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1.  Stop Orders to Reduce Inappropriate Urinary Catheterization in Hospitalized Patients: A Randomized Controlled Trial 
Hospitalized patients frequently have urinary catheters inserted for inappropriate reasons. This can lead to urinary tract infections and other complications.
To assess whether stop orders for indwelling urinary catheters reduces the duration of inappropriate urinary catheterization and the incidence of urinary tract infections.
A randomized controlled trial was conducted in three tertiary-care hospitals in Ontario, Canada. Patients with indwelling urinary catheters were randomized to prewritten orders for the removal of urinary catheters if specified criteria were not present or to usual care.
Six hundred ninety-two hospitalized patients admitted to hospital with indwelling urinary catheters inserted for ≤48 h.
The main outcomes included days of inappropriate indwelling catheter use, total days of catheter use, frequency of urinary tract infection, and catheter reinsertions.
There were fewer days of inappropriate and total urinary catheter use in the stop-order group than in the usual care group (difference −1.69 [95% CI −1.23 to −2.15], P < 0.001 and −1.34 days, [95% CI, −0.64 to −2.05 days], P < 0.001, respectively). Urinary tract infections occurred in 19.0% of the stop-order group and 20.2% of the usual care group, relative risk 0.94 (95% CI, 0.66 to 1.33), P = 0.71. Catheter reinsertion occurred in 8.6% of the stop-order group and 7.0% in the usual care group, relative risk 1.23 (95% CI, 0.72 to 2.11), P = 0.45.
Stop orders for urinary catheterization safely reduced duration of inappropriate urinary catheterization in hospitalized patients but did not reduce urinary tract infections.
PMCID: PMC2517898  PMID: 18421507
urinary tract infections; urinary catheters; randomized controlled trial; stop order
2.  Current Trends in the Management of Difficult Urinary Catheterizations 
Routine urinary catheter placement may cause trauma and poses a risk of infection. Male catheterization, in particular, can be difficult, especially in patients with enlarged prostate glands or other potentially obstructive conditions in the lower urinary tract. Solutions to problematic urinary catheterization are not well known and when difficult catheterization occurs, the risk of failed catheterization and concomitant complications increase. Repeated and unsuccessful attempts at urinary catheterization induce stress and pain for the patient, injury to the urethra, potential urethral stricture requiring surgical reconstruction, and problematic subsequent catheterization. Improper insertion of catheters also can significantly increase healthcare costs due to added days of hospitalization, increased interventions, and increased complexity of follow-up evaluations. Improved techniques for catheter placement are essential for all healthcare personnel involved in the management of the patient with acute urinary retention, including attending emergency physicians who often are the first physicians to encounter such patients. Best practice methods for blind catheter placement are summarized in this review. In addition, for progressive clinical practice, an algorithm for the management of difficult urinary catheterizations that incorporates technology enabling direct visualization of the urethra during catheter insertion is presented. This algorithm will aid healthcare personnel in decision making and has the potential to improve quality of care of patients.
PMCID: PMC3555603  PMID: 23359117
3.  Urinary tract infections in the critical care unit: A brief review 
The use of indwelling catheters in the Critical Care Units (CCUs) has a major role in determining the incidence and the morbidity as well as mortality from hospital-acquired urinary tract infections (UTIs). Instituting evidence-based protocols can significantly reduce both the prevalence of indwelling catheterization as well as the incidence of hospital-acquired UTIs. The prevalence of catheter-associated urinary tract infections (CAUTIs) in the CCUs is directly linked to the widespread use of indwelling catheters in these settings. CAUTIs result in significant cost escalation for individual hospitals as well as the healthcare system as a whole. A UTI is an inflammatory response to colonization of the urinary tract, most commonly by bacteria or fungi. A UTI should be differentiated from the mere detection of bacteria in the urinary tract. This condition, referred to as asymptomatic bacteriuria, is common and does not require treatment, especially in the patient with an indwelling urinary catheter. A CAUTI occurs when a patient with an indwelling urinary catheter develops 2 or more signs or symptoms of a UTI such as hematuria, fever, suprapubic or flank pain, change in urine character, and altered mental status. CAUTI is classified as a complicated UTI. The current review highlights the important management issues in critical care patients having CAUTI. We performed a MEDLINE search using combinations of keywords such as urinary tract infection, critical care unit and indwelling urinary catheter. We reviewed the relevant publications with regard to CAUTI in patients in CCU.
PMCID: PMC3902573  PMID: 24501490
Catheter-associated urinary tract infection; critical care unit; urinary tract infection
4.  A randomized controlled trial to assess the efficacy and cost-effectiveness of urinary catheters with silver alloy coating in spinal cord injured patients: trial protocol 
BMC Urology  2013;13:38.
Patients with non-acute spinal cord injury that carry indwelling urinary catheters have an increased risk of urinary tract infection (UTIs). Antiseptic Silver Alloy-Coated Silicone Urinary Catheters seems to be a promising intervention to reduce UTIs; however, actual evidence cannot be extrapolated to spinal cord injured patients. The aim of this trial is to make a comparison between the use of antiseptic silver alloy-coated silicone urinary catheters and the use of standard urinary catheters in spinal cord injured patients to prevent UTIs.
The study will consist in an open, randomized, multicentre, and parallel clinical trial with blinded assessment. The study will include 742 spinal cord injured patients who require at least seven days of urethral catheterization as a method of bladder voiding. Participants will be online centrally randomized and allocated to one of the two study arms (silver alloy-coated or standard catheters). Catheters will be used for a maximum period of 30 days or removed earlier if the clinician considers it necessary. The main outcome will be the incidence of UTIs by the time of catheter removal or at day 30 after catheterization, the event that occurs first. Intention-to-treat analysis will be performed, as well as a primary analysis of all patients.
The aim of this study is to assess whether silver alloy-coated silicone urinary catheters improve ITUs in spinal cord injured patients. ESCALE is intended to be the first study to evaluate the efficacy of the silver alloy-coated catheters in spinal cord injured patients.
Trial registration
PMCID: PMC3735409  PMID: 23895463
Spinal cord injuries; Urinary tract infection; Urinary catheters; Protocol; Randomized clinical trial
5.  Posttraumatic ventral urethral fistula: a case report 
Cases Journal  2009;2:8644.
We present the first case reported in the medical literature of a patient with a posttraumatic urethral fistula accompanied by retraction urethral catheter with balloon.
Case presentation
A 69-year-old man was admitted to our hospital with the recurrence urinary tract infection. The patient reports history of urethral trauma, which is retraction urethral catheter with balloon 2 years ago. Cystoscopy and fistulography were performed, and urethrocutaneous fistula was detected. Initial surgical treatment consisted of surgical debridement of fistula tissue, and a urethral catheterization was performed. After 4 weeks of the operation the urethral fistula resolved. In a follow-up period of 24 months no recurrence and no urinary tract infection were occurred.
Self retraction of the urethral catheter with balloon may result with clinically important urethral fistula. A wide range of possible options such as complete excision of the fistula tract and primary closure may be considered for individual cases.
PMCID: PMC2827111  PMID: 20181212
6.  Novel Antiseptic Urinary Catheters for Prevention of Urinary Tract Infections: Correlation of In Vivo and In Vitro Test Results▿  
Antimicrobial Agents and Chemotherapy  2009;53(12):5145-5149.
Urinary catheters are widely used for hospitalized patients and are often associated with high rates of urinary tract infection. We evaluated in vitro the antiadherence activity of a novel antiseptic Gendine-coated urinary catheter against several multidrug-resistant bacteria. Gendine-coated urinary catheters were compared to silver hydrogel-coated Foley catheters and uncoated catheters. Bacterial biofilm formation was assessed by quantitative culture and scanning electron microscopy. These data were further correlated to an in vivo rabbit model. We challenged 31 rabbits daily for 4 days by inoculating the urethral meatus with 1.0 × 109 CFU streptomycin-resistant Escherichia coli per day. In vitro, Gendine-coated urinary catheters reduced the CFU of all organisms tested for biofilm adherence compared with uncoated and silver hydrogel-coated catheters (P < 0.004). Scanning electron microscopy analysis showed that a thick biofilm overlaid the control catheter and the silver hydrogel-coated catheters but not the Gendine-coated urinary catheter. Similar results were found with the rabbit model. Bacteriuria was present in 60% of rabbits with uncoated catheters and 71% of those with silver hydrogel-coated catheters (P < 0.01) but not in those with Gendine-coated urinary catheters. No rabbits with Gendine-coated urinary catheters had invasive bladder infections. Histopathologic assessment revealed no differences in toxicity or staining. Gendine-coated urinary catheters were more efficacious in preventing catheter-associated colonization and urinary tract infections than were silver hydrogel-coated Foley catheters and uncoated catheters.
PMCID: PMC2786341  PMID: 19805562
7.  Catheter-Associated Infections 
Archives of internal medicine  2004;164(8):842-850.
Intravascular catheters and urinary catheters are the 2 most commonly inserted medical devices in the United States, and they are likewise the two most common causes of nosocomially acquired bloodstream infection. Biofilm formation on the surfaces of indwelling catheters is central to the pathogenesis of infection of both types of catheters. The cornerstone to any preventive strategy of intravascular catheter infections is strict attention to infection control practices. Antimicrobial-impregnated intravascular catheters are a useful adjunction to infection control measures. Prevention of urinary catheter–associated infection is hindered by the numbers and types of organisms present in the periurethral area as well as by the typically longer duration of catheter placement. Antimicrobial agents in general have not been effective in preventing catheter-associated urinary tract infection in persons with long-term, indwelling urethral catheters. Preventive strategies that avoid the use of antimicrobial agents may be necessary in this population.
PMCID: PMC2963580  PMID: 15111369
8.  Role of suprapubic catheterization in retention of urine1 
One hundred and nine male patients took part in a randomized trial of elective suprapubic or urethral catheterization in retention of urine. The self-retaining trocar suprapubic catheter proved safe and reliable in trained hands and its use was associated with a low incidence of side effects. The suprapubic catheter when used to allow continuous flow resection appeared to lead to decreased blood loss and reduced resection time. No decrease in urinary infection rate over the period of hospital stay was noted in the suprapubic group. The suprapubic catheter was more comfortable than the urethral and also allowed a trial of voiding prior to removal. Use of the suprapubic catheter was not associated with an increased hospital stay.
PMCID: PMC1438229  PMID: 7005439
9.  Reducing Inappropriate Urinary Catheter Use: A Statewide Effort 
Archives of internal medicine  2012;172(3):255-260.
Indwelling urinary catheters may lead to both infectious and non-infectious complications and are often used in the hospital setting without an appropriate indication. The objective of this study was to evaluate the results of a statewide quality improvement effort to reduce inappropriate urinary catheter use.
Retrospective analysis of data collected between 2007 and 2010 as part of a statewide collaborative initiative before, during, and after an educational intervention-promoting adherence to appropriate urinary catheter indications. The data was collected from 163 inpatient units in 71 participating Michigan hospitals. The intervention consisted of engaging clinicians about the appropriate indications for urinary catheter use and promoting the daily assessment of urinary catheter necessity during daily nursing rounds. The main outcome measures were change in prevalence of urinary catheter use and adherence with appropriate indications. We used flexible generalized estimating equation (GEE) and multilevel methodology to estimate rates over time while accounting for the clustering of patients within hospital units.
The urinary catheter utilization rate decreased from 18.1% (95% CI: 16.8–19.6) at baseline to 13.8% (95% CI: 12.9–14.8) at end of year 2 (p <0.001). The proportion of catheterized patients with appropriate indications increased from 44.3% (95% CI: 40.3–48.4) to 57.6% (95% CI: 51.7–63.4) by the end of year 2 (p = 0.005).
A statewide effort to reduce inappropriate urinary catheter utilization was associated with a significant reduction in catheter use and improved compliance with appropriate use. The effect of the intervention was sustained for at least 2 years. Word count: 249
PMCID: PMC3718283  PMID: 22231611
urinary catheter; device utilization; healthcare-associated infection; patient safety
10.  Hydrophilic Catheters 
Executive Summary
To review the evidence on the effectiveness of hydrophilic catheters for patients requiring intermittent catheterization.
Clinical Need
There are various reasons why a person would require catheterization, including surgery, urinary retention due to enlargement of the prostate, spinal cord injuries, or other physical disabilities. Urethral catheters are the most prevalent cause of nosocomial urinary tract infections, that is, those that start or occur in a hospital.
A urinary tract infection (UTI) occurs when bacteria adheres to the opening of the urethra. Most infections arise from Escherichia coli, from the colon. The bacteria spread into the bladder, resulting in the development of an infection.
The prevalence of UTIs varies with age and sex. There is a tenfold increase in incidence for females compared with males in childhood and throughout adult life until around 55 years, when the incidence of UTIs in men and women is equal, mostly as a consequence of prostatic problems in men. Investigators have reported that urethritis (inflammation of the urethra) is found in 2% to 19% of patients practising intermittent catheterization.
The Technology
Hydrophilic catheters have a polymer coating that binds o the surface of the catheter. When the polymer coating is submersed in water, it absorbs and binds the water to the catheter. The catheter surface becomes smooth and very slippery. This slippery surface remains intact upon insertion into the urethra and maintains lubrication through the length of the urethra. The hydrophilic coating is designed to reduce the friction, as the catheter is inserted with the intention of reducing the risk of urethral damage.
It has been suggested that because the hydrophilic catheters do not require manual lubrication they are more sterile and thus less likely to cause infection. Most hydrophilic catheters are prepackaged in sterile water, or there is a pouch of sterile water that is broken and released into the catheter package when the catheter is ready to use.
Review Strategy
The Medical Advisory Secretariat searched for reports of systematic reviews of randomized controlled trials (RCTs), meta-analyses of RCTs, and RCTs. The following databases were searched: Cochrane Library International Agency for Health Technology Assessment (fourth quarter 2005), Cochrane Database of Systematic Reviews (fourth quarter 2005), Cochrane Central Register of Controlled Trials (fourth quarter 2005), MEDLINE (1966 to the third week of November 2005), MEDLINE In-Process and Other Non-indexed Citations (1966 to November 2005), and EMBASE (1980 to week 49 in 2005). Search terms were urinary catheterization, hydrophilic, intermittent, and bladder catheter.
The Medical Advisory Secretariat also conducted Internet searches of Medscape ( for recent reports on trials that were unpublished but presented at international conferences. In addition, the Web site Current Controlled Trials ( was searched for ongoing trials on urinary catheterization.
Summary of Findings
Five RCTs were identified that compared hydrophilic catheters to standard catheters. There was substantial variation across the studies in terms of the reason for catheterization, inclusion criteria, and type of catheter used. Two studies used reusable catheters in the control arm, while the other 3 RCTs used single-use catheters in the control arm. All 5 RCTs focused mainly on males requiring intermittent catheterization. Age varied considerably across studies. One study consisted of young males (mean age 12 years), while another included older males (mean age 71 years).
The RCTs reported conflicting results regarding the effectiveness of the hydrophilic catheters compared with standard catheters in terms of rates of UTIs. All 5 RCTs had serious limitations. Two of the studies were small, and likely underpowered to detect significant differences between groups. One RCT reported 12-month follow-up data for all 123 patients even though more than one-half of the patients had dropped out of the study by 12 months. Another RCT had unequal groups at baseline: the patients in the hydrophilic group had twice the mean number of UTIs at baseline compared with the standard catheter group. The fifth RCT used catheters to treat patients with bladder cancer; therefore, the results of their study are not generalizable to the population requiring intermittent catheterization.
Two studies did not find significant differences between the hydrophilic and standard catheter groups for patient satisfaction. Another RCT reported conflicting results; however, the overall opinion of the catheters was not significantly different between the treatment groups. A fourth RCT found that the hydrophilic catheters were substantially more comfortable than standard catheters. The fifth RCT did not report results for quality of life or patient satisfaction. Similar to the results for effectiveness, it is not possible to clearly establish if there is a significant difference in patient satisfaction between the patients using hydrophilic catheters and those using standard catheters.
Patients requiring intermittent catheterization use, on average, 4 to 5 intermittent catheters per day. Patients admitted to hospitals using intermittent catheters typically do not reuse catheters, owing to the potential increased risk of infection in hospital. Patients self-catheterizing at home are more likely to reuse catheters. Standard catheters cost about $1.00 to $1.50/catheter. Hydrophilic catheters cost about $2.00 to $5.00/catheter, depending on the type and whether they have antibiotics inside. All hydrophilic catheters are single-use.
At this time there is insufficient evidence to indicate whether hydrophilic catheters are associated with a lower rate of UTIs and improved patient satisfaction among people requiring intermittent catheterization.
PMCID: PMC3386556  PMID: 23074500
11.  Enterovesical Fistula: A Rare Complication of Urethral Catheterization 
Advances in Urology  2009;2009:591204.
This report describes the case of an eighty-two-year old lady with an indwelling urethral catheter inserted eight years prior to her presentation to manage her urinary incontinence. She underwent radiotherapy for muscle-invasive bladder cancer (stage T2b) in 1991 and had a laparotomy and drainage of an appendicular abscess in her early twenties. She presented with a short history of fecaluria, pneumaturia, and passage of urine per rectum. On laparotomy she was found to have an inflated catheter balloon that has eroded through the bladder wall into the lumen of a terminal ileal segment. To our knowledge this is the first reported case in literature of a patient developing an enterovesical fistula as a result of a urethral catheter eroding through the bladder wall into the bowel lumen. There are numerous known complications of long-term urethral catheterization. They include recurrent urinary tract infections, recurrent pyelonephritis, sepsis, urethral stricture, blocked and retained catheters, among many other reported complications. This case describes an unusual presentation secondary to an even more unusual complication. This should be considered when handling patients with indwelling urethral catheters inserted in unhealthy bladders.
PMCID: PMC2719788  PMID: 19657455
12.  Postoperative catheterization after anterior colporrhaphy: 2 versus 5 days. A multicentre randomized controlled trial 
Introduction and hypothesis
The aim of this study was to compare the number of temporary catheter replacements and urinary tract infections after indwelling catheterization for 2 versus 5 days following an anterior colporrhaphy.
Two hundred forty-six patients were randomly assigned to 2 or 5 days of indwelling catheterization. Outcome measures were temporary catheter replacements because of post-voiding residual >200 mL after removal of the indwelling catheter, urinary tract infections, and hospital stay. All patients were analyzed according to the intention to treat principle.
Compared to the 5-day protocol group, in the 2-day protocol group more patients needed temporary catheter replacement (9% versus 28%, odds ratio (OR) 4.0, confidence interval (CI) 1.9–8.3, p < 0.01), whereas less patients had a urinary tract infection (37% versus 22%, OR 0.5, CI 0.3–0.9, p = 0.02) and median hospital stay was lower.
Removal of an indwelling catheter after 2 versus 5 days following anterior colporrhaphy is associated with more temporary catheter replacements, but less urinary tract infections and a shorter hospital stay.
PMCID: PMC3051058  PMID: 20960149
Cystocele; Anterior colporrhaphy; Indwelling catheterization; Urinary retention; Temporary catheter replacement; Urinary tract infection
13.  Role of biofilm in catheter-associated urinary tract infection 
The predominant form of life for the majority of microorganisms in any hydrated biologic system is a cooperative community termed a “biofilm.” A biofilm on an indwelling urinary catheter consists of adherent microorganisms, their extracellular products, and host components deposited on the catheter. The biofilm mode of life conveys a survival advantage to the microorganisms associated with it and, thus, biofilm on urinary catheters results in persistent infections that are resistant to antimicrobial therapy. Because chronic catheterization leads almost inevitably to bacteriuria, routine treatment of asymptomatic bacteriuria in persons who are catheterized is not recommended. When symptoms of a urinary tract infection develop in a person who is catheterized, changing the catheter before collecting urine improves the accuracy of urine culture results. Changing the catheter may also improve the response to antibiotic therapy by removing the biofilm that probably contains the infecting organisms and that can serve as a nidus for reinfection. Currently, no proven effective strategies exist for prevention of catheter-associated urinary tract infection in persons who are chronically catheterized.
PMCID: PMC2963581  PMID: 15153930
14.  Ultrastructure of Proteus mirabilis Swarmer Cell Rafts and Role of Swarming in Catheter-Associated Urinary Tract Infection  
Infection and Immunity  2004;72(7):3941-3950.
Proteus mirabilis is a common cause of catheter-associated urinary tract infection (C-UTI). It blocks indwelling urethral catheters through the formation of extensive crystalline biofilms. The obstruction of urine flow can induce episodes of pyelonephritis, septicemia, and shock. P. mirabilis exhibits a type of motility referred to as swarming, in which multicellular rafts of elongated, hyperflagellated swarmer cells form and move rapidly in concert over solid surfaces. It has been suggested that swarming is important in the pathogenesis of C-UTI. In this study we generated a set of stable transposon mutants deficient in swarming and used them to assess the role of swarming in the migration of P. mirabilis over urinary catheters. Swarming was found to be essential for migration over all-silicone catheters. Swarming-deficient mutants were attenuated in migration over hydrogel-coated latex catheters, but those capable of swimming motility were able to move over and infect these surfaces. A novel vapor fixation technique for the preparation of specimens and scanning electron microscopy were used to resolve the ultrastructure of P. mirabilis multicellular rafts. The flagellar filaments of P. mirabilis were found to be highly organized during raft migration and were interwoven in phase to form helical connections between adjacent swarmer cells. Mutants lacking these novel organized structures failed to swarm successfully. We suggest that these structures are important for migration and formation of multicellular rafts. In addition, the highly organized structure of multicellular rafts enables P. mirabilis to initiate C-UTI by migration over catheter surfaces from the urethral meatus into the bladder.
PMCID: PMC427392  PMID: 15213138
15.  Complicated Catheter-Associated Urinary Tract Infections Due to Escherichia coli and Proteus mirabilis 
Clinical Microbiology Reviews  2008;21(1):26-59.
Catheter-associated urinary tract infections (CAUTIs) represent the most common type of nosocomial infection and are a major health concern due to the complications and frequent recurrence. These infections are often caused by Escherichia coli and Proteus mirabilis. Gram-negative bacterial species that cause CAUTIs express a number of virulence factors associated with adhesion, motility, biofilm formation, immunoavoidance, and nutrient acquisition as well as factors that cause damage to the host. These infections can be reduced by limiting catheter usage and ensuring that health care professionals correctly use closed-system Foley catheters. A number of novel approaches such as condom and suprapubic catheters, intermittent catheterization, new surfaces, catheters with antimicrobial agents, and probiotics have thus far met with limited success. While the diagnosis of symptomatic versus asymptomatic CAUTIs may be a contentious issue, it is generally agreed that once a catheterized patient is believed to have a symptomatic urinary tract infection, the catheter is removed if possible due to the high rate of relapse. Research focusing on the pathogenesis of CAUTIs will lead to a better understanding of the disease process and will subsequently lead to the development of new diagnosis, prevention, and treatment options.
PMCID: PMC2223845  PMID: 18202436
16.  Living donor renal transplant recipients tolerate early removal of bladder catheters 
Recipients of living donor renal grafts enjoy numerous benefits compared with deceased donor kidney recipients. Bladder catheterization allows for the continuous determination of urinary output and, theoretically, may prevent urinary leaks. A series of 25 consecutive renal transplants was reviewed to evaluate the timing of removal of bladder catheters after transplantation. Removing urinary catheters as early as 24 h to 48 h post-transplant showed no increase in undesirable outcomes. More than 50% of the patients had invasive bladder catheters in place for only one or two days. Early removal was associated with a lower rate of urinary tract infections, decreased length of hospitalization and possibly less discomfort, in the absence of detrimental effects.
PMCID: PMC2780850  PMID: 22477495
Catheter; Donor; Foley; Infection; Kidney; Live; Satisfaction; Transplant; Urinary
17.  Prospective randomised trial of two devices for suprapubic catheterisation in general surgical patients. 
Compared with urethral catheterisation, suprapubic catheterisation is associated with a reduced incidence of urinary infection and urethral stricture and it facilitates a controlled trial of micturition. A prospective comparison of two types of suprapubic catheter was performed in 70 patients, using a specially designed catheter mounted on a trocar for insertion (Suprapubic Ingram Trocar), and a disposable trocar and cannula (Add-a-Cath) and standard Foley catheter. A suprapubic catheter was inserted successfully in 63 patients. Overall there was a low incidence of urinary tract infection (4.3%) and the only significant catheter-related problem was suprapubic leakage of urine, which was self-limiting in all but one patient. Although there is little objective difference between the systems tested, we prefer the Add-a-Cath system for its simplicity and economy. This trial provides further support for the more frequent use of suprapubic catheters in general surgical practice.
PMCID: PMC2502311  PMID: 8017815
18.  Lock-Out Valve to Decrease Catheter-Associated Urinary Tract Infections 
Advances in Urology  2014;2014:765756.
Patients with long-term indwelling urinary catheters are at an increased risk for urinary tract infection due to bacteriuria. Catheter-associated urinary tract infections (CAUTIs) are a significant source of morbidity and mortality in long-term care facilities as well as in ambulatory patients requiring long-term catheterization. There is increased interest in the financial impact of CAUTI as Medicare no longer provides reimbursement for nosocomial CAUTIs. Ascending bacteria may in part enter the closed drainage system when the patient switches between leg and night collection bags. In an attempt to reduce this ascent, a double valve lock-out system was devised that maintains a closed system during bag exchange. The concept is introduced and CAUTIs are reviewed.
PMCID: PMC3918347  PMID: 24575127
19.  Removal of Foley Catheters in Live Donor Kidney Transplant Recipients on Postoperative Day 1 Does Not Increase the Incidence of Urine Leaks 
Catheterization of the urinary bladder during kidney transplantation is essential. The optimal time to remove the Foley catheter postoperatively is not universally defined. It is our practice to remove the Foley catheter on postoperative day 1 in live donor kidney transplant recipients who meet our standardized protocol criteria. We believe that early removal of Foley catheters increases patient comfort and mobility, decreases the risk of catheter associated urinary tract infections, and allows for decreased hospital length of stay. The hypothetical risk of early removal of Foley catheters would be the increased risk of urine leak. We reviewed 120 consecutive live donor kidney transplant recipients and found that there was not an increased incidence of urine leaks in patients whose Foley catheters were removed on postoperative day 1.
PMCID: PMC3699223  PMID: 24436583
Foley; urine leak; kidney transplantation; Doppler ultrasonography; outcomes
20.  Invasive carcinoma of urinary bladder in a patient with a spinal cord injury with non-functioning Brindley sacral anterior root stimulator: a case report 
Cases Journal  2008;1:137.
Anterior sacral root stimulation combined with sacral posterior rhizotomy restores bladder function in spinal cord-injured patients suffering from hyperactive bladder. After successful implantation of bladder stimulator, urinary infection rate decreases, and patients are able to get rid of indwelling urinary catheters, which in turn reduce the risks for vesical malignancy. We present a spinal cord injury patient with non-functioning Brindley sacral anterior root stimulator, who developed carcinoma of urinary bladder.
Case presentation
A Caucasian male, who was born in 1943, sustained paraplegia at T-4 (ASIA-B) in 1981. This patient underwent implantation of sacral anterior root stimulator in September 1985. The bladder stimulator started giving trouble since 1996 and the patient went back to using indwelling urethral catheter. In August 2006, this patient passed blood in urine after a routine change of indwelling catheter. Cystoscopy showed unhealthy bladder mucosa. Bladder biopsy revealed carcinoma, which was infiltrating bundles of muscularis propria. Many of the nests showed evidence of squamous differentiation, while others could be transitional or squamous. This patient underwent cystectomy with lymphadenectomy in March 2007 in a hospital nearer his home. Histology showed three nodes involved. This patient has been doing well since the operation.
Occurrence of vesical malignancy in this patient with non-functioning bladder stimulator is a timely reminder to all health professionals, and health care managers that concerted efforts should be made to rectify a non-functioning sacral anterior root stimulator as soon as possible. Otherwise, facilities should be made available in the community for the spinal cord injury patient to use intermittent catheterisation and thereby, avoid permanent indwelling catheter, vesical calculi and urine infections, which are risk factors for bladder cancer.
PMCID: PMC2546370  PMID: 18761737
21.  Engineering out the risk for infection with urinary catheters. 
Emerging Infectious Diseases  2001;7(2):342-347.
Catheter-associated urinary tract infection (CAUTI) is the most common nosocomial infection. Each year, more than 1 million patients in U.S. acute-care hospitals and extended-care facilities acquire such an infection; the risk with short-term catheterization is 5% per day. CAUTI is the second most common cause of nosocomial bloodstream infection, and studies suggest that patients with CAUTI have an increased institutional death rate, unrelated to the development of urosepsis. Novel urinary catheters impregnated with nitrofurazone or minocycline and rifampin or coated with a silver alloy-hydrogel exhibit antiinfective surface activity that significantly reduces the risk of CAUTI for short-term catheterizations not exceeding 2-3 weeks.
PMCID: PMC2631699  PMID: 11294737
22.  Biofilm formation of Klebsiella pneumoniae on urethral catheters requires either type 1 or type 3 fimbriae 
Urinary catheters are standard medical devices utilized in both hospital and nursing home settings, but are associated with a high frequency of catheter-associated urinary tract infections (CAUTI). In particular, biofilm formation on the catheter surface by uropathogens such as Klebsiella pneumoniae causes severe problems. Here we demonstrate that type 1 and type 3 fimbriae expressed by K. pneumoniae enhance biofilm formation on urinary catheters in a catheterized bladder model that mirrors the physico-chemical conditions present in catheterized patients. Furthermore, we show that both fimbrial types are able to functionally compensate for each other during biofilm formation on urinary catheters. In situ monitoring of fimbrial expression revealed that neither of the two fimbrial types is expressed when cells are grown planktonically. Interestingly, during biofilm formation on catheters, both fimbrial types are expressed, suggesting that they are both important in promoting biofilm formation on catheters. Additionally, transformed into and expressed by a nonfimbriated Escherichia coli strain, both fimbrial types significantly increased biofilm formation on catheters compared with the wild-type E. coli strain. The widespread occurrence of the two fimbrial types in different species of pathogenic bacteria stresses the need for further assessment of their role during urinary tract infections.
PMCID: PMC3410544  PMID: 22448614
CAUTI; type 1 fimbriae; biofilm; Klebsiella pneumoniae; type 3 fimbriae
23.  Early development of bacterial community diversity in emergently placed urinary catheters 
BMC Research Notes  2012;5:332.
Approximately 25% of hospitalized patients have a urinary catheter, and catheter associated urinary tract infection is the most common nosocomial infection in the US, causing >1 million cases/year. However, the natural history of the biofilms that rapidly form on urinary catheters and lead to infection is not well described.
We characterized the dynamics of catheter colonization among catheters collected from 3 women and 5 men in a trauma burn unit with different indwelling times using TRFLP and culture. All patients received antibiotic therapy. Results: Colony-forming units increased along the extraluminal catheter surface from the catheter balloon to the urethra, but no trend was apparent for the intraluminal surface. This suggests extraluminal bacteria come from periurethral communities while intraluminal bacteria are introduced via the catheter or already inhabit the urine/bladder. Richness of operational taxonomic units (OTUs) increased over time on the intraluminal surface, but was constant extraluminally.
OTU community composition was explained best by time rather than axial location or surface. Our results suggest that catheter colonization can be very dynamic, and possibly have a predictable succession.
PMCID: PMC3500218  PMID: 22738659
Urinary tract infection; Microbial ecology; Biofilms; Urinary catheter
24.  Prevention of Urinary Tract Infections After Vaginal Surgery 
The technique of care of the bladder and indwelling catheter during the postoperative period was altered to determine whether the incidence of urinary tract infections following vaginal surgery could be reduced. Sixty-nine patients undergoing various types of vaginal reparative surgery were studied. Irrigation of the bladder was carried out with a closed system, four times daily, using chlorhexidine diacetate 1:20,000. Only 12 of the 69 patients showed urinary infection after removal of the catheter, a marked reduction in the usual incidence. It is suggested, therefore, that this technique is helpful in preventing urinary infection after vaginal surgery. It was noted, however, that a further 12 patients who were free of infection at the time of removal of the catheter subsequently developed infection as a result of catherization for residual urine. It is recommended that routine catheterization for residual urine be abandoned.
PMCID: PMC1921338  PMID: 13952553
25.  Making the Hospital Safer for Older Adult Patients: A Focus on the Indwelling Urinary Catheter 
The Permanente Journal  2011;15(1):49-52.
The needs of hospitalized geriatric patients differ from the needs of hospitalized younger adults. In an attempt to improve systems of care for the older adult, the Centers for Medicare and Medicaid Services classified urinary tract infections related to the use of indwelling urinary catheters (IUC) as one of eight “never events.” The insertion of an IUC is a commonly performed procedure that can cause an array of iatrogenic complications. In addition, the placement of an IUC without medical indication is a risk factor for prolonged hospitalization and inpatient mortality. Foley catheterization has been documented as a culprit in urosepsis and as being associated with geriatric syndromes such as delirium and functional impairment. This article will discuss the indications for the IUC, the complications that can occur because of the IUC, and comment on the Kaiser Permanente Southern California Region's efforts to minimize the unnecessary use of the IUC. Thoughtful and judicious use of the IUC, such as minimizing the use of urinary catheterization, either by not inserting an IUC or by removing it as soon as it is no longer needed, will most likely reduce inpatient morbidity and improve the health of the hospitalized older adult.
PMCID: PMC3048634  PMID: 21505618

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