The Tip of The Spear: Rethinking Urine, Fecal Pathogens & CAUTI In The Male Patient.
- urologyxy
- Mar 24, 2020
- 10 min read
Updated: Feb 16
If There Are No Rules, Can They Be Broken
Catheter-associated urinary tract infection (CAUTI) is the most frequent health care–associated infection in the United States. Urinary catheter use is common, with approximately 1 in 5 patients admitted to an acute care hospital receiving an indwelling catheter. With each day of catheter use, the threat of bacteriuria increases 5%.
The National Healthcare Safety Network (NHSN) asserts that complications associated with CAUTI cause discomfort to the patient, prolonged hospital stay, and increased cost and mortality. It has been estimated that each year, more than 13,000 deaths are associated with urinary tract infections (UTI's).
According to the Association For Professionals In Infection Control And Epidemiology's APIC Guide to the Elimination of CAUTI, UTI's account for more than 30% of all infections reported to NHSN and are a leading cause of secondary bloodstream infection (BSI). UTI's increases the length of hospital stays typically by 2-4 days. They also result in antimicrobial overuse and antimicrobial resistance.
In an article titled "Management of the Urologic Sepsis Syndrome" published in the European Association of Urology's Supplements, the authors remind their audience:
In approximately one-third of patients with sepsis, the source of infection is the urinary tract. The management of sepsis has rapidly changed over the past two decades, and a review of urosepsis management is paramount. It is estimated that in 30% of patients with severe sepsis and septic shock, the underlying reason is a urinary tract infection (UTI).
According to the English translation of Urologielehrbruch.de:
Urosepsis is a systemic reaction of the body (SIRS) to a bacterial infection of the urogenital organs with the risk of life-threatening symptoms including shock.
UTI is serious, but urosepsis is even more so.
Fecal Pathogens Are A Major Contributor To CAUTI
The Centers For Disease Control And Prevention (CDC) identifies the pathogens most commonly associated with CAUTI as:
• E. coli 26% • Enterococci 16% • P. aeruginosa 12% • Candida species 9% • K. pneumoniae 6% • Enterobacter species 6%
The two most frequent pathogens, E. Coli and Enterococci, are transmitted generally through fecal exposure.
IAD = U + F + S
The WOCN community has reminded the medical profession that incontinence-associated dermatitis (IAD) stems from the effects of urine (U), feces (F), and containment devices on the skin (S). The skin’s pH contributes to its barrier functions and defenses against bacteria and fungus; ideal pH is 5.0 to 5.9. Urine pH ranges from 4.5 to 8.0; the higher range is alkaline and contributes to skin damage.
Skin moisture is not necessarily damaging. But when moisture that contains irritating substances, such as alkaline urine, contacts the skin for a prolonged period, damage can occur.
Fecal incontinence leads to active fecal enzymes on the skin, which contribute to skin damage. Fecal bacteria can penetrate the skin, increasing the risk of secondary infection. When fecal bacteria mix with urine, the consequences can be devastating.
Many articles have addressed the need to improve diaper design to address IAD through the improvement of air-permeability, few have addressed the need to prevent the mixing of skin, urine, and feces.
Invasion Of The Spear. Telling One Spear From Another
According to an article for the journal Ostomy Wound Management, male catheters can be broadly classified as intermittent use, indwelling urinary catheters, and external catheters.
Intermittent catheters, usually straight catheters, are inserted several times a day, for just long enough to drain the bladder, and then removed. The patient is usually taught how to insert the catheter himself. It is usually inserted into the bladder through the urethra. The sterile catheter is usually pre-lubricated at the manufacturer to reduce the risk of any discomfort when inserted. One end of the catheter is either left open-ended to allow drainage into a toilet or temporarily attached to a bag to collect and measure the urine. The other end is guided through the urethra until it enters the bladder and urine starts to flow. When the flow of urine stops, the catheter can be removed. A new catheter is used each time.
An indwelling urinary catheter is inserted in the same way as an intermittent catheter, but the indwelling catheter is left in place. The catheter is held in the bladder by a water-filled balloon, which prevents it falling out. These types of catheters are often known as Foley catheters. Urine is drained through a tube connected to a collection bag, which can either be strapped to the inside of the leg or attached to a stand on the floor. Indwelling catheters are sometimes fitted with a valve. The valve can be opened to allow urine to be drained into a toilet, and closed to allow the bladder to fill with urine until drainage is convenient.
In the UK, most indwelling catheters need to be changed at least every three months. Customary practice in the United States and elsewhere may vary.
An external catheter, usually a condom catheter, is a catheter placed outside the body. It’s typically necessary for men who do not have urinary retention problems but have serious functional or mental disabilities, such as dementia. A device that looks like a condom covers the penis head. A tube leads from the condom device to a drainage bag. These catheters are generally more comfortable and carry a lower risk of infection than indwelling catheters. Condom catheters usually need to be changed daily, but some brands are designed for longer use.
Although suprapubic catheters constitute another type of external catheter, they fall outside the scope of this discussion. A suprapubic catheter is a type of catheter that is left in place.
Rather than being inserted through the urethra, the catheter is inserted through a hole in the patient's abdomen and then directly into the bladder.
A suprapubic catheter is used when the urethra is damaged or blocked, or when someone is unable to use an intermittent catheter.
The catheter may be secured to the side of the body and attached to a collection bag strapped to the leg. Alternatively, a valve can be attached that opens to allow urine to be drained into a toilet, and closes to allow the bladder to fill with urine until drainage is convenient.
This type of catheter is usually changed every six to eight weeks.
A Pointed Question: The Tip of The Spear
Is it important to build a barrier between the male genital area and the fecal matter that carry the pathogens that cause UTI?
Rethinking The Before, During & After The Catheter Is The Spear Poisoned?
A close and detailed examination of catheter use highlights numerous points in time and circumstances when pathogens could and sometimes do contaminate the catheter and endanger the patient.
Catheter Insertion
When is a urinary catheter inserted at a hospital or facility? Is it usually done in an emergency room or prior to an urgent procedure?
How clean is the patient when the catheter is inserted? Was just the meatus cleaned? Was the genital area including the scrotum and anus scrubbed and cleaned? Was the entire body cleaned? Does the drapery placed prior to catheter insertion serve a purpose?
Pre-Catheterization
Where did the catheter come from? The nearest cart or supply closet?
Who has ownership of the catheter supply? What was the chain of catheter custody? At what point in handling the catheter did the caregiver put on gloves? And does the caregiver believe the gloves are primarily for self-protection or preventing cross-contamination?
After opening the catheter container, how is it handled? If the catheter is not pre-lubricated, is the surgical lubricant container single use or shared? Where was the surgical lubricant before this insertion?
In lubricating and inserting the catheter, was there a risk that the tip of the catheter got contaminated?
Catheter Maintenance & Ownership
Who owns the catheter? After the urinary catheter is inserted, who is responsible for its care and maintenance? Is there joint responsibility between the patient and the staff? Has the patient been instructed on how to keep the catheter free of pathogens? Which caregiver is responsible for it on each shift? Who is responsible on the next shift? Who prepares the daily documentation of the continuing need? Who is in charge of re-evaluating the catheter's continuing need? When is the next re-evaluation of the catheterization?
Catheter Maintenance Without Fecal Incontinence
Urinary incontinence is far more common than fecal incontinence. Not all catheters are associated with briefs and diapers.
Is the tip of the catheter near the meatus protected? Is it shielded from cross contamination from fecal matter on gowns and sheets?
Is the front of the catheter protected from the patient's dirty or contaminated hands touching it intentionally or accidentally?
Every facility has protocols to minimize the risk of falls going to and from the toilet. Does the caregiver engage in proper sanitation prior to assisting the patient to the toilet?
Is the bathroom properly cleaned? Does the other patient sharing the room pose any risk? Should the patient touch the safety bars and the toilet seat without gloves? What precautions are asked of family members and visitors?
Does the caregiver assist the patient in washing his hands before going to the toilet? Washing hands after the process is for the benefit of others. Washing hands before is for the benefit of the patient.
The "splash factor" matters. On the toilet, splashes from the bowl present additional concerns. The evacuation of both watery and solid stools can spray contaminated water on any exposed area of the patient.
The splash factor is clear with Bristol stool type 7, but also occurs with Bristol stool type 1.
On the toilet, where does the scrotum and penis rest? Is the front of the catheter protected from the splashing? Could these contaminated droplets spawn another incubation zone on the patient's exposed areas?
Is the patient aware of proper toilet paper wiping techniques? Could there be residual from the toilet paper? Is 1 ply or 10 ply toilet paper better to minimize residual risks? Besides papers, were wipes used? What types of wipes? Is it time to rethink everyday habits?
Where were the wipes used? The fecal residue was likely cleaned from the buttocks, but were they cleaned from the catheter?
How clean is the patient when he leaves the restroom? What other areas are there of potential contamination?
Catheter Maintenance With Immobility & Fecal Incontinence
Although many of the same issues from above apply to the bed-ridden individual, the closed environment and lack of mobility add even more risks of spreading fecal pathogens to the front of the catheter.
How clean is the bed? When was the last time the sheets were changed? Is the top sheet and blanket routinely touching the front of the catheter? Have the sheets become a potential source of contamination?
Does the fecal incontinent patient, consciously or unconsciously touch the front of the catheter? Is there an itch that needs to be scratched? Is the front of the catheter wrapped to minimize risks?
After a bowel movement (BM), how is the patient cleaned? Does the caregiver wipe away from the high-risk zones? What is done to sanitize the "squooshy", moist areas of the genitals hospitable to pathogen incubation? How can one avoid missing spots?
What types of wipes were used on the patient? Where were the wipes used? The fecal matter may have been cleaned from the buttocks and other hot zones but was it cleaned from the catheter?
What was used to wipe the front of the catheter? Did the cleaning meet both the visual and scientific test? Is the patient clean all over?
Once the patient was sanitized, what is being done to maintain patient cleanliness?
Catheter Extraction
When the time comes to remove the catheter, the patient is usually in much better shape. He might be freshly bathed. Are the conditions sanitary during removal? Are proper cleanliness procedures applied to removal?
During removal of the catheter, the urethra and skin are usually raw. Are harmful pathogens from the bladder being dragged across the open sores in the urethra? What is done to protect the raw skin upon removal of the catheter?
Is the patient cleaned up after removal of the catheter to avoid post-extraction infection?
Closing Thoughts
The statistics on extended catheter use indicate that contracting CAUTI is often a question of when, not if. The CDC Toolkit reminds professionals that fecal pathogens are a major contributing factor to CAUTI.
Research is needed now to explore whether shielding the penis and scrotum with a sanitary wrap will potentially limit the transfer of fecal pathogens to the front of a catheter? Will that shield also reduce the occurrence of IAD's?
A re-examination of the cleanliness protocols associated with the insertion, maintenance, and removal of catheters might be in order.
This re-think might also require a re-evaluation of toilet design and toilet paper selection for high risk patients.
The goal is to minimize the risk of fecal pathogens migrating to the catheter and maintaining sanitary conditions at each step of the procedure.
Too often, institutions have been slaves to the old ways. That has led to a reactive response rather than a proactive one.
An evaluation of new "spears and shields" and/or an alternative to catheters are needed.
The time has arrived to end simply limiting the damage from "old spears without shields"
The objective is to make CAUTI a thing of the past. Do not blame the medical profession. If there are no rules about the mixing of urine and fecal pathogens, they cannot be broken.
Happy researching!
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http://annals.org/aim/fullarticle/744548/catheter-associated-urinary-tract-infection-medicare-rule-changes. Saint S, Meddings JA, Calfee D, Kowalski CP, Krein SL. Catheter-Associated Urinary Tract Infection and the Medicare Rule Changes. Ann Intern Med. 2009;150:877–884. doi: 10.7326/0003-4819-150-12-200906160-00013
https://nhsn.cdc.gov/nhsntraining/courses/2017/C06 National Healthcare Safety Network Catheter-associated Urinary Traction Infection (CAUTI) 2017
Klevens, RM., Edward, JR., et al. “Estimating Healthcare-associated Infections and Deaths in U.S. Hospitals”. Public Health Reports 122: (2007):160-166.
http://www.apic.org/Resource_/EliminationGuideForm/c0790db8-2aca-4179-a7ae-676c27592de2/File/APIC-CAUTI-Guide.pdf APIC Guide to the Elimination of CAUTI (2008). Gould C., Catheter-Associated Urinary Tract infection (CAUTI) Toolkit, CDC
Management of the Urologic Sepsis Syndrome. Tandogdu, Zafer et al. European Urology Supplements , Volume 15 , Issue 4 , 102 - 111
http://www.urology-textbook.com/urosepsis.html . Dr. med. Dirk Manski Last update 13.5.2018
Also see: Hotchkiss und Karl 2003 HOTCHKISS, R. S. ; KARL, I. E.: The pathophysiology and treatment of sepsis. In: N Engl J Med 348 (2003), Nr. 2, S. 138–50 and Tauchnitz 1991 TAUCHNITZ, C: Sepsis. In: HAHN, H (Hrsg.) ; FALKE, D (Hrsg.) ; KLEIN, P (Hrsg.): Medizinische Mikrobiologie. Berlin, Heidelberg : Springer, 1991, S. 501–507
Image Source: http://publichealth.lacounty.gov/acd/docs/IPCourseDayOne/CAUTI.pdf
http://publichealth.lacounty.gov/acd/docs/IPCourseDayOne/CAUTI.pdf Gould C., Catheter-Associated Urinary Tract infection (CAUTI) Toolkit, CDC
Image Source: https://i.pinimg.com/originals/4b/c4/e0/4bc4e0647a8b154c5a1d77ce7538c938.jpg
How to manage incontinence-associated dermatitis. By Nancy Chatham, MSN, RN, ANP-BC, CWOCN, CWS, and Carrie Carls, BSN, RN, CWOCN, CHRN. Wound Care Advisor. May/June 2012. Issue 1, Number 1. http://woundcareadvisor.com/how-to-manage-incontinence-associated-dermatitis/
See: Improving diaper design to address incontinence associated dermatitis. Beguin et al. BMC Geriatrics 2010, 10:86 http://www.biomedcentral.com/1471-2318/10/86
Internal and External Urinary Catheters: A Primer for Clinical Practice. 12/01/08 Ostomy Wound Manage. 2008;54(12):18-35.Diane K. Newman, RNC, MSN, CRNP, FAAN
https://www.nhs.uk/conditions/urinary-catheters/types/ . National Health Service. © Crown Copyrigh
https://www.nhs.uk/conditions/urinary-catheters/types/ . National Health Service. © Crown Copyright
Image source: https://www.nhs.uk/conditions/urinary-catheters/types/ . National Health Service. © Crown Copyright
https://www.healthline.com/health/urinary-catheters#types . "Urinary Catheters" by Jacquely Cafasso. Medically reviewed by Carissa Stephens, RN, CCRN, CPN on August 11, 2017
Image Source: https://www.shopcatheters.com/p-mabis-dmi-mcguire-style-suspensory-male- urinal.html?msclkid=84cf455081b11fef05c21e357a9f2132&utm_source=bing&utm_medium=cpc&utm_campaign=Urological%20S upplies%20Shopping&utm_term=4580290564885935&utm_content=Urinals
Image Source: https://www.coloplast.us/Global/3_Bladder%20and%20Bowel/Videos/Conveen/MoveenBag_still_704x396.jpg
https://www.nhs.uk/conditions/urinary-catheters/types/ . National Health Service. © Crown Copyright
Image compliments of UI Medical LLC. www.UiMed.com
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This article was authored by Dr. Marion Somers (drmarion@uimed.com) and Marc Harris (marcmharrisb@outlook.com). Dr. Somers has operated a thriving geriatric care management practice during the past four decades and is currently clinical director of UI Medical in Long Beach, California. Marc Harris is an analyst with WBA based in Greenwich, Connecticut. This article was originally published in October 2018.
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