Urinary Tract Infection: A Case Study
Healthcare providers implement various techniques that help prevent a patient from contracting nosocomial infections. Perhaps the most common acquired and treated infection is a urinary tract infection caused by long-term indwelling catheter use. The use and insertion of catheters is typically avoided in hospitals because any catheter associated UTI that occurs while the patient is hospitalized, is no longer reimbursable. The population that has the greatest risk for developing UTI’s is older adults that reside in long-term care facilities that have medical conditions which require the use of long-term indwelling catheters (LTIC), usually more than 30 days. Conditions such as urinary retention, cognitive deficits, or urine leakage preventing a stage 3 or stage 4 pressure ulcers from healing are just a few examples why an LTIC may be indicated. Although infection is inevitable for these patients, ways to prevent catheter associated urinary tract infections (CAUTI), in clinical settings are being reviewed. The article “Preventing infection in elders with long-term indwelling urinary catheters”, examines three preventative measures: use of sliver tipped catheters, cranberry juice extract, and oral vaccine OM-89
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(Bjornson & Macera, 2009, p. 127). Before exploring ways to prevent CAUTI, understanding the physiological reasons these patients are prone to recurrent UTI’s is essential in treatment.
The body’s natural response to an invader is to attack, which means that an indwelling urinary catheter is treated as a foreign body by the immune system. Within 6 hours of catheter placement, biofilm formation begins to adhere to the catheter providing a rich habitat for microorganisms to infect the host (Bjornson & Macera, 2009). Biofilm is responsible for approximately 65%-80% of infections and are up to 1000 times less receptive to antibiotics (Bjornson & Macera, 2009). The most frequent microbe to infect the host is the gram negative E. coli, as quickly as 1-3 days after catheter
placement. Even though biofilm formation is not preventable, it is most important for the insertion of the catheter be placed using sterile technique. Any disruption compromises the host and serves as a gateway for bacteria to invade. Healthcare providers need to assure sterile placement, assess the catheter regularly, provide daily maintenance of a clean, closed drainage system, monitor I&O, and obtain a urine culture. Once an infection occurs, the use of antibiotics comes into play. Exposure to antibiotics can introduce supra-infections, notably C. difficile (Bjornson & Macera, 2009 p. 129). This poses another threat in prevention and treatment measures for UTI’s because reinfection occurs; the consequence results in drug resistance to antibiotics. The author’s intent is to research ways to prevent these challenges from happening, before infection occurs. In the case of silver alloy catheters, there have been numerous studies using silver and silver products on catheters with some evidence that they reduce bacterial adherence, minimize biofilm formation and migration to the bladder, reduce patient discomfort, and overall minimize the risk of CAUTI (Bjornson & Macera, 2009, p. 131). In comparison to conventional latex or silicone catheters, the silver alloy-coated catheters indicated a UTI reduction rate of 27%-73% in short-term catheter use: less than 30 days. However, all the completed studies used latex based products and with the rising number of latex allergies, most hospitals have adopted “latex free” policies, which resulted in silicone-based catheters. Because silver alloy tipped catheters were performed on short-term use, results may not be transferrable to the older adult population using LTIC (Bjornson & Macera, 2009, p. 131-132). In the study of cranberry products, many theories have proposed that cranberries may prevent UTI’s by lowering urinary pH because of its acidity and were thought to have antibacterial properties in its composition. However, in clinical trials, cranberry juice did not alter urinary pH or detect bactericidal or bacteriostatic composition. Using cranberry does show some promise in prophylactic effect of re-current infections. It has been discovered that cranberry juice may actually interfere with the attachment of microbes to the host’s tissue. The shape of the bacteria changed altering the adhesive capacity, showing a delayed onset of infection (Bjornson & Macera, 2009). Many of the studies performed showed no adverse reactions, but further research is needed to determine the daily optimal dosage specific to the elder patient population who use LTIC. The final approach in preventing CAUTI is the use of an oral “vaccine”. The idea was introduced 40 years ago with the thought of “priming” the host’s immune system by introducing the inactivated bacteria E. coli. Because the primary cause of UTI’s is from E. coli, it was decided to manufacture the drug with 18 strains of it naming it OM-89. Studies proved that the use of OM-89 against placebo showed a significant decrease in the number of UTI’s (Bjornson & Macera, 2009, p.133). With minimal adverse reaction, less frequent symptoms of UTI’s, and decrease in antibiotic use with the control group, OM-89 proves to be the best preventative measure for CAUTI. Furthermore, exploring more ways to prevent UTI in the older adult needs to be continued and current research indicates that medical advances are headed in the right direction. The first step in preventing CAUTI’s starts with basic nursing care: using sterile technique. It is a critical step in assuring patient safety and lowering healthcare costs. I see firsthand in the emergency department the consequences of inadequate care of long-term catheter use. We frequently admit older patients from nursing homes that are diagnosed with urosepsis or severe UTI’s, all who present with catheters that appear to be neglected. The removal of the catheter is imminent, and reinsertion is later determined. The uses of bedpans, urinals, or condom catheters are then put in place. Our protocols indicate that urinary catheters are not to be placed without a doctor’s order. In the event that it is absolutely necessary for the patient to have one, sterile technique is used to place it and it is removed as soon as possible. It is rare that an indwelling catheter is placed in ER, but there are conditions that warrant short-term catheter use. Strategies I use to prevent infection include choosing the most appropriate size, assuring aseptic and sterile technique, protecting the tubing by securing it, and monitoring catheter related problems. These prevention measures are instilled in my mind and will remain throughout my nursing career, whether it be in ER, ICU, or floor nursing.
References
Bjornson, L & Macera, L, June 2009. Preventing infection in elders with long-term indwelling urinary catheters. American Academy of Nurse Practitioners. Pages 127-134. Doi:10.1111/j.1745-7599.2010.00588.x
(Bjornson & Macera, 2009, p. 127). Before exploring ways to prevent CAUTI, understanding the physiological reasons these patients are prone to recurrent UTI’s is essential in treatment.
The body’s natural response to an invader is to attack, which means that an indwelling urinary catheter is treated as a foreign body by the immune system. Within 6 hours of catheter placement, biofilm formation begins to adhere to the catheter providing a rich habitat for microorganisms to infect the host (Bjornson & Macera, 2009). Biofilm is responsible for approximately 65%-80% of infections and are up to 1000 times less receptive to antibiotics (Bjornson & Macera, 2009). The most frequent microbe to infect the host is the gram negative E. coli, as quickly as 1-3 days after catheter
placement. Even though biofilm formation is not preventable, it is most important for the insertion of the catheter be placed using sterile technique. Any disruption compromises the host and serves as a gateway for bacteria to invade. Healthcare providers need to assure sterile placement, assess the catheter regularly, provide daily maintenance of a clean, closed drainage system, monitor I&O, and obtain a urine culture. Once an infection occurs, the use of antibiotics comes into play. Exposure to antibiotics can introduce supra-infections, notably C. difficile (Bjornson & Macera, 2009 p. 129). This poses another threat in prevention and treatment measures for UTI’s because reinfection occurs; the consequence results in drug resistance to antibiotics. The author’s intent is to research ways to prevent these challenges from happening, before infection occurs. In the case of silver alloy catheters, there have been numerous studies using silver and silver products on catheters with some evidence that they reduce bacterial adherence, minimize biofilm formation and migration to the bladder, reduce patient discomfort, and overall minimize the risk of CAUTI (Bjornson & Macera, 2009, p. 131). In comparison to conventional latex or silicone catheters, the silver alloy-coated catheters indicated a UTI reduction rate of 27%-73% in short-term catheter use: less than 30 days. However, all the completed studies used latex based products and with the rising number of latex allergies, most hospitals have adopted “latex free” policies, which resulted in silicone-based catheters. Because silver alloy tipped catheters were performed on short-term use, results may not be transferrable to the older adult population using LTIC (Bjornson & Macera, 2009, p. 131-132). In the study of cranberry products, many theories have proposed that cranberries may prevent UTI’s by lowering urinary pH because of its acidity and were thought to have antibacterial properties in its composition. However, in clinical trials, cranberry juice did not alter urinary pH or detect bactericidal or bacteriostatic composition. Using cranberry does show some promise in prophylactic effect of re-current infections. It has been discovered that cranberry juice may actually interfere with the attachment of microbes to the host’s tissue. The shape of the bacteria changed altering the adhesive capacity, showing a delayed onset of infection (Bjornson & Macera, 2009). Many of the studies performed showed no adverse reactions, but further research is needed to determine the daily optimal dosage specific to the elder patient population who use LTIC. The final approach in preventing CAUTI is the use of an oral “vaccine”. The idea was introduced 40 years ago with the thought of “priming” the host’s immune system by introducing the inactivated bacteria E. coli. Because the primary cause of UTI’s is from E. coli, it was decided to manufacture the drug with 18 strains of it naming it OM-89. Studies proved that the use of OM-89 against placebo showed a significant decrease in the number of UTI’s (Bjornson & Macera, 2009, p.133). With minimal adverse reaction, less frequent symptoms of UTI’s, and decrease in antibiotic use with the control group, OM-89 proves to be the best preventative measure for CAUTI. Furthermore, exploring more ways to prevent UTI in the older adult needs to be continued and current research indicates that medical advances are headed in the right direction. The first step in preventing CAUTI’s starts with basic nursing care: using sterile technique. It is a critical step in assuring patient safety and lowering healthcare costs. I see firsthand in the emergency department the consequences of inadequate care of long-term catheter use. We frequently admit older patients from nursing homes that are diagnosed with urosepsis or severe UTI’s, all who present with catheters that appear to be neglected. The removal of the catheter is imminent, and reinsertion is later determined. The uses of bedpans, urinals, or condom catheters are then put in place. Our protocols indicate that urinary catheters are not to be placed without a doctor’s order. In the event that it is absolutely necessary for the patient to have one, sterile technique is used to place it and it is removed as soon as possible. It is rare that an indwelling catheter is placed in ER, but there are conditions that warrant short-term catheter use. Strategies I use to prevent infection include choosing the most appropriate size, assuring aseptic and sterile technique, protecting the tubing by securing it, and monitoring catheter related problems. These prevention measures are instilled in my mind and will remain throughout my nursing career, whether it be in ER, ICU, or floor nursing.
References
Bjornson, L & Macera, L, June 2009. Preventing infection in elders with long-term indwelling urinary catheters. American Academy of Nurse Practitioners. Pages 127-134. Doi:10.1111/j.1745-7599.2010.00588.x