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