had 10 times less friction than a regular catheter with jelly. Of 30 patients, 12 (40%) maintained sterile, 18 had bacteriuria of which only 4 had episodes of urinary sepsis and chronic infection. Six men had occasional insertion difficulties and developed strictures. Use of the catheter seems to reduce the incidence of urethral trauma.

Singh & Thomas (1997) subsequently pointed out the difficulties of managing female tetraplegics with CIC and pointed out that many patients required indwelling catheters even though patients that had CIC fared better. By 1997, Sylora, et al. reported that CIC through a mitrofanoff canal is a useful option, particularly for patients with quadriplegia to carry out CIC through the belly button. Van Hala, et al., (1997) surveyed 165 patients and found that only 2% used sterile catheterization and 98% used CIC. Giannantoni, et al. (1998) reported that CIC is superior for preventing upper urinary tract disease, compared to those who used tapping or abdomenal straining with vesicoureteral reflux.

Weld & Dmoshowski (2000) studied 316 patients with spinal cord injury and found 398 complications, 236 of which occurred in 61 of 114 patients who had chronic urethral catheterization, 57 in 25 of 92 patients who do CIC, 57 in 24 of 74 patients who voided spontaneously, and 48 in 18 of 36 patients who had suprapubic catheters. In other words, 53% of patients with chronic indwelling catheters, 27% of patients who use CIC, 32% of spontaneous voiders, and 50% of patients who use suprapubic catheters have complications. Those who use CIC had the lowest complication rate. Weld, et al. (2000) also reported that 6.2% of those who use indwelling catheters had proteinuria, compared to 1% of those who use CIC, 1.3% in those who spontaneously void.

Overseas Use of Intermittent Catheterization

CIC has become the international standard of bladder care after spinal cord injury. In 2002, Biering-Sorenson concluded that suprapubic cystotomy drainage in patients is preferred to that of indwelling urethral catheters. In 2004, Generao, et al. at UC Davis followed 42 children with spinal cord injury for up to 15 years and found that 40 of 42 of these patients use CIC and 37 use anti-spasmodics. No patient had reflux, hydronephrosis, or renal scarring. A majority had “safe bladder capacity”. He concluded that CIC and anti-spasmodics prevent upper tract damage and this was the optimal approach to handling bladder complications of spinal cord injury.

The cost of catheters may have discouraged use of intermittent catheterization in countries around the world and encouraged the use of chronic indwelling urethral catheterization. For example, while South Korea adopted the U.S. practice of CIC (Oh, et al., 2005), doctors in Japan have been less willing to use intermittent catheterization. For example, Kitahara, et al. (2006) surveyed urological management of spnal cord injury in Japan, finding that fewer doctors used intermittent catheterization than in the United States. In third world countries, the cost of catheters is prohibitive and extreme examples of catheters reuse have been reported. For example, in India and China, there has been no choice. The average patient must use CIC or chronic indwelling catheters.

In 2004, Kovindha, et al. {Kovindha, 2004 #24277} from Chiang Mai in Thailand assessed 28 men with spinal cord injury who used indwelling catheterize during the acute phase and then performed self-catheterization with a silicone catheter. According to the study, the 26 men re-used each catheter for an average of 3 years (1-7 years). During this period, they had the following complications (number of complaints): urethral bleeding (3), episodes of pus per urethra (5), epididymitis (5), passing of stones (4), occasional foul smelly urine (18), feber and cloudy urine in the past year (10). Seventeen of the patients had ultrasonography done and four had pathological kidney findings and one had bladder calculi. Electron microscopic examination of the reused catheters revealed encrustation but no obstruction of the urine. There was however, a 20% increase in the stiffness of the catheter.

It is essential, however, to point out that sterile intermittent catheterization is important for the hospital setting. Because there are so many antibiotic resistant pathological organisms in hospitals, sterile intermittent catheterization is essential in the hospital setting. It is also important to point that that some individuals are much more susceptible to urinary tract infections than others, probably for genetic reasons. Such people should use sterile intermittent catheterization. However, for the majority of people, CIC has become the standard and has reasonably low infections rates. Many studies have shown that CIC is better than chronic indwelling urethral catheters.

References

1. Biering-Sorensen F (2002). Urinary tract infection in individuals with spinal cord lesion. Curr Opin Urol. 12: 45-9. Clinic for Para- and Tetraplegia, The Neuroscience Centre, Copenhagen, Denmark. finbs@rh.dk. Urinary tract infection is the most frequently reported secondary impairment in individuals with spinal cord lesion. The most prevalent risk indicator is an indwelling catheter. Hydrophilic catheters for clean intermittent catheterization may induce lower rates of bacteriuria and long-term urethral complications. Due to chronic bacterial infection within biofilms, an antibacterial treatment based on a urinary culture of bacteria in the urine and its antimicrobial susceptibility may fail to eradicate catheter-associated urinary tract infection. No commercially available drugs are sufficiently active against the bacteria in a mature biofilm. Biomaterials may be modified to decrease the formation of a biofilm. Silver alloy catheters are effective in preventing urinary tract infection when indwelling urinary catheterization is necessary. The risk of systemic argyria in long-term use needs to be evaluated. Suprapubic cystostomy drainage in patients with neurogenic bladder is preferred to an indwelling urethral catheter. In cases of recurring urinary tract infection in patients with a permanent urinary catheter, it may be beneficial to change the catheter every 1 or 2 weeks. There is some evidence that cranberry products may prevent urinary tract infection. In the future, bacterial interference and vaccination may be a possibility for prevention of urinary tract infection.
   
2. Cardenas DD, Mayo ME and Turner LR (1995). Lower urinary changes over time in suprasacral spinal cord injury. Paraplegia. 33: 326-9. Department of Rehabilitation Medicine, University of Washington, Seattle 98195, USA. This paper reviews 179 patients (23 females and 156 males) with suprasacral spinal cord injury (SCI) who underwent videourodynamic evaluation to compare maximum detrusor pressure, compliance, and trabeculation with methods of bladder management, years post-injury, and age. The patients were divided into four groups based on mode of bladder management: clean intermittent catheterization (CIC), indwelling catheter (IND), external collector (EC), and voiding (V). Maximum pressure decreased significantly with increasing age for those using EC (P < 0.01) and CIC (P < 0.05). Maximum pressure also decreased significantly with years post-injury for patients on EC (P < 0.01) and was highest the first decade after injury and progressively decreased through the fifth decade. Post-hoc tests indicated more severe trabeculation in patients in the EC group than in either the CIC or IND groups. Age and trabeculation did not correlate in those on EC. We conclude that patients with long-standing suprasacral SCI using EC are more likely to have lower detrusor pressures than are those with less chronic SCI. This finding may reflect the effects of age as well as reduced survival in those using EC with chronically elevated detrusor pressure.
   
3. Chai T, Chung AK, Belville WD and Faerber GJ (1995). Compliance and complications of clean intermittent catheterization in the spinal cord injured patient. Paraplegia. 33: 161-3. Department of Surgery, University of Michigan Medical Center, Ann Arbor 48109-0330, USA. The optimal management of the neuropathic bladder secondary to spinal cord injury remains unsettled. Some have advocated the use of chronic indwelling catheters in tetraplegic patients supposedly due to comparable complication rates with non-indwelling catheter management. We assessed the urological complication and compliance rates in a group of spinal cord injured patients followed over a mean of 5.9 years. Complication rates from clean intermittent catheterization were comparable if not better than the rates previously reported for clean intermittent catheterization and significantly better than chronically catheterized patients. The compliance rate in our series was 71% as determined by the number of patients remaining on clean intermittent catheterization at their last urological follow-up. We conclude that the use of clean intermittent catheterization can provide optimal management of the lower urinary tract in spinal cord injured patients.
   
4. Giannantoni A, Scivoletto G, Di Stasi SM, Silecchia A, Finazzi-Agro E, Micali I and Castellano V (1998). Clean intermittent catheterization and prevention of renal disease in spinal cord injury patients. Spinal Cord. 36: 29-32. IRCCS Rehabilitation Hospital S. Lucia, Rome, Italy. Upper urinary tract complications have been reported in about 20-30% of spinal cord injury patients. Their pathogenesis is linked to the presence of high-pressure uninhibited detrusor contractions, high leak point pressure and low bladder compliance. The aim of this study was to evaluate the incidence of upper urinary tract complications in two homogeneous groups of spinal cord injury patients with different bladder emptying modalities (intermittent catheterization vs. tapping, abdominal straining, Crede's manoeuvre) and the relationship with clinic and urodynamic features. A total of 17 patients (22%) had upper urinary tract complications. The incidence of both urinary tract dilatation and vesicoureteral reflux was significantly lower in patients having intermittent catheterization (P = 0.03 and 0.04 respectively). Intermittent catheterization thus seems to be effective in preventing upper urinary tract disease in spinal cord injury patients requiring mechanical bladder emptying modalities. The finding of upper urinary tract complications also in patients having intermittent catheterization showing high intravesical pressures stresses the need of adding anticholinergic medications to the rehabilitation regimen of these patients.
   
5. Gray M, Rayome R and Anson C (1995). Incontinence and clean intermittent catheterization following spinal cord injury. Clin Nurs Res. 4: 6-18; discussion 19-21. Clean intermittent catheterization (CIC) is commonly used by individuals with neuropathic bladder dysfunction caused by spinal injury. Although the incidence of urologic complications such as infection, calculi, and urethral erosion have been documented for patients managed by CIC, little is known about the incidence or characteristics of urinary incontinence among these patients. One hundred and fifty patients who had been discharged on CIC were investigated via a structured interview. Contrary to speculations in the literature, only 54% of those individuals who performed CIC experienced any incontinent episodes and 53% of those noted only episodic incontinence, with minimal or moderate volume leakage. A variety of strategies were used to attempt to prevent urinary leakage. Generally, patients demonstrated a lack of knowledge concerning nonpharmacological strategies to alleviate incontinence. This research provides a basis for nursing management strategies to reduce the incidence and severity or urinary leakage among spinal injured patients managed by intermittent catheterization.
   
6. King RB, Carlson CE, Mervine J, Wu Y and Yarkony GM (1992). Clean and sterile intermittent catheterization methods in hospitalized patients with spinal cord injury. Arch Phys Med Rehabil. 73: 798-802. Rehabilitation Institute of Chicago, IL 60611. The purpose of this study was to compare the incidence of urinary infection using clean intermittent catheterization with the incidence of infection using sterile intermittent catheterization in patients hospitalized with spinal cord injury who were not receiving prophylactic antibiotics. Forty-six patients were assigned randomly to a clean (n = 23) or sterile (n = 23) study group. Catheterizations were done at least every six hours. Infection was defined as bacteriuria greater than or equal to 100,000 organisms/mL or greater than or equal to 10,000 organisms per mL with fever of 100 degrees F or greater. Results of urinary dipslides were recorded daily. Twenty-eight subjects (60.9%) converted to greater than or equal to 100,000 organisms per mL. Method of catheterization was neither associated significantly with development of greater than or equal to 100,000 organisms per mL. (X2[1,46] = .36, p = .55) nor with symptomatic infections (X2[1,46] = .15, p = .70). Data support the use of clean intermittent catheterization under the conditions used in this study, including the use of a sterile catheter each day and careful monitoring of infection and technique. Before using this method with other diagnostic groups or in different clinical settings, further investigation is needed.
   
7. Kovindha A, Mai WN and Madersbacher H (2004). Reused silicone catheter for clean intermittent catheterization (CIC): is it safe for spinal cord-injured (SCI) men? Spinal Cord. 42: 638-42. Department of Rehabilitation Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand. STUDY DESIGN: Study of reusable catheter. OBJECTIVE: To investigate whether a silicone cathether reused over years for clean intermittent catheterization (CIC) was safe for spinal cord injured (SCI) men. SETTING: Maharaj Hospital, Chiang Mai, Thailand. METHOD: A cross-sectional study was obtained from SCI men who had used CIC with a reusable silicone catheter for more than a year. Demographic data, urological management and urinary tract complications focusing on the radiologic status of the urethra were reviewed and analyzed. In addition, two reused and one new catheters were studied under electron microscope for catheter morphology (surface and lumen) and stiffness. RESULTS: There were 28 SCI men included in this study. The average duration of CIC use was 4.8 years and the average time of usage for each catheter was 3 years (range 1-7 years). In all, 26 men previously used indwelling catheterization (ID) during the acute phase. In all, 23 men performed self-catheterization. Regarding urinary complications, three reported urethral bleeding, five had episodes of pus per urethra, five had epididymitis, four had passing stones, 18 had occasional foul smelly urine, 10 developed fever and cloudy urine during the past year. Of 17 patients who had ultrasonography done, four had pathologic findings in kidney and one had bladder calculi. Demographic data, urinary management and complications did not have significant relation to the abnormality of the urethrogram or urinary tract infection. However, where the frequency of CIC was higher, the abnormality of the urethra was lower (P<0.05). All had serum Cr level < or =1.3 mg/dl. Electron microscopic findings of reused catheters for 2 years revealed encrustation but no obstruction in the lumens and 20% increase in stiffness. CONCLUSION: The clinical outcome, especially with regard to urethral abnormalities with this reusable silicone catheter is as good as with a disposable one. However, to reuse urinary catheters, one should consider the increasing risk of infection. For SCI patients in developing countries, CIC with a reusable silicone catheter may be a suitable and safe choice if one cleans and applies it properly to reduce infection. In order to answer the question how long a person in a developing country should use the same silicone catheter, further research should be conducted.
   
8. Lavallee DJ, Lapierre NM, Henwood PK, Pivik JR, Best M, Springthorpe VS and Sattar SA (1995). Catheter cleaning for re-use in intermittent catheterization: new light on an old problem. SCI Nurs. 12: 10-2. Clean intermittent catheterization is a common method of urinary elimination for people with Spinal Cord Injuries. The methods of catheter cleaning for re-use, however, have not been validated with research studies. This study compared the effectiveness of Hydrogen Peroxide, vinegar, dishwashing detergent, and tap water alone to clean catheters contaminated with Pseudomonas aeruginosa and Escherichia coli. The effect of rinsing and drying before cleaning was also examined, as well as the effect of storage in paper or plastic bags after cleaning. Results indicated that rinsing and drying catheters immediately after use was the most effective at reducing bacteria to very near zero. Elements of a procedure are outlined, as well as plans for further development and testing of a rinse & dry procedure for catheter cleaning and re-use.
   
9. Maynard FM and Diokno AC (1982). Clean intermittent catheterization for spinal cord injury patients. J Urol. 128: 477-80. Charts were reviewed retrospectively for 65 patients with traumatic spinal cord injury discharged from the hospital between 1972 and 1977 on clean intermittent catheterization for management of neurogenic bladders. While 54 patients were still using clean intermittent catheterization 9 had discontinued its use and 2 were lost to followup. Complete urologic followup records were available for 28 long-term clean intermittent catheterization users, with an average followup of 3.7 years. Complications seen in this group included nephrolithiasis-3 cases, cystolithiasis--3, epididymitis--4 and urinary tract infection--12. No patient had hydronephrosis or radiographic pyelonephritis. Clean intermittent catheterization appears to be a safe and satisfactory alternative for long-term management of the neurogenic bladder of selected spinal cord injury patients, since the incidence of serious renal complications is low. Factors that should be considered before long-term clean intermittent catheterization is recommended include type of neurogenic bladder, prognosis for recovery, incontinence despite medication, history of urethral trauma, host resistance, physical independence in self-catheterization, compliance and patient preference.
   
10. Maynard FM and Diokno AC (1984). Urinary infection and complications during clean intermittent catheterization following spinal cord injury. J Urol. 132: 943-6. A total of 50 patients with recent spinal cord injury secondary to trauma participated in a prospective study of urinary complications during an interval of clean intermittent catheterization at initial hospitalization in a spinal cord injury unit. Patients were assigned randomly to groups receiving or not receiving a prophylactic antibacterial preparation. Both groups were divided further into subgroups in which laboratory infections (bacteriuria more than 100,000 organisms per ml.) were treated with definitive antibiotics or in which antibiotic treatment was given only for clinical infections (fever more than 100F or urethral discharge and bacteriuria). Antibacterial prophylaxis significantly reduced the probability of laboratory infection but not the probability of clinical infection, although a trend was noted toward fewer clinical infections. No significant reduction was noted in the probability of clinical infection in subgroups treated promptly for laboratory infection.
    
11. NIDRR (1993). The prevention and management of urinary tract infections among people with spinal cord injuries. National Institute on Disability and Rehabilitation Research consensus statement. January 27-29, 1992. SCI Nurs. 10: 49-61. The Urinary Tract Infection Consensus Conference brought together researchers, clinicians, and consumers to arrive at consensus on the best practices for preventing and treating urinary tract infections in people with spinal cord injuries; the risk factor and diagnostic studies that should be done; indications for antibiotic use; appropriate follow-up management; and needed future research. Urinary tract infection (UTI) was defined as bacteriuria (102 bacteria/ml of urine) with tissue invasion and resultant tissue response with signs and/or symptoms. Asymptomatic bacteriuria represents colonization of the urinary tract without symptoms or signs. Risk factors include: over-distention of bladder, vesicoureteral reflux, high pressure voiding, large post-void residuals, presence of stones in urinary tract, and outlet obstruction. Possible physiologic/structural, behavioral, and demographic risk factors were identified also, Indwelling catheterization, including suprapubic, and urinary diversion and the drainage methods most likely to lead to persistent bacteriuria. Infection risk is reduced with intermittent catheterization, but more severely disabled people who require catheterization by others are at greater risk for UTIs. Clean self-intermittent catheterization does not pose a greater risk of infection than sterile self-intermittent catheterization and is much more economic. However, care must be given to proper cleansing of reusable catheters. Quantitative urine-culture criteria for the diagnosis of bacteriuria include: catheter specimens from individuals on intermittent catheterization > or = 10(2) cfu/ml; clean-void specimens from catheter-free males using condom collection devices > or = 10(4) cfu/ml; and specimens from indwelling catheters of any detectable concentration. Dip stick screening tests may offer promise as an early warning system of UTI since they can be self-administered. Symptomatic UTI should be treated with antibiotics for 7 to 14 days. Longer courses have not been beneficial. In patients with symptomatic UTIs, it is not necessary to wait for the results of cultures before starting treatment. Asymptomatic bacteriuria need not be treated with antibiotics. There is little evidence presently to support the use of antibiotics to prevent infections. Following a recent episode of febrile UTI, possible contributing prior events should be reviewed. The upper tracts should be evaluated (imaging studies) to identify possible abnormalities. A common concern among people with spinal cord injuries is that physicians will alter bladder management programs without regard to lifestyle needs. Social/vocational flexibility may be more important to them than a state-of-the-art bladder management program. Future research should focus on obtaining more representative samples and investigate psycho-social-vocational implications as well as additional clinical-medical factors.
    
    
12. Oh SJ, Ku JH, Jeon HG, Shin HI, Paik NJ and Yoo T (2005). Health-related quality of life of patients using clean intermittent catheterization for neurogenic bladder secondary to spinal cord injury. Urology. 65: 306-10. Department of Urology, Seoul National University College of Medicine, Seoul, South Korea. OBJECTIVES: To determine the psychological and social status of patients using clean intermittent catheterization for neurogenic bladder according to health-related quality of life (HRQOL). METHODS: We conducted a prospective trial involving 132 patients (81 men and 51 women, mean age 41.8 years, range 18 to 80 years) using clean intermittent catheterization because of neurogenic bladder secondary to spinal cord injury. The 150 controls (90 men and 60 women) lived in the same region as the patients and were frequency matched to ensure equal age and sex distributions. HRQOL was measured using the Medical Outcomes Study 36-Item Short-Form General Health Survey (SF-36). RESULTS: The SF-36 scores did not reveal any significant differences between the men and women in the patient group. The SF-36 scores of the patients were significantly lower than those of the general population. When patients and controls were divided into two groups according to sex and age, the SF-36 scores of the patients were significantly lower than the controls across both sex and all age groups, other than the energy and vitality scale, the differences for which were not statistically significant in women and those younger than 50 years. CONCLUSIONS: Our findings suggest that patients using clean intermittent catheterization because of neurogenic bladder secondary to spinal cord injury generally exhibit a reduced quality of life in all health domains as assessed by the SF-36.
    
13. Perkash I and Giroux J (1993). Clean intermittent catheterization in spinal cord injury patients: a followup study. J Urol. 149: 1068-71. Spinal Cord Injury Service, Department of Veterans Affairs, Palo Alto, California. A followup study on nonhospitalized spinal cord injury patients using clean intermittent catheterization was conducted to evaluate long-term clean intermittent catheterization for any genitourinary complications, and to institute and evaluate prompt management. A total of 50 patients (36 paraplegics and 14 quadriplegics) was followed for 3 months to 6.5 years (average followup 22 months). All patients had a baseline urodynamic study and renal scan before they were discharged from the hospital. Patients with a reflex bladder and sustained, high intravesical pressures (greater than 40 cm. water) were placed on anticholinergic medication to lower voiding pressures and maintain continence. Those on clean intermittent catheterization and condom drainage were also given alpha-blockers to achieve low pressure voiding and to control autonomic dysreflexia. Of 50 patients 43 (86%) acquired a total of 364 events of significant bacteriuria (10(4) or more colony-forming units per ml.) at a rate of 13.63 infections per 1,000 patient-days on clean intermittent catheterization. Subclinical symptoms for urinary tract infection were noted in 22 of the 43 patients (51%), whereas clinical symptoms for urinary tract infection were recorded in 16 of 43 (37%). These symptoms included fever in 8 patients, chills in 3, hematuria in 3 and flank pain in 2. There were 31 genitourinary complications in 21 patients noted during periodic diagnostic evaluations, with 6 classified as upper tract. Of 50 patients 4 (8%) required rehospitalization for urological problems. One patient died of questionable sepsis. Transurethral sphincterotomy was performed in 15 of the 50 patients (30%) and transurethral prostatectomy was done in 1 for multiple reasons, for example high intravesical voiding pressures, difficult catheterization, repeated symptomatic urinary tract infections or per patient request to discontinue clean intermittent catheterization. Of 7 patients who were catheterized by others 4 elected to discontinue long-term clean intermittent catheterization after an average of 13 months. Overall, 33 patients (66%) discontinued clean intermittent catheterization and 17 are still being followed on a long-term basis. Clean intermittent catheterization is a successful long-term option to drain bladders in spinal cord injury patients who can perform catheterization independently.
    
14. Sylora JA, Gonzalez R, Vaughn M and Reinberg Y (1997). Intermittent self-catheterization by quadriplegic patients via a catheterizable Mitrofanoff channel. J Urol. 157: 48-50. Children's Health Care-Minneapolis, Minnesota, USA. PURPOSE: Neurogenic bladder due to cervical spinal cord injury is often best managed by clean intermittent catheterization. Limited upper extremity function makes patients with quadriplegia dependent on caregivers for clean intermittent catheterization. The Mitrofanoff umbilical appendicovesicostomy provides easy access to the bladder in patients with all types of access difficulty. We evaluated the Mitrofanoff umbilical appendicovesicostomy in 7 patients with quadriplegia. MATERIALS AND METHODS: Four men and 3 women with cervical spinal cord injury underwent the Mitrofanoff umbilical appendicovesicostomy with appendix (5) or ileum (2). RESULTS: All patients are continent and able to self-catheterize via the umbilical stoma. In 1 patient with an ileal Mitrofanoff umbilical appendicovesicostomy umbilical incontinence was repaired surgically and stomal stenosis developed in 1, which required stomal revision. All patients use the stoma regularly. Four patients have moved out of care facilities and are living more independently. CONCLUSIONS: The Mitrofanoff catheterizable channel is a valuable option for bladder management in patients with quadriplegia. Clean intermittent self- catheterization allows these patients independent function and facilitates their return to productive lives outside care facilities.
    
15. Takechi S, Nishio S, Yokoyama M, Iwata H and Takeuchi M (1995). [Clean intermittent catheterization in neurogenic bladder patients with vesicoureteral reflux]. Nippon Hinyokika Gakkai Zasshi. 86: 1520-4. Department of Urology, Ehime University School of Medicine, Japan. (BACKGROUND): For neurogenic bladder (NGB) patients with vesicoureteral reflux (VUR), renal deterioration constitutes a primary threat to survival. Although anti-reflux surgery for those patients was reported to be effective, the efficacy of clean intermittent catheterization (CIC) in such patients still remains to be clarified. (METHODS): Sixteen neurogenic bladder patients with VUR were treated with CIC. Eight of them had spina bifida and 3 had radical hysterectomy for uterine cancer. Other 5 patients had spinal cord injury, spondyrocace, measles encephalopathy, and 2 unknown diseases, respectively. Hyperactive bladder was noted in 11 patients, whereas hypoactive bladder was noted in 3. Three patients were not evaluated. (RESULTS): VUR was improved in only 3 patients (3 ureters), whose VUR grades were not more than III. Nine patients (13 ureters) had to have antireflux surgery. Although 3 of them needed bladder augmentation afterwards, the success rate of the antireflux surgery was 84.6%. (CONCLUSION): We concluded that CIC alone was not effective to control VUR in neurogenic bladder patients. Nevertheless, CIC remained a good treatment option when VUR was managed surgically.
    
16. Van Hala S, Nelson VS, Hurvitz EA, Panzi A, Bloom DA and Ward MJ (1997). Bladder management in patients with pediatric onset neurogenic bladders. J Spinal Cord Med. 20: 410-5. Department of Physical Medicine & Rehabilitation, University of Michigan Medical Center, Ann Arbor, USA. Our objective was to determine which clean intermittent catheterization (CIC) methods and supplies were used by patients with pediatric onset neurogenic bladders and to relate methodology and materials to reported urinary tract infections. Data were collected via questionnaires distributed by mail and at clinic visits at our university tertiary care outpatient pediatric rehabilitation clinic. Questionnaires were given to 165 patients. Fifty-nine percent were returned (68 patients with myelomeningocele, 27 with pediatric onset spinal cord injury (SCI) and two with other diagnoses). Mean age was 12 years (range 1-27). Fifty-four percent of patients participated in their own CIC. Only two percent used sterile catheterization technique, whereas 98 percent used CIC. A sterile catheter was employed with clean technique by 22 percent. Catheters were reused by 76 percent. Subjects used a wide ranging number of catheters per month, with a median of 5.3. There was no correlation between the number of urinary tract infections (UTIs) per year and the type of catheter used or the use of prophylactic antibiotics. Compared with patients with myelomeningocele, subjects with SCI were significantly more likely to use sterile catheters (p = 0.04), > 10 catheters per month (p = 0.01) and gloves (p < 0.001). Subjects who used gloves or more catheters were more likely to experience UTI. These data suggest that clean reused supplies are not related to an increased likelihood of UTI and should be considered a way to lower costs in these populations.
    
17. Waller L, Jonsson O, Norlen L and Sullivan L (1995). Clean intermittent catheterization in spinal cord injury patients: long-term followup of a hydrophilic low friction technique. J Urol. 153: 345-8. Department of Neurosurgery, Sahlgrenska Hospital, Gothenburg, Sweden. Clean intermittent self-catheterization is an established option in bladder management of spinal cord injury patients. Several early and a small number of long-term studies have reported good preventive or therapeutic effects on hydronephrosis, vesicourethral reflux, urinary tract infection and incontinence. Most reports describe the use of small catheters and liberal use of jelly but urethral complications, such as strictures and false passages, seem to increase with the length of followup. All 30 spinal cord injury patients in this retrospective study had used disposable hydrophilic, low friction catheters from the early shock phase to a median of 7 years (range 5 to 9). There were 26 upper motor neuron and 4 lower motor neuron lesions. After tap water soaking, the surface layer of the catheter coating has a friction constant more than 10 times lower than that for a regular plastic catheter (Nelaton) with chlorhexidine jelly. There was no hydronephrosis, pyelonephritis or renal scarring. In 3 patients who had decreased the clean intermittent self-catheterization regimen, signs of upper tract dilatation developed but the excretory urogram returned to normal after correction of the regimen. Of 30 patients 12 (40%) maintained sterile urine, while 4 of the remaining 18 with bacteriuria had episodes of urinary sepsis and chronic infections. Two patients had epididymitis. Of 6 men with occasional insertion difficulties when the clean intermittent self-catheterization regimen started after the indwelling catheter had been removed 4 showed yielding signs of strictures during the subsequent clean intermittent self-catheterization regimen. In 1 patient 2 dilation attempts had failed but the patient can perform the clean intermittent self-catheterization regimen. One patient with Crohn's disease had advanced urethral changes in the acute phase but could perform clean intermittent self-catheterization with a small catheter. One patient has had recurrent modifications of the urethral wall but no development of a false passage. The study indicates that patients who use hydrophilic low friction low friction catheters do as well as or better than patients using conventional catheters. Above all, there is no increase in severe urethral complications with time after injury. Progression towards strictures after early urethral trauma seems to be preventable by the use of this catheter.
    
18. Weld KJ and Dmochowski RR (2000). Effect of bladder management on urological complications in spinal cord injured patients. J Urol. 163: 768-72. Department of Urology, University of Tennessee, Memphis, USA. PURPOSE: The optimal method of bladder management in spinal cord injured patients remains controversial. We investigated the association of type of bladder management with urological complications in these patients. MATERIALS AND METHODS: We retrospectively reviewed the medical records, upper tract imaging and video urodynamics of 316 posttraumatic spinal cord injured patients. Mean followup plus or minus standard deviation since injury was 18.3+/-12.4 years. Patients were categorized according to bladder management method, including chronic urethral catheterization, clean intermittent catheterization, spontaneous voiding and suprapubic catheterization in 114, 92, 74 and 36, respectively. No significant differences in patient age at injury, followup interval, or level, completeness or mechanism of injury were noted among bladder management method groups. Infection, stone disease, urethral complications and radiographic abnormalities were recorded. RESULTS: Of the 398 complications recorded 236 developed in 61 (53.5%) patients on chronic urethral catheterization, 57 in 25 (27.2%) on clean intermittent catheterization, 57 in 24 (32.4%) who voided spontaneously and 48 in 16 (44.4%) on suprapubic catheterization. The intermittent catheterization group had statistically significant lower complication rates compared with the urethral catheterization group and no significantly higher complication rates relative to all other management methods for each type of complication studied. The percent of patients with complications was greater in the chronic urethral catheterization group only 5 years after injury, while the percent in all other management groups remained similar up to 15 years after injury. CONCLUSIONS: Clean intermittent catheterization is the safest bladder management method for spinal cord injured patients in terms of urological complications. Inappropriate selection of a bladder management method not only adversely affects patient quality of life, but also has a significant detrimental impact on the economic status of the health care system.
    
19. Weld KJ, Wall BM, Mangold TA, Steere EL and Dmochowski RR (2000). Influences on renal function in chronic spinal cord injured patients. J Urol. 164: 1490-3. Departments of Urology and Biostatistics, University of Tennessee and Nephrology Section, Veterans Affairs Medical Center, Memphis, Tennessee, USA. PURPOSE: The optimal method of bladder management in the spinal cord injured population remains controversial. We determined the significance of bladder management and other factors on renal function in this population. MATERIALS AND METHODS: We retrospectively reviewed the medical records and upper tract imaging studies of 308 patients with a mean followup of 18.7 years since injury. Renal function was assessed by serum creatinine, creatinine clearance and proteinuria measurement, and by upper tract abnormalities on renal ultrasound and nuclear medicine renal scan. Independent variables evaluated for an influence on renal function included patient age, interval since injury, injury level and completeness, vesicoureteral reflux, history of diabetes mellitus and bladder management method. RESULTS: Mean serum creatinine plus or minus standard deviation in patients on chronic Foley catheterization, clean intermittent catheterization and spontaneous voiding was 1.08 +/- 0.99, 0.84 +/- 0.23 and 0.97 +/- 0.45 mg./dl. (analysis of variance p = 0.05, Student's t test p = 0.10), and mean creatinine clearance was 91.1 +/- 46.5, 113.4 +/- 39.8 and 115 +/- 49 ml. per minute, respectively (analysis of variance and Student's t test p <0.01), respectively. Proteinuria was present in 19 patients (6.2%) in the Foley catheterization, 3 (1%) in the clean intermittent catheterization and 4 (1.3%) in the spontaneous voiding group (chi-square test p <0.01), while there were upper tract abnormalities in 56 (18.2%), 20 (6.5%) and 24 (7.8%) patients, respectively (chi-square test p <0.01). Multiple regression analyses revealed no significant predictors of serum creatinine, although older patient age and Foley catheterization significantly predicted low creatinine clearance. Additional logistic regression analyses showed that Foley catheterization was associated with proteinuria and vesicoureteral reflux was associated with upper tract abnormalities. CONCLUSIONS: While renal function may be preserved by all forms of bladder management, chronic indwelling catheters may contribute to renal deterioration.
    
20. Wu Y, Hamilton BB, Boyink MA and Nanninga JB (1981). Reusable catheter for long-term sterile intermittent catheterization. Arch Phys Med Rehabil. 62: 39-42. A new resterilizable, low cost, and convenient catheter for long-term sterile intermittent catheterization of the neurogenic bladder is described. Average self-catheterization time is 2 minutes. It can be performed successfully in a wheelchair. Estimated average cost per catheterization is 10 to 20 cents. The reduced cost and greater convenience of the Wu Reusable Catheter make sterile long-term intermittent catheterization feasible for spinal cord injured patients. This should lead to reduction of urologic morbidity encountered with indwelling and external catheterization.
    

[JustinB]

JustinB... I am very sorry. In the process of editing my response to your comment... I inadvertently wiped out your comments, which I thought were excellent. Unfortunately, I cannot restore them but will try from memory to do so.

Basically, you summarized the findings that clean intermittent catheterization is as safe as sterile intermittent catheterization except under certain special circumstances that include hospitals and people who are susceptible to infections. I agree with this summary.

You also asked whether the is any evidence concerning the type of material. There is unfortunately little reliable controlled randomized trials providing information on this. I think that the difference between the different materials and coatings are not great. On the other hand, I think that such information would be very useful...

I did a quick literature survey, came across additional information, and then put them in a post that follows this.

I apologize for erasing your post.

Wise.

[Wise Young]

Urinary catheters are made of several different materials:

• Latex catheters. These are rubber catheters. When coated, they are long-lasting and comfortable. They are sterilizable. Their major drawback is that they can stimulate latex allergy.
  • Hydrogel coated latex. These have smooth surfaces and can be used for long term, up to 12 weeks. They are not suitable for patients allergic to latex.
  • Teflon coated latex catheter. These are smooth but the coating reduces the lumen size. These can be used for up to 28 days and are more resistant to encrustation. The Teflon coating can wear thin. These are not suitable for patients with latex (rubber) allergies.
• Silicone catheters. Silicone rubber is also known as “silastic”. Made by Dow Corning, silastic is relatively smooth, resistant to chemicals, autoclavable or gas sterilizable, easily modified and moded, and soft. Therefore, it has been a favoriate material for catheters. Because they are soft and compliant, they can be placed for long period, up to 12 weeks. They have wide lumens for drainage and do not stimulate allergy to latex. Cuffing of balloons may occur and may interfere with reomoval suprapubically.
  • Rounded catheter tip. A rounded catheter tip is lease traumatic. Most conventional catheters have square cut or beveled catheters with edges that can damage the urethra. Examples include ehte IntiSilf silicone catheter.
  • Slicone elastomer-coated latex. They have smooth low-friction surfaces and are good for long term use, up to 12 weeks. However, they are not suitable for patients allergic to latex.
  • Hydrogel coated silicone catheters. These have smooth coats, usable up to12 weeks, non-allergenic for latex, but tend to be rigid and uncomfortable.
• Polyurethane catheters. Polyurethane is a kind of plastic. Because it is stronger than silastic, it can have thinner walls and therefore larger lumen (entire channel diameter). t can be sterilized by EtO gas but not autoclavable.
  • Hydrogel coated polyurethane. These are so-called hydrated or hydro-coated cathters that are smoother than plain poloyurethane. These accumulate less bacteria and dirt. Rounded tips are better as well.
• Polyvinyl chloride (PVC). These have large diameters and allows good drainage but are uncomfortable to long term use because they are stiff. They can be reused but must be rinsed thoroughly. Soap deposits can irritate the urethra.
  
• Polyethylene catheters. These are strong catheters that are quite inexpensive and can be purchased in 25-foot rolls. They are non-reactive, have no additives or plasticizers, heat-sterilizable. They tend to be stiffer and more abrasive.

The use of uncoated catethers is not recommended even for short-term. Latex can cause discomfort and tissue trauma, as well as allergies. Catheters come in following sizes. Each French size is a third (1/3) of a millimeter. The most common urinary catheter sizes are 16 or 18 French. Most catheters are 16” long and sizes range from 6Fr to 18 Fr. They can be coude-tipped (bent) and soft funnel-tipped. The catheters may have various types of coating. For example, hydrophilic and teflon coatings are particularly smooth and provide low-friction surfaces.

Table 1. Sizes of catheters

                 Diameters
French  Gauge    Inner     Outer                  
1        27      0.1 mm    0.4 mm
2        23      0.3 mm    0.6 mm
3        20      0.5 mm    0.9 mm
3.5      18      0.6 mm    1.2 mm
4        18      0.6 mm    1.2 mm     
5        16      0.7 mm    1.7 mm      
6        13      1.3 mm    2.4 mm
9        11      1.6 mm    3.2 mm
12                         4.0 mm
14                         4.7 mm
16                         5.3 mm
18                         6.0 mm
20                         6.7 mm
22                         7.4 mm
24                         8.0 mm
26                         8.7 mm
28                         9.4 mm
30                        10.0 mm
32                        10.7 mm
34                        11.3 mm
36                        12.0 mm
38                        12.7 mm
40                        13.4 mm
42                        14.0 mm
46                        16.0 mm

Clinical evidence for optimal catheter solution is limited. Antibiotic solutions are not effective. For cleaning catheters, acetic acid (vinegar) is frequently recommended. A solution of 0.25% acetic acid solution is used to irrigate the bladder. Prepare with distilled or tap water that has been oiled and cooled. Add plain white vinegar, approximately 0.25% by volume. For example, add 0.25 ml to a 100 ml of water, 5 teaspoons of vinegar to a pint of water, 10 teaspoons to a quart, 13 teaspoons to a gallon of water. http://www.spinalcord.ar.gov/Publica...1-5/fact5.html

The following solutions should not be used routinely in people with chronic spinal cord injury due to irritation of bladder and urethra or because they are ineffective:

• Citric acid 3.23% for pH 4 and 6% for pH 2 solutions. These are useful for dissolution of struvite crystals on the catheter tips but the catheters must be carefully rinsed because these are irritating.
• Mandelic acid 1%. These reduce micro-organisms which produce urease creating alkaline conditions. It counters proteus vulgaris. When used for installation into the bladder, 19 days of twice daily installation are required for effect. This should not be routinely used.
• Chlorhexidine 0.02%. This is an antiseptic. It is of limited value and not recommended because it may lead to the flourishing of resistance organisms.

Catheter-associated infections are the most common complication of spinal cord injury. The risk of an infection with routine catheterization is 1-2% per procedure. The risk of an infection with an indwelling catheter is 5% per day accumulating (Tambyah, et al., 2002). Each infection increases length of stay by 5-6 days. The following practices reduce catheter-induced urinary tract infection:

• • Hygienic practice is an integral and important part of preventing catheter-related urinary tract infection, including washing and drying hands, and using alcohol.
  • Sterile gloves are not necessary for intermittent catheterization, as long as good hand washing, meatal cleansing, and clean handling of catheter prior to insertion is observed (Bakke & Digranes, 1991). However, sterile gloves are recommended for placement of long-term indwelling catheters, including replacementof suprapubic catheters.
  • Meatal cleansing. Frequent and vigorus meatal cleansing with antiseptic solutions is unnecessary and increase risk of infection (Kunin, 1984, Garibaldi, 1980; Burke, et al., 1981, 1983). However, meatal cleansing at the time of catheterization does reduce infections. Daily bathing and showering is encouraged.
  • Regular timely catheterization reduces over-distiension of the bladder and reduces infections.
  • Appropriate choices of catheter size and type helps reduce infections. For intermittent catheterization, smaller catheters minimize urethral trauma and improve patient comfort. So, smaller catheters should be used. For indwelling urethral or suprapubic catheters, bigger catheters are better, to avoid leakage around the catheter.
  • A lubricating gel with local anesthetics reduces risk of trauma to the urethra, improves patient comfort, and reduces autonomic dysreflexia. If such gels are used, single-use containers reduce infection risk.
  • Urethral strictures should be regularly dilated to prevents recurrence.
  • Closed drainage systems reduces risk of catheter-related infection (Kunin, 1997).
  • Who is doing the catheterization?. If paid caregivers and healthcare works are carrying out intermittent catheterization, aseptic technique should be carried out. However, catheterization by friends, family, or self should be “clean”.

The attachment is from the National Health Service in Scotland.

References Cited

• Tambyah PA, Knasinski V and Maki DG (2002). The direct costs of nosocomial catheter-associated urinary tract infection in the era of managed care. Infect Control Hosp Epidemiol. 23: 27-31. Department of Medicine, University of Wisconsin Medical School, University of Wisconsin, Madison, USA. OBJECTIVE: To determine the additional direct costs of hospitalization attributable to catheter-associated urinary tract infection (CAUTI) in 1,497 newly catheterized patients. DESIGN: Prospective observational and laboratory study. SETTING: University hospital. METHODS: Data were collected on risk factors for CAUTI (defined as > 10(3) colony-forming units [CFU]/mL), severity of illness, and diagnostic and therapeutic interventions in consenting newly catheterized patients. Daily urine cultures were obtained from each newly catheterized patient, but the results of these cultures were not revealed to his or her physician. During the study, one of the investigators (DGM) reviewed each patient's record and made a judgment as to which of the diagnostic tests and treatments ordered and what incremental length of stay could reasonably be ascribed to his or her CAUTI. The total hospital costs for each patient were also obtained. RESULTS: Overall, 235 patients acquired CAUTIs during the study; most of the CAUTIs were completely asymptomatic, and only 52% were diagnosed by the patients' physicians using the hospital laboratory. Only 1 patient with a CAUTI had a secondary bloodstream infection. Thirty-three (13%) of the CAUTIs were caused by Escherichia coli; 63 (25%) by Klebsiella, Enterobacter, Citrobacter, Pseudomonas aeruginosa, or other antibiotic-resistant, gram-negative bacilli; 87 (35%) by enterococci or staphylococci; and 67 (27%) by Candida species. The 123 CAUTIs diagnosed by the hospital laboratory were judged to have been responsible for an additional $20,662 in extra costs of diagnostic tests and $35,872 in extra medication costs, a mean of $589 (median, $356) per CAUTI. CAUTIs caused by E. coli cost considerably less than infections caused by other gram-negative bacilli ($363.3 +/- $228.2 vs $690.4 +/- $783.7; P = .02) or yeasts ($821.2 +/- $2,169.9). There were less striking differences in the costs per CAUTI caused by staphylococci or enterococci ($387.1 +/- $434.8). CONCLUSIONS: The extra direct costs associated with nosocomial CAUTI found in this prospective study, which was done in the era of managed care during the late 1990s, are substantially lower than those reported in the largest comparable studies done more than 15 years ago, most of which were retrospective, reflecting the powerful impact of cost-containment measures that are now implemented in managed care.
• Bakke A and Digranes A (1991). Bacteriuria in patients treated with clean intermittent catheterization. Scand J Infect Dis. 23: 577-82. Department of Surgery, University of Bergen, Haukeland Hospital, Norway. Bacteriuria has been studied in 407 patients treated with clean intermittent catheterization (CIC) during 1 year. Significant bacteriuria was found in 50.6% of 1413 analyzed urine samples. Escherichia coli was the dominating species (54.8%). The relative distribution of species was different in males and females, but there were no differences between the CIC patients and a reference group of outpatients. On the other hand, a higher frequency of resistance among enterobacteria was found in samples from CIC patients compared to the reference group. The majority of CIC patients with bacteriuria had no symptoms, and bacteriuria per se does not seem to be an indication for treatment in most of these patients.
• Kunin CM (1984). Genitourinary infections in the patient at risk: extrinsic risk factors. Am J Med. 76: 131-9. The indwelling urinary catheter is an essential part of modern medical care. It is widely used to relieve temporarily anatomic or physiologic urinary obstruction, to facilitate surgical repair of the urethra and surrounding structures, to provide a dry environment for comatose or incontinent patients, and to permit accurate measurement of urinary output in severely ill patients. Unfortunately, when poorly managed, the indwelling catheter may present a hazard to the very patients it is designed to protect. It is the leading cause of nosocomial induced urinary tract infections and the most common prediposing factor in fatal gram-negative sepsis in hospitals. Catheters drain the bladder, but they obstruct the urethra, producing other major problems such as urethral strictures and epididymitis. Advances in catheter care since the introduction of closed drainage are reviewed. The best means of prevention is the avoidance of use when unnecessary and prompt removal when the need no longer exists. This practice is of particular importance in long-term care institutions. Alternate methods include intermittent catheterization in the paraplegic patient, condom drainage in the nonobstructed patient, and direct drainage of the bladder through the skin. Most recent studies have attempted to improve care of the indwelling catheter by either prevention of periurethral infection (the most common route of acquisition) or sterilization of the drainage bag to prevent ascending infection and cross infection. Thus far, these methods have been unsatisfactory. A new approach to designing drainage systems is clearly needed. Finally, all studies failed to demonstrate the ability of systemic antimicrobial therapy to eradicate catheter-associated infections other than temporarily. Instead, excessive use of antibiotics has led to the emergence of resistant strains that may be spread to other patients through contaminated urine.
• Garibaldi RA, Burke JP, Britt MR, Miller MA and Smith CB (1980). Meatal colonization and catheter-associated bacteriuria. N Engl J Med. 303: 316-8.
• Burke JP, Jacobson JA, Garibaldi RA, Conti MT and Alling DW (1983). Evaluation of daily meatal care with poly-antibiotic ointment in prevention of urinary catheter-associated bacteriuria. J Urol. 129: 331-4. Meatal care with a poly-antibiotic ointment twice daily was evaluated in a prospective, randomized, controlled study of patients with temporary indwelling urethral catheters. Bacteriuria was acquired in 14 of 214 patients treated (6.5 per cent), compared to 16 of 214 patients not given treatment (7.5 per cent). The rate of bacteriuria was slightly lower in the treated than in the untreated group by each of 4 different statistical methods. In a subset of female patients at high risk a significant reduction in the rate of bacteriuria in treated patients was found by 1 method of analysis. These results contrast to previous studies in our hospital in which meatal care, using either nonantiseptic soap and water or an iodophor solution and ointment, was found to predispose to bacteriuria in high risk female patients. The benefit, if any, of meatal care with poly-antibiotic ointment appears to be small.
• Burke JP, Garibaldi RA, Britt MR, Jacobson JA, Conti M and Alling DW (1981). Prevention of catheter-associated urinary tract infections. Efficacy of daily meatal care regimens. Am J Med. 70: 655-8. To evaluate the efficacy of daily cleansing of the urethral meatus-catheter junction in preventing bacteriuria during closed urinary drainage, randomized, controlled trials of two widely recommended regimens for meatal care were completed. In 32 (16.0 percent) of 200 patients given twice daily applications of a povidone-iodine solution and ointment bacteriuria was acquired, as compared with 24 (12.4 percent) of 194 patients not given this treatment. In 28 (12.2 percent) of 229 patients given once daily meatal cleansing with a nonantiseptic solution of green soap and water bacteriuria was acquired, as compared with 18 (8.1 percent) of 23 patients not given special meatal care. There was no evidence in either trial of a beneficial effect of meatal care. Moreover, each of four different statistical methods indicated that the rates of bacteriuria were higher in the treated groups than in the untreated groups. In subsets of female patients at high risk in both studies significantly higher rates of bacteriuria were noted in the treated groups than in the untreated groups. Current methods of meatal care appear to be hazardous, as well as expensive, and cannot be recommended as measures to control infection.

[dan_nc]

Originally Posted by Wise Young

The following solutions should not be used routinely in people with chronic spinal cord injury due to irritation of bladder and urethra or because they are ineffective:

• Citric acid 3.23% for pH 4 and 6% for pH 2 solutions. These are useful for dissolution of struvite crystals on the catheter tips but the catheters must be carefully rinsed because these are irritating.
• Mandelic acid 1%. These reduce micro-organisms which produce urease creating alkaline conditions. It counters proteus vulgaris. When used for installation into the bladder, 19 days of twice daily installation are required for effect. This should not be routinely used.
• Chlorhexidine 0.02%. This is an antiseptic. It is of limited value and not recommended because it may lead to the flourishing of resistance organisms.

Dr. Young, is it bad to use surgilube for intermittent catheterization? The label states that it contains chlorhexidine gluconate.

[Wise Young]

Originally Posted by dan_nc

Dr. Young, is it bad to use surgilube for intermittent catheterization? The label states that it contains chlorhexidine gluconate.

dan,

Surgilube or K-Y jelly is recommended by a number of sources as the lubricant to use. I know that what I posted suggested that chlorhexidine is not an effective antimicrobial and that overuse may result encourage overgrowth of resistant organisms. Using it as a lubricant is not irritating to the urethra and the jelly is sterile. The chlorhexidine is just an added bonus.

In 2002, Stickler reported that chlorhexidine applied to the skin was effective in removing gram-positive bacteria but not gram negative. Analysis of antibiotic resistance patterns revealed that chlorhexidine-resistant strains are also multi-drug resistance. For that reason, chlorhexidine use for cleaning the skin and meatus prior to catheterization has been abandoned.

Chlorhexadine was particularly popular in UK where it was in a product called Instillagel (a prefilled syring containing 2% lignocaine and 0.25% chlorhexidine in a sterile lubricant gel. Doherty (1999) indicated that this was the product of choice for placement of indwelling catheters.

In 1995, Waller, et al. reported that long-term followups of studies of patients who used small catheters and lubricating jellies were nevertheless developing urethral complication. They studied patients who had used disposable catheters with hydrogel coating. Although the number of infections seem quite high to me, the authors concluded that patients who used hydrophilic low friction catheters do as well or better than patients using conventional catheters with chlorhexidine jelly.

Note, however, that early studies suggest that chlorhexidine may be useful. For example, in 1990, Sanderon & Weissler did a direct comparisoin of chlorhexidine, soap, and antibiotics on bacteriuria in people with spinal cord injury. The patients were body washed daily with chlorhexidine soap and then chlorhexidine cream was applied to the glans daily. They found a significant reduction in bacteriuria in patients not receiving antibiotics. In patients that were being washed with soap only, there was a 74% incidence of bacteriuria. However, those that received chlorhexidine had only 60% incidence of bacteriuria. However, this did not result in significant reduction in symptomatic urine tract infections nor the absence of perineal coliforms.

Wise.

References

• Stickler DJ (2002). Susceptibility of antibiotic-resistant gram-negative bacteria to biocides: a perspective from the study of catheter biofilms. Symp Ser Soc Appl Microbiol. 163S-170S. Cardiff School of Biosciences, Cardiff University, Cardiff, UK. Bacteria resistant to both the agents deployed to prevent infections and those used to treat infections would be formidable nosocomial pathogens. The aim of this paper is to review the evidence that gram-negative bacteria resistant to antibiotics and biocides have emerged and been responsible for catheter-associated urinary tract infection. A study of patients undergoing intermittent bladder catheterization revealed that the frequent application of the antiseptic chlorhexidine to the perineal skin prior to the insertion of the catheter was effective against the normal gram-positive skin flora but not against the gram-negative organisms that subsequently colonized this site. Organisms such as Providencia stuartii, Pseudomonas aeruginosa and Proteus mirabilis were repeatedly isolated from the skin of these patients and inevitably went on to cause urinary infections. The minimum inhibitory concentration (MIC) of chlorhexidine for many of these strains proved to be 200-800 microg ml(-1) compared with the 10-50 microg ml(-1) recorded for reference strains of gram-negative species. A subsequent survey of over 800 gram-negative isolates from urinary tract infections in patients from both hospitals and the community revealed that chlorhexidine resistance was not a widespread phenomenon, but was restricted to these species and to units where the care of catheterized patients involved the extensive use of chlorhexidine. Analysis of the antibiotic resistance patterns revealed that the chlorhexidine-resistant strains were also multidrug resistant. Other clinical studies also reported catheter-associated infections with chlorhexidine- and multidrug-resistant strains of Pr. mirabilis when chlorhexidine was being used extensively. This species poses particular problems to the catheterized patient. Chlorhexidine thus proved counterproductive in the care of catheters and its use in this context has been largely abandoned. Suggestions of reintroducing this agent in the form of biocide-impregnated catheters should be resisted.
  
• Doherty W (1999). Instillagel: an anaesthetic antiseptic gel for use in catheterization. Br J Nurs. 8: 109-12. West Herts Community Health NHS, Watford. Instillagel is a prefilled syringe containing lignocaine 2% and chlorhexidine 0.25% in a sterile lubricant gel. It is available in two sizes, 11 ml and 6 ml, for male and female catheterization respectively, and for intermittent self-catheterization. It has been used successfully for these purposes for many years, and its usage in the community setting is increasing. It is used for surface anaesthesia by many UK urologists. It is easily applied by both nurse and patient and remains the product of choice when performing indwelling catheterization. It also has an important role in stricture therapy where patients require extra lubrication for the passage of a catheter or an anaesthetic effect to provide patient comfort following the procedure. Instillagel has the added benefit of an antibacterial effect due to its chlorhexidine content.
  
• Waller L, Jonsson O, Norlen L and Sullivan L (1995). Clean intermittent catheterization in spinal cord injury patients: long-term followup of a hydrophilic low friction technique. J Urol. 153: 345-8. Department of Neurosurgery, Sahlgrenska Hospital, Gothenburg, Sweden. Clean intermittent self-catheterization is an established option in bladder management of spinal cord injury patients. Several early and a small number of long-term studies have reported good preventive or therapeutic effects on hydronephrosis, vesicourethral reflux, urinary tract infection and incontinence. Most reports describe the use of small catheters and liberal use of jelly but urethral complications, such as strictures and false passages, seem to increase with the length of followup. All 30 spinal cord injury patients in this retrospective study had used disposable hydrophilic, low friction catheters from the early shock phase to a median of 7 years (range 5 to 9). There were 26 upper motor neuron and 4 lower motor neuron lesions. After tap water soaking, the surface layer of the catheter coating has a friction constant more than 10 times lower than that for a regular plastic catheter (Nelaton) with chlorhexidine jelly. There was no hydronephrosis, pyelonephritis or renal scarring. In 3 patients who had decreased the clean intermittent self-catheterization regimen, signs of upper tract dilatation developed but the excretory urogram returned to normal after correction of the regimen. Of 30 patients 12 (40%) maintained sterile urine, while 4 of the remaining 18 with bacteriuria had episodes of urinary sepsis and chronic infections. Two patients had epididymitis. Of 6 men with occasional insertion difficulties when the clean intermittent self-catheterization regimen started after the indwelling catheter had been removed 4 showed yielding signs of strictures during the subsequent clean intermittent self-catheterization regimen. In 1 patient 2 dilation attempts had failed but the patient can perform the clean intermittent self-catheterization regimen. One patient with Crohn's disease had advanced urethral changes in the acute phase but could perform clean intermittent self-catheterization with a small catheter. One patient has had recurrent modifications of the urethral wall but no development of a false passage. The study indicates that patients who use hydrophilic low friction low friction catheters do as well as or better than patients using conventional catheters. Above all, there is no increase in severe urethral complications with time after injury. Progression towards strictures after early urethral trauma seems to be preventable by the use of this catheter.
  
• Sanderson PJ and Weissler S (1990). A comparison of the effect of chlorhexidine antisepsis, soap and antibiotics on bacteriuria, perineal colonization and environmental contamination in spinally injured patients. J Hosp Infect. 15: 235-43. Royal National Orthopaedic Hospital, Stanmore, Middlesex. The effect of chlorhexidine antisepsis on bacteriuria, perineal colonization by coliforms and environmental contamination by these organisms was investigated in spinally injured patients treated by intermittent catheterization. Patients were body washed daily in chlorhexidine and chlorhexidine cream was applied to the glans penis after each catheterization. Urine cultures were obtained each day. A statistically significant reduction in bacteriuria was achieved by antisepsis in male patients not receiving antibiotics, from 74% of urine cultures in patients receiving soap to 60% with antisepsis (P less than 0.01). No effect of antisepsis was found on perineal coliform colonization, nor on contamination of bed sheets or the environment by these organisms. There was a significant reduction in perineal coliforms by antibiotics.

[dan_nc]

Dr. Young, thank you for the explanation! I will continue to use the surgilube.

[bob clark]

Hi Wise,

I'll try to make this concise but that's a tall order for me!

I've read all the material that you've posted including the Urinary_Cath_COMPLETE.pdf. It appears as though most of the material is old or dated, at least preceding the invention or creation of Microcyn/Dermacyn. Microcyn/Dermacyn is the brand name of the "Super-Oxygenated Water" that you posted about a year ago or so ago. It's "supposed" to be more effective than chlorine bleach in killing bacteria but is "supposedly" harmless to human tissue. It's used for cleansing and debriding severe, raw and open decubitus ulcers, especially those in diabetics. So "should" be mild and safe enough to use on the urethral membrane.

1- Assuming this is true and for the sake of argument let's assume that "clean" versus "sterile" intermittent catheterization are equally effective.

2- I believe the below quote is in regards to the initial insertion of an indwelling catheter but nonetheless it's evidence that killing bacteria at the meatal level is somewhat effective in reducing UTIs when done at the time of the initial insertion. As with "Intermittent Catheterization".

3- "Meatal cleansing. Frequent and vigorus meatal cleansing with antiseptic solutions is unnecessary and increase risk of infection (Kunin, 1984, Garibaldi, 1980; Burke, et al., 1981, 1983). However, meatal cleansing at the time of catheterization does reduce infections. Daily bathing and showering is encouraged."

4- Does this assertion not point to the fact that the bacteria is farther into the meatus, meaning the urethra, perhaps an inch or two or three or more and that the bacteria is then being pushed into the bladder by the catheter causing bacterial colonization of the bladder or a UTI?

5- If the bacteria could be killed inside the urethra by injecting the Microcyn/Dermacyn an inch or two or three or more (assuming it's as safe and effective as "advertised") into the urethra, would this procedure not be worthy of a clinical trial?

6- Am I crazy (don't answer that!) or is the bacteria that causes UTIs located somewhere inside the urethra before it enters the bladder? Is the bacteria somehow entering the meatus, then multiplying inside the "human urethral incubator" and then being pushed into the bladder to either bacterially colonize the bladder or cause a UTI in it?

7- If we could keep the meatus, thus the urethra, free from bacteria, would this not considerably lower the incidence of bacterial colonization of the bladder and/or a UTI?

8- As you may know I've been doing this with H2O2, which is a harsh chemical, for two years now and I don't believe that I'm bacterially colonized and I know that I don't have a UTI.

9- Would you please consider setting up a clinical trial using my technique of injecting the urethra with the supposedly safe and effective Microcyn/Dermacyn to see if you're able to replicate my success in remaining bacterially uncolonized and UTI-free for two years? If you do I'll shut up about it!

Thank you for your time.... and patience!

Bob.

[Steven Wayne]

Wise Young will probably throw this message out because it challenges his literatire review . Chart review studies are not evidence based medicine in regard to evaluating medical devices.The FDA is the expert agency and final authority in America. If the studies that Wise Young mentioned were submitted to the FDA they would be rejected.There are no studies that examine the proper cleaning method. If cleaning a catheter is safe what are the EXACT instructions that should be put on the packaging of the catheter. Federal regulations state that if you claim a medical device can be reused the instructions must be on the packaging and approved by the FDA.The personal attack Wise Young is talking about was just a respomce by a post on Jan 8 by KLD that ther are many studies that show reusing is safer than sterile which is FALSE . Does the moderator of this forum respect FDA Regulations?

SW

[stephen212]

I've been cathing for 24 years. At first, I was doing a combination of CIC and wearing an external. About 14 years ago, I was compelled to give up the externals and do CIC exclusively as I started to experiment with the various anticholinergic meds. I didn't get a lot of UTIs, but I was good for at least 2+ per year. And there were also sporadic episodes of urethral irritation and bleeding. At this time I was using Davol red rubber catheters and then the stiffer red vinyl Dover catheters.

When I switched urologists, he prescribed LoFrics, the first brand of hydrophilics on the market, I believe. What a night and day difference they made! I've been using various hydrophilics ever since, still with great success. However, I accumulated a good deal of urethral scarring from my pre-hydrophilic days. In fact, the last time I went in for a cystoscopy, my doctor couldn't pass either the flexible or rigid cystoscope due to the thick scarring. I left the office with a steady flow of blood trickling out of my pecker from his efforts.

My urologist suggested a procedure to clear away the scar tissue, but a physician friend of mine (a cardiologist) said that there was little point in having this done seeing as I was (and still am) able to easily pass the hydrophilic catheters.

Hydrophilic catheters cannot be reused. If for no other reason, then, given my own N of 1 case history, I am a strong believer for single use only usage per the clearly printed instructions on the packaging of every catheter sold.

Oh, and since switching over to hydrophilics, and the absence of urethral trauma associated with them, I very rarely get UTIs. It's been years since I had one.

So to those that argue that we should all be reusing catheters: just because your mileage may vary doesn't mean I should have to vary mine.

[Wise Young]

Steve,

There are only three circumstances in which we remove posts on this site. The first is if the post is spam by somebody who is unrelated to the community. The second is if the post is overtly commercial by somebody who is a legitimate member of the community and we generally give more leeway to such posts The third is when a post attacks another member and usually after it has occurred repeatedly. The policy is that if the moderator thinks that a post is violating the no-attack rule of the site, the post is moved to a private forum for review by the other moderators. If the consensus is that it is an attack and should be removed, it is removed. Otherwise, it is restored. In either case, an explanation or warning is usually posted.

Can you help me put up a poll? I think that this is the time for it. We have close to 18,000 members on this site, 70% of whom have spinal cord injury. While more than half of the members have not visited us in 2007, we still probably have several thousand members who are spinal injured and visit us frequently. Let us find out what method people use for catheterization, the type of catheters, whether it is clean, etc. I don't know all the options. Can you help me design such a poll and we can post it? Thank you.

Wise.