Indwelling Catheter Management: From Habit-based to Evidence-based Practice

Author(s): 
JoAnn Mercer Smith, BSN, RN, CWOCN

After drying, items should be stored in a covered container.

Routes of Infection

     Studies indicate that bacteria enter the bladder by three routes: the catheter-meatal junction, catheter-drainage tubing connection, and the drainage bag outlet device3 (see Figure 3). Current prevention and management strategies focus on these three routes of entry.

     Catheter-meatal junction. Bacteria enter the bladder from periurethral contamination at time of catheter insertion or later due to capillary action.3 Periurethral bacterial colonization has been found to be an important risk factor in both men and women; however, extra-luminal migration at the catheter-meatal junction is thought to occur more frequently in women, due to their short urethra.3,30 Nursing procedure manuals recommend washing the perineal area thoroughly with soap and water before the sterile catheterization procedure begins; in practice this is not routinely done unless the patient has fecal incontinence. This important step should not be omitted.

     Insertion of an indwelling catheter is a sterile procedure and strict aseptic technique should be followed. Either a 10% povidone iodine or 1% to 2% aqueous chlorhexidine solution can be used to clean the meatus and surrounding area.8 Although routine perineal care is recommended, catheter manipulation should be avoided because it is thought to contribute to bacterial migration into the bladder around the catheter-meatal junction.8 At one time, scheduled meatal care was considered to be effective and necessary after catheter insertion; however, studies have not demonstrated that meatal care with soap, water, povidone iodine, or antibacterial ointments or creams decreases the incidence of CAUTI.8 Petrolatum-based creams or ointments can degrade latex catheters and should be avoided.

     Catheter drainage bag tubing connection. Maintaining a closed drainage system has been found to be key in preventing CAUTI.3 Studies have shown that bacteriuria occurs within 4 days when open systems are used compared to 30 days when a closed system is used.3,31 Nurses should select catheter kits that have the catheter preconnected and sealed at the catheter-drainage bag junction.

     Closed system maintenance can be difficult for home care patients who frequently switch from standard drainage bags at night to leg bags during the day. These frequent breaks in the system greatly increase the risk of CAUTI. Currently, no leg bag systems have been designed to hold the urine volume produced during sleep. However, nurses can attach a sterile leg bag to the catheter at the time of insertion and use extension tubing to attach the standard drainage bag to the leg bag at bedtime. The standard drainage bag is removed and cleaned each morning. In light of the importance of maintaining a closed system, further product development is needed in this area.

     Drainage bag outlet device. Studies have shown that retrograde bacterial migration from the urine drainage bag outlet tube to be a major source of bacterial contamination.3 A study by Maki et al32 found that allowing the drainage tubing to drop lower than the drainage bag was associated with a significant increased risk of CAUTI. Infection control drainage bags with microbicidal outlet tubes and complete bacteriostatic urine collection systems with microbicidals compounded throughout the drainage bag are now available.

     Drainage bags are designed with either an anti-reflux valve or anti-reflux chamber to prevent reflux of contaminated urine from the bag into the tubing. Drainage bags should be positioned below the level of the patient’s bladder.

References: 

1. Dobson C, Naidu S, Johnson M. Nurses’ perceptions of urinary catheter selection and management. Urology Nursing. 1996;16:140–144.
2. Evans E. Indwelling catheter care: dispelling the misconceptions. Geriatric Nursing. 1999;20(2):85–89.
3. Maki DG, Tambyah PA. Engineering out the risk of infection with urinary catheters. Emerg Infect Dis. 2001;7(2)342–347.
4. Wilde M. Meanings and practical knowledge of people with long-term urinary catheters. Journal of Wound Ostomy Continence Nursing. 2003;30(1):33–39.
5. Saint S, Veenstra DL, Sullivan SD, et al. The potential clinical and economic benefits of silver alloy urinary catheters in preventing urinary tract infection. Arch Intern Med. 2000;160(17):2670–2675.
6. Cravens DD, Zweig S. Urinary catheter management. Am Fam Physician. 2000;61(2):369–376.
7. Fanti JA, Newman DK, Colling J, et al. Clinical Practice Guidelines, No. 2, 1996 Update: Urinary Incontinence in Adults. Acute and Chronic Management. Rockville, Md. US Department of Health and Human Services. Public Services Agency for Health Care Policy and Research; March 1996. AHCPR Publication No.96-0682.
8. Wong ES, Hooten TM. Guideline for prevention of catheter-associated urinary tract infection. Center for Disease Control and Prevention. 1981;Feb. [serial online]. Available at: http://www.cdc.gov/ncidod/hip/GUIDE/uritract.htmnece. Accessed September 8, 2003.
9. Addison R, Mould C. Risk assessment in suprapubic catheterization. Nursing Standard. 2002;14(36):43–46.
10. Robinson J. Deflation of a foley catheter balloon. Nursing Standard. 2003;17(27):33–38.
11. Mitsui T, Minami K, Furuno T, et al. Is suprapubic cystostomy an optimal urinary management in high quadriplegics? A comparative study of suprapubic cystostomy and clean intermittent catheterization. Eur Urol. 2000; 38(4):434–438.
12. Nomura S. Ishido T, Teranishi J, Makiyama K. Long-term analysis of supra-pubic cyctostomy drainage in patients with neurogenic bladders. Urologia Internationalis. 2000;65(4):185–189.
13. Parkin J, Scanlan J, Woolley M, et al. Urinary catheter “deflation cuff” formation: clinical audit and quantitative in vitro analysis. British Journal of Urology. 2002;90(7):666–671.
14. Liss GM, Sussman GL. Latex sensitization: occupational versus general prevalence rates. Am J Ind Med. 1999;35(2):196–200.
15. Vila L, Sanchez G, Ano M, et al. Risk factors for latex sensitization among health care workers. J Investig Allergol Clin Immunol. 1999;9(6):356–360.
16. Department of Health and Human Services. FDA. Federal Register: Natural Rubber-Containing Medical Devices; User Labeling, Federal Register 1997;62(189):51021–51030.
17. Tullock AGS. Ferguson AF. Catheter-induced urethritis: a comparison between latex and silicone catheters in a prospective clinical trial. British Journal of Urology. 1985;57(3):325–328.
18. Studder UE, Bishop MC, Zingg EJ. How to fill silicone catheter balloons. Urology. 1983;22(3):300–302.
19. Salgado CD, Karchmer TB, Farr BM. Prevention of catheter-associated urinary tract infections. In: Wenzel RP, ed. Prevention and Control of Nosocomial Infections, 4th ed. Philadelphia, Pa.: Lippincott Williams & Wilkins; 2003;297–311.
20. Robinson J. Urethral catheter selection. Nursing Standard. 2001;15(25):39–42.
21. Newman DK. Managing indwelling urethral catheters. Ostomy/Wound Management. 1998;44(12):26–35.
22. Chinnes L, Dillion A, Fauerbach L. Home Care Handbook of Infection Control 2002. Washington, DC: Association of Professionals in Infection Control and Epidemiology (APIC);2002.
23. Gerard L, Sueppel C. Lubrication technique for male catheterization. Urology Nursing. 1997;17(4):156–158.
24. Cancio LC, Sabanegh ES JR, Thompson IM. Managing the foley catheter. Am Fam Physician. 1993;48(5):829–836.
25. Wilde M. Long-term indwelling urinary catheter care:conceptualizing the research base. J Adv Nurs. 1997;25(6):1252–1261.
26. Hanchett M. Techniques for stabilizing urinary catheters. Am J Nurs. 2002;102(3):44–48.
27. Getliffe K. Managing recurrent urinary catheter blockage: problems, promises and practicalities. Wound Ostomy Continence. 2003;30(3):146–151.
28. Dille C, Kirchhoff K. Increasing the wearing time of vinyl urinary drainage bags with bleach. Rehabilitation Nursing. 1993;18(5):292–295.
29. Rutala WA, Barbee SL, Aquiar NC, et al. Antimicrobial activity of home disinfectants and natural products against potential human pathogens. Infect Control Hosp Epidemiol. 2000;21(1):33–38.
30. Daifuku R. Stann WE. Association of rectal urethral colonization with urinary tract infection in patients with indwelling catheters. JAMA. 1984;252(15)2028–20230.
31. Warren JW. Catheter-associated urinary tract infections. Int J Antimicrob Agents. 2001;17(4):299–303.
32. Maki DG, Knasinski V, Halvorson K, Tambyah PA. Risk factors for catheter-associated urinary tract infection: a prospective study showing the minimal effect of catheter care violations on the risk of CAUTI (abstract). Infect Control Hosp Epidemiol. 2000;21:165.
33. Stickler DJ. Bacterial biofilms and encrustations of urethral catheters. Biofouling. 1996;94:293–305.
34. Donlan RM. Biofilms and device-associated infections. Emerg Infect Dis CDC. 2001;(7)2:277–281.
35. Kunin CM, Chin QF, Chambers S. Formation of encrustations on indwelling urinary catheters in the elderly: a comparison of different types of catheter materials in “blocker” and “nonblocker”. J Urol. 1987;138(4):899–902.
36. Tambyah PA, Maki DG. Catheter-associated urinary tract infection is rarely symptomatic; a prospective study of 1,497 catheterized patients. Arch Intern Med. 2000;160(5):678–682.
37. Gammack JK. Use and management of chronic urinary catheters in long-term care: much controversy, little consensus. Journal of the American Medical Directors Association. 2002;3(3):162–168.
38. McGeer A, Campbell B, Emori TG, et al. Definitions of infection for surveillance in long-term care facilities. Am J Infect Control. 1991;19(1):1–7.
39. Switters DM. Assessing leakage from around the urethral catheter. Urological Nursing. 1989;9(3):8–10.
40. Bhatia NN, Bergman A. Cystometry: unstable bladder and urinary tract infection. Brit J Urol. 1986;58(2):134–137.
41. Ziemann LK, Lastauskas NM, Ambrosini G. Incidence of leakage from indwelling urinary catheters in home-bound patient. Home Healthcare Nurse. 1984;2(5):22–26.
42. Stickler DJ. Hewitt P. Activity of antiseptics against biofilms of mixed bacterial species growing on silicone surfaces. Eur J Clin Microbiol Infect Dis. 1991;10:416–421.
43. Morris NS, Stickler DJ. Does drinking cranberry juice produce urine inhibitory to the development of crystalline, catheter-blocking Proteus mirabilis biofilms? BJU Int. 2001;88(3):192–197.











































Anonymoussays: January 10.2010 at 23:59 pm

Hi there, thanks for this wonderful article. have gotten quite a bit of insight on evidence-based practice on the care of IDC.

Reply to this comment »
Anonymoussays: October 2.2009 at 19:47 pm

Excellent article. I work in a facility where they are filling 30 ml balloons with 10 ml and wondering constantly why they are leaking . Foleys are being changed on a continual basis because of lack of knowledge. All we have is 14 & 16 fr 30- ml . Of course orders are always for 14 , 16 10 ml. And the story goes on and on . i printed this article and I am going to leave in the DON's desk. Directions are right on the foleys by the way , " fill 30 ml only with 30 ml " Yet they still fill the balloons with 10 ml , and the foleys fall out. I left a note to order 14 and 16 fr 5 ml . Hopefully this article will do some good

Reply to this comment »

Post new comment

  • Web page addresses and e-mail addresses turn into links automatically.
  • Lines and paragraphs break automatically.
  • Use to create page breaks.

More information about formatting options

Image CAPTCHA
Enter the characters shown in the image.