Intermittent catheterization in the rehabilitation setting: a comparison of clean and sterile technique. Clean intermittent catheterization: safe, cost-effective bladder management for male residents of VA nursing homes. Effect of a single-use sterile catheter for each void on the frequency of bacteriuria in children with neurogenic bladder on intermittent catheterization for bladder emptying. Bacteriuria in intermittent catheterization users: the effect of sterile versus clean reused catheters. Clean and sterile intermittent catheterization methods in hospitalized patients with spinal cord injury. A comparison of open and closed catheterization techniques in rehabilitation patients. A prospective randomized trial of the LoFric hydrophilic coated catheter versus conventional plastic catheter for clean intermittent catheterization. Do catheter washouts extend patency time in long-term indwelling urethral catheters? A randomized controlled trial of acidic washout solution, normal saline washout, or standard care. A prospective, randomized trial comparing continuous bladder drainage with catheterization at abdominal hysterectomy. A study comparing sterile and nonsterile urethral catheterization in patients with spinal cord injury. Intermittent catheterization with a prelubricated catheter in spinal cord injured patients: a prospective randomized crossover study. Once-daily irrigation of long-term urethral catheters with normal saline. Lack of benefit. Randomized multi-centre trial of the effects of a catheter coated with hydrogel and silver salts on the incidence of hospital-acquired urinary tract infections.
To compare the onset of symptomatic urinary tract infection in individuals with spinal cord injury in a rehabilitation setting who are randomized to clean or sterile intermittent catheterization technique.
                Randomized controlled design.
                Spinal cord rehabilitation units in western Canada.
                Thirty-six patients with cervical spinal cord injuries requiring intermittent catheterization by nursing staff were recruited. None had a previous history of voiding dysfunction or urinary tract infections. Interventions: Subjects were randomized to either clean or sterile intermittent catheterization technique. Protocols for both clean and sterile techniques were standardized and followed by nursing staff and caregivers.
                Primary outcome measure was symptomatic urinary tract infection as diagnosed by urine culture > or = 10(5) colony-forming units/mL, pyuria (> or =10 leukocytes on high-power field), and accompanying symptoms.
                A total of 189 urine specimens from 36 subjects were cultured. Of the 36 subjects, 15 (43%) developed a symptomatic urinary tract infection: 6/16 (37%) from the clean group; 9/20 (45%) from the sterile group (P> 0.05). Mean time to onset for symptomatic urinary tract infection for the clean group was 3.0 (standard deviation (SD) 2.4) weeks and for the sterile group, 3.6 (SD 1.3) weeks (P> 0.05). The most common urinary organisms at onset of symptomatic urinary tract infection were Enterococcus species followed by Klebsiella.
                Clean intermittent catheterization in the rehabilitation setting does not appear to place the patient with spinal cord injury at increased risk for developing symptomatic urinary tract infection, and has significant cost and time saving benefits for the health care system, as well as enhancing the transition for the patient from rehabilitation to community. To compare the safety and cost of clean versus sterile intermittent bladder catheterization in male nursing home residents. To provide evidence to support the hypothesis that intermittent catheterization is a valid, alternative method of bladder management in male residents of long-term care in whom urinary retention is a documented problem.
                Randomized clinical trial.
                Three long-term care sites having predominantly male populations.
                Eighty male veterans, residents of three long-term care facilities, ranging in age from 36 to 96 years with a mean age of 72.
                Standardized procedures for clean and sterile intermittent catheterization (IC) were implemented by staff nurses at each site. Patients were randomized into clean and sterile IC groups. Nursing time and catheterization equipment usage were recorded using bar code readers. Clinical data were collected from the medical chart. Treatment of urinary tract infection was prescribed by the medical personnel responsible for each individual resident.
                We compared the number of treatment episodes for symptomatic bacteriuria between groups randomized to receive either clean or sterile intermittent catheterization. Laboratory analysis of blood and urine was done on predetermined days. Control variables were research site and patient history of urinary tract infection within the last 6 months. A cost comparison of nursing time and equipment usage for the two catheterization techniques was also performed.
                No significant differences were found between clean and sterile groups with regard to number of treatment episodes, time to first infection, type of organism cultured, or cost of antibiotic treatment. The cost of sterile technique was considerably higher both in terms of nursing time and supplies.
                Findings from this study demonstrate that clean technique intermittent catheterization is a safe and cost-effective bladder management technique with male, nursing home residents, despite the frailty of this high risk population. An annual savings of approximately $1460 per patient in nursing time and catheterization supplies could be anticipated if a patient were catheterized an average of four times per day substituting clean IC technique for sterile IC technique. The frequency of bacteriuria is high in children with neurogenic bladder on intermittent catheterization for bladder emptying. In an effort to decrease bacteriuria, we examined whether the method of catheter care was responsible for the high rate of bacteriuria. For this, the frequency of bacteriuria was examined in the same patient on single-use sterile catheters and on reused clean catheters.
                A prospective, randomized, crossover trial was conducted with 10 patients who were randomized to 4 months of a new, sterile catheter for intermittent catheterization and 4 months of reuse of a clean catheter for intermittent catheterization. Each week, a urine sample was collected and symptoms of infection and medication use were recorded.
                A total of 158 urine samples were collected during 164 patient-weeks on the new catheter method for each void; 115 (73%) were positive for a pathogen. Of the 161 samples collected during 169 patient-weeks on the standard, reuse method for voiding, 123 (76%) were positive (115 [73%] of 158 vs 123 [76%] of 161). Escherichia coli was the most common pathogen detected during both method periods.
                A new, sterile catheter for each void did not decrease the high frequency of bacteriuria in patients with neurogenic bladder on intermittent catheterization. Monthly urine cultures were analyzed at the University of Alberta Department of Medical Microbiology and Infectious Diseases to determine whether single-use sterile catheters and clean technique reduced the incidence of bacterial colonization in those using long-term intermittent self-catheterization. Thirty subjects with spina bifida, ages 3 years to 16 years, entered a crossover study with random assignment to 6 months of sterile single-use catheters or clean reused catheters. Seventeen subjects were catheterized by a parent or caregiver; 13 were responsible for self-catheterization and cleaning of the catheters. Six months of descriptive data were also collected at Alberta Children's Hospital from a similar group of subjects with spina bifida who used sterile catheters only. In the crossover group, 38% of all urine cultures were positive regardless of whether sterile single-use or clean reused catheters were employed. The other group using only sterile catheters had a 36% positive culture rate. No difference in positive cultures was found between males and females or between children who catheterized themselves and children whose parents catheterized them. The authors concluded that plastic urethral catheters may be reused. 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. An effective method was sought to decrease the incidence of urinary tract infections acquired by hospitalized rehabilitation patients requiring catheterization. The purpose of this study was to determine whether there was a difference in the incidence of urinary tract infections that occurred following use of two types of intermittent catheterization techniques: open catheterization and closed catheterization. The incidence of infection in both the control (open catheterization) and experimental (closed catheterization) groups was analyzed. In the control group, 9 of 14 patients (5 stroke, 4 spinal cord injured [SCI]) completed all four urine tests. Two patients developed a 20,000 colony count of enterococcus on the fourth urine sample using open catheterization. In the experimental group, 11 (4 stroke, 7 SCI) out of 16 patients maintained colony counts below 100,000 organisms per ml; one patient had a 16,000 colony count using closed catheterization. Qualitative data revealed that patients had a positive response to the closed system. We compared the incidence of hematuria, pyuria and clinical urinary tract infection in patients who performed intermittent self-catheterization using a hydrophilic coated LoFric (Astra Tech AB, Mölndal, Sweden) or standard plastic catheter.
                A total of 62 male patients who performed intermittent self-catheterization to manage neurogenic bladder were randomized into 2 treatment groups at 3 American study sites. Outcome measures included urinary tract infection, microhematuria, pyuria and satisfaction rates.
                Of the 62 enrolled patients 49 completed the 12-month study. The withdrawal rate was not different in the 2 groups. At the end of the study there was statistically significantly less hematuria in the hydrophilic coated catheter group compared with controls. In addition, there was a significant decrease in the urinary tract infection rate from baseline in the hydrophilic coated catheter group but not in controls.
                Use of the hydrophilic coated catheter by patients on intermittent self-catheterization is associated with less hematuria and a significant decrease in the incidence of urinary tract infections. Therefore, it may be preferable for some patients, especially those with a history of difficult catheterization, urethral trauma or a high rate of urinary tract infection. Blockage of long-term indwelling catheters with mineral deposit is an ongoing management issue, but evidence on optimal management is lacking. Our purpose was to examine whether catheter washouts prevent or reduce catheter blockage.
                A multisite randomized controlled trial.
                Adults with long-term indwelling catheters that required changing every 3 weeks or less, living in the community, and requiring supportive or continuing care were recruited. Participants were randomly assigned to 1 of 3 groups: control (usual care, no washout), saline washout, or commercially available acidic washout solution (Contisol Maelor Pharmaceuticals Ltd, Wrexham, UK).
                At baseline visit, the catheter was changed and participants were followed weekly for 8 weeks, with checks for catheter patency and urine pH. Participants randomized to saline or commercial solution had a weekly washout with the appropriate solution. Endpoints were 8 weeks (completion data), 3 or more catheter changes in the 8-week period, or symptomatic urinary tract infection (UTI) requiring antibiotics. The study hypothesis was that catheter life would be extended by 25% in the commercial solution group. It was not possible to blind participants or research nurses to washout versus no intervention, but participants in the saline and washout solution groups were blinded to solution type.
                One hundred twelve potential participants were screened; 73 were enrolled, randomized, and included in the final analysis. Of these, 53 completed the full 8 weeks of data collection; 16 terminated early because of 3 catheter changes or self-reported 'UTI'. Other reasons for termination were hematuria, latex sensitivity, deceased/severe illness, or personal choice. Analysis of variance was used to analyze mean differences on demographic variables and mean number of weeks in study. Kaplan-Meier survival curve analysis showed no statistical difference between the groups in time to first catheter change.
                At this time, the evidence is insufficient to state whether catheter washout with saline or Contisol is more effective than usual care with no washout in preventing blocking. No increased risk of UTI was associated with washout regimes. To compare the infection rate and post-operative morbidity between in-dwelling urinary catheterization and 'in-out' catheterization at the time of routine total abdominal hysterectomy.
                The study comprised 100 patients who were blindly randomized to have either an indwelling Foley catheter or an 'in-out' catheterization at the time of surgery. Follow-up data on the retention of urine, urinary symptoms and infection were obtained.
                Of the 95 patients with complete data, 36% of those undergoing in-out catheterization had urinary retention after operation, requiring bladder emptying, compared with 4% of those receiving an indwelling catheter (P < 0.001). In addition, 29% of the catheterized group had urinary tract bacteriuria compared with 13% of the uncatheterized group (P < 0.025).
                This randomized controlled trial showed that in-out urinary catheterization at the time of routine abdominal hysterectomy was associated with a significantly higher incidence of post-operative urinary retention compared with in-dwelling catheterization, and may have implications for long-term bladder function. This study was designed to determine the effect of sterile and nonsterile intermittent catheterization on the incidence of urinary tract infection (UTI) in patients after spinal cord injury. The study included 29 patients with neurogenic bladder dysfunction treated with intermittent catheterization. One group of 14 patients was on sterile catheterization; another group of 15 patients was on nonsterile catheterization. On a weekly basis, urine samples were obtained and analyzed. A total of 122 urine samples were analyzed. The patients on sterile catheterization had a 28.6% UTI incidence; the group using a nonsterile catheterization technique had a UTI incidence of 42.4%. The most common urinary pathogen in both groups was E. coli (65%). The cost of antibiotics for patients on the sterile catheterization program was only 43% of the cost of antibiotics for those on the nonsterile program. However, the sterile kits cost 371% of the cost of the catheterization kits for the patients in the nonsterile program, so the total cost of managing neurogenic bladder on the sterile program was 277% of the cost of the nonsterile program. We compared the safety and patient acceptance of a conventional Nélaton and a prelubricated nonhydrophilic catheter in 18 spinal cord injured patients on intermittent catheterization.
                In a prospective crossover study each catheter was used for 7 weeks and the initial course was randomized. Urinalysis and urine culture were performed at 2, 4 and 7 weeks. Urethral trauma was evaluated by urethral cell count on the surface of each catheter used on the last day of each study period. Patient satisfaction was assessed at the end of the study by a questionnaire using multiple visual analog scales.
                Urinary tract infection was identified in 12 and 4 patients on a Nélaton and a prelubricated nonhydrophilic catheter (p = 0.03), while asymptomatic bacteruria was identified in 18 and 8 (p = 0.0244), respectively. The mean urethral cell count plus or minus standard deviation on the catheter surface was 6.7 +/- 2.8 x 10(4) and 15.1 +/- 8.9 x 10(4) for the prelubricated nonhydrophilic and the Néelaton catheter, respectively (p = 0.01). The prelubricated nonhydrophilic catheter resulted in a better mean satisfaction score than the Nélaton catheter (2.33 +/- 1.06 versus 4.72 +/- 2.13, p = 0.022). Urethral bleeding was reported in 2 patients during the study period while using the Nélaton catheter.
                The prelubricated nonhydrophilic catheter is a safe, effective and comfortable option in spinal cord injured patients on intermittent self-catheterization. Urinary incontinence is often managed with a long-term urethral catheter after other methods have failed. Such urethral catheterization is associated with polymicrobial bacteriuria, catheter obstruction, fever, bacteremia, urinary tract stones, and death. Periodic catheter irrigation is a common but untested management procedure intended to prevent catheter obstruction, fevers, and/or bacteremia. To evaluate this technique, we performed a randomized crossover trial comparing ten weeks of once-daily normal saline irrigation with ten weeks of no irrigation in 32 long-term catheterized women. The incidence of catheter obstructions and febrile episodes and the prevalence and species of bacteriuria were similar whether examined as completed crossover patients (N = 23) or as partially completed trials (N = 9). Once-daily irrigation with normal saline of long-term urethral catheters is a time-consuming and costly procedure that is unlikely to have an impact on the morbidity associated with such catheters. Catheters coated with hydrogel and silver salts have been proposed to prevent hospital-acquired urinary tract infections (UTI). We carried out a randomized, prospective, double-blind multi-centre trial to compare those catheters with classical urinary tract catheters. We included in the study 199 patients requiring urethral catheterization for more than three days: 109 in group 1 (classical catheter) and 90 in group 2 (catheter coated with hydrogel and silver salts). Urine from the patients was tested for 10 days after the insertion of the catheter (reactive dipsticks each day and diagnostic urinalysis every two days). The UTI associated with catheterization was defined on the basis of bacterial and cytological criteria (>10(5)cfu bacteria per mL and >10 leucocytes per mm(3)). Twenty-two UTIs were recorded: 13 in group 1 and nine in group 2. The cumulative incidence of UTI associated with catheterization was 11.1% overall, 11.9% for group 1 and 10% for group 2; the odds ratio was 0.82 (95% confidence interval: 0.30 to 2. 20); the cumulative incidence for UTI, calculated by the Kaplan-Meier method was 36.3 overall, 35.2 in group 1 and 36.0 in group 2; the overall incidence density was 19 per thousand days of catheterization, 21 in group 1 and 18 in group 2. The differences between the two groups were not significant. Overall, we feel that there is not enough evidence to conclude that catheters coated with silver salts and hydrogel give greater protection than classical catheters and to recommend widespread use.
                Copyright 2000 The Hospital Infection Society.
Intermittent catheterisation is a critical aspect of healthcare for individuals with incomplete emptying who are otherwise unable to void adequately to protect bladder and renal health. There is a lack of evidence to state that incidence of UTI is affected by use of sterile or clean technique, coated or uncoated catheters, single (sterile) or multiple use (clean) catheters, self-catheterisation or catheterisation by others, or by any other strategy. The current research evidence is weak and design issues are significant. In light of the current climate of infection control and antibiotic resistance, further, well-designed studies are strongly recommended. Based on the current data, it is not possible to state that one catheter type, technique or strategy is better than another.