Which action will help prevent accidental dislodgement of an indwelling urinary catheter

Overview  |  Bacteriuria  |  CAUTIs  |  Catheter-Associated Biofilms
Encrustations  |  Urosepsis  |  Urethral Damage  |  Common Urethral Complications  |  References

Catheter-Associated Complications

Catheter related problems due to an indwelling urinary catheter (IUC) have existed as long as urinary catheters have been utilized.  This section will review IUC complications: infectious complications such as (symptomatic bacterial infection, cystitis, pyelonephritis, urosepsis, and epididymitis), catheter blockage (due to calculi, biofilms, and encrustations), catheter related malignancy, hematuria, stones, urethral stricture and fistula from urethral injury, traumatic hypospadias, and periurethral urine leakage. 

Catheter-associated UTIs (CAUTIs)

Extraluminal contamination may occur as the catheter is inserted, by contamination of the catheter from any source. Extraluminal contamination is thought to also occurby microorganisms ascending from the perineum along the surface of the catheter. Most episodes of bacteriuria in catheterized women are believed to occur through the extraluminal entry of organisms. Fecal strains contaminate the perineum and urethral meatus, and then ascend to the bladder along the external surface to cause bacteriuria, catheter biofilm formation, and encrustation. Intraluminal contamination occurs by ascent of bacteria from a contaminated catheter, drainage tube, or urine drainage bag.

Microorganisms can migrate up the catheter into the bladder within 1 to 3 days.

At least 66% of CAUTIs result from extraluminal contamination, whereas 34% are a result of the intraluminal route.

There are three catheter-associated entry points for bacteria:

1. the urethral meatus, with the introduction of bacteria occurring on insertion of the catheter, 
2. the junction of the catheter-bag connection, especially when a break in the closed catheter system occurs, or
3. the drainage port of the collection bag.

All 3 of these mechanisms involved in the pathogenesis of colonization and infection of the urinary tract combine to make CAUTI very difficult to prevent in individuals with urinary catheters in place for longer than 2 weeks.

Bacteriuria

Bacteriuria (bacteria in the urine) usually occurs in most patients who have a catheter in place for 2 to 10 days. A large number and a variety of types of organisms are present in the periurethral area and in the distal part of the urethra that may be introduced into the bladder at the time of catheter insertion.

Other factors that increase the risk of bacteriuria include the presence of residual urine because of inadequate bladder drainage in the bladder (urine stasis promotes bacterial growth), ischemic damage to the bladder mucosa through overdistention, mechanical irritation from the presence of a catheter, and biofilm formation on the catheter intraluminal surface.

Once a catheter is placed, the daily incidence of bacteriuria is 3 to 10%. Between 10% and 30% of patients who undergo short-term catheterization (i.e., 2 to 4 days) develop bacteriuria and are asymptomatic. Between 90% and 100% of patients who undergo long-term catheterization develop bacteriuria.

About 80% of nosocomial UTIs are related to urethral catheterization; only 5 to 10% are related to genitourinary manipulation. The presence of potentially pathogenic bacteria and an indwelling catheter predisposes to the development of a nosocomial UTI.  The bacteria may gain entry into the bladder during insertion of the catheter, during manipulation of the catheter or drainage system, around the catheter, and after removal.

Two catheter hygiene principles should be used to prevent bacteriuria:

1. a “closed” system should be used, and 
2. the catheter should be removed as soon as possible.

A systematic review suggested that sealed (e.g., taped, presealed) drainage systems contribute to preventing bacteriuria.  The basic components of a closed system include the catheter, a preconnected collecting tube with a needleless aspiration port for obtaining a urine specimen, and a vented drainage bag with a port for drainage.

Catheter-associated bacteriuria is usually asymptomatic and uncomplicated, and is left untreated as it gradually resolves in an otherwise normal urinary tract after the catheter is removed.

Catheter-Associated Urinary Tract Infections

A CAUTI is the most common nosocomial infection in hospitals and nursing homes, comprising more than 40% of all institutionally acquired infections.

CAUTIs are considered complicated UTIs and are the most common complication associated with long-term catheter use.

CAUTIs may occur at least twice a year in patients with long-term indwelling catheters, requiring hospitalization. They are associated with increased urosepsis, septicemia, and mortality. Catheters are a good medium for bacterial growth because bacterial biofilms (layers of organisms) adhere to the many surfaces of the catheter system.  Most CAUTIs involve multiple organisms and resistant bacteria from catheter-associated biofilms (discussed later). These include Enterobacteriaceae other than E. coli (e.g., Klebsiella, Enterobacter, Proteus, and Citrobacter), pseudomonas aeruginosa, enterococci and staphylococci, and Candida. Candiduria is especially common in individuals with prolonged urinary catheterization receiving broad-spectrum, systemic antimicrobial agents.

A CAUTI is more likely to occur in women than men; because of the shorter female urethra and because of the urethra’s close proximity to the anus, bacteria have a shorter distance to travel.

Due to increased antibiotic use, there has been an increase in antibiotic-resistant microorganisms, particularly P. aeruginosa and C. albicans, two organisms frequently involved in device-associated nosocomial infections. A problem in hospitals and LTC facilities is infection with vancomycin-resistant Enterococcus (VRE) and methicillin resistant staphylococcus aureus (MRSA). In patients with long-term indwelling urinary catheters, symptoms of catheter-related infection are often nonspecific. Symptoms of a UTI are caused by an inflammatory response of the epithelium of the urinary tract to invasion and colonization by bacteria. Among catheterized individuals, clinical manifestations of UTI (pain, urgency, dysuria, fever, and leukocytosis) are uncommon even when bacteria or yeast is present, and are no more prevalent with positive urine culture results than with negative results.

Confusion or unexplained fever may be the only symptoms of catheter-related CAUTI in patients residing in nursing homes.

Diagnosing catheter-related infection in patients with spinal cord injury (SCI) may be especially challenging from history and physical examination because of a frequent lack of localizing symptoms. Often, the only symptom of catheter-related UTI in individuals with SCI is fever, diaphoresis, abdominal discomfort, or increased muscle spasticity.

Catheter-Associated Biofilms

Once an indwelling urinary catheter is inserted, bacteria quickly develop into colonies known as biofilms (living layers) that adhere to the catheter surface and drainage bag.

A biofilm is a collection of microorganisms with altered phenotypes that colonize the surface of a medical device such as an indwelling urinary catheter.

Urine contains protein that adheres to and primes the catheter surface. Microorganisms bind to this protein layer and thus attach to the surface. Such bacteria are different from free-living planktonic bacteria (bacteria that float in urine). Urinary catheter biofilms may initially be composed of single organisms, but longer exposures inevitably lead to multi-organism biofilms. Bacteria in biofilms have considerable survival advantages over free-living microorganisms, being extremely resistant to antibiotic therapy.

The link between biofilm and infection is that the biofilm provides a sustained reservoir for microorganisms that, after detachment, can infect the patient. These biofilms

The urine then becomes alkaline (increased pH), causing the production of ammonium ions, followed by crystallization of calcium and magnesium phosphate within the urine. These crystals are then incorporated into the biofilm, resulting in encrustation of the catheter over a period of time.

Several features of biofilms have important implications for the development of antimicrobial resistance in organisms growing within the biofilm. Because the presence of the biofilm inhibits antimicrobial activity, organisms within the biofilm cannot be eradicated by antimicrobial therapy alone. The urinary biofilm provides a protective environment for the microorganisms, which allows evasion of the activity of antimicrobial agents. The biofilm also allows for microbial attachment to catheter surfaces in a manner that does not allow for removal with gentle rinsing, such as irrigation. Biofilms can begin to develop within the first 24 hours after catheter insertion. Biofilms have reportedly become so thick in some circumstances as to block a catheter lumen. The presence of urinary catheter biofilms has important implications for antimicrobial resistance, diagnosis of UTIs, and the prevention and treatment of CAUTIs.

Encrustations

Mineral deposition within the catheter biofilm causes encrustations, which are unique to biofilms formed on urinary catheters. Encrustations are seen typically on the inner surface of the catheter and can build to block catheter flow completely. They can coat the balloon, making it hard to deflate. Once the balloon is deflated, they fall off into the bladder.

Urosepsis

Urosepsis can result from a UTI, leading to generalized sepsis, and death from severe UTIs has been reported. Mortality has been documented as more than 3 times higher in catheterized than in noncatheterized individuals.

Urethral Damage

Urethral damage occurs primarily in men because the catheter may interfere with drainage of seminal secretions. Urethral catheterization in men is associated with epididymitis, orchitis, scrotal abscess, prostatitis, and prostatic abscess. It can start at the time of insertion of the catheter but increases with long-term catheter use.

Difficulty passing the catheter may mean that the catheter has encountered a urethral stricture, has entered or created a false passage in the urethra, or that its passage is blocked by an obstructing prostate, bladder neck, or sphincter. The catheter may turn on itself and curl in the urethra.

The following are common urethral complications:

1. Urethritis, or inflammation of the urethral meatus, is a major source of discomfort and contributes to a breakdown in tissue integrity. It may be due to the frequent insertion of catheters or forceful catheterization against an obstruction. Urethritis may occur more frequently in patients who have latex catheters.
2. Erosion (tearing) of the urethra, primarily the urinary meatus, occurs in individuals who have had indwelling catheters for a long period of time. This erosion is usually secondary to catheter tension on the distal urethra at the meatus. The manner in which a catheter is secured should be alternated to prevent prolonged tension or pressure at an individual site. Also, larger size catheters can lead to catheter obstruction and provide increased pressure at the meatus causing urethral erosion in both men and women.  In men, erosion occurs from the meatus down the glans and a ventral erosion can result in hypospadias.  Creation of a false passage can occur primarily in men with persisting urethral strictures. Men with enlargement of the prostate gland are most at risk.
3. Urethral fistulas can develop in patients being managed long term with a urethral catheter. Such fistula formation most commonly develops in women between the bladder and the anterior vaginal wall. Many times the woman who has developed a fistula will complain of leakage and drainage from the vagina.

Other complications associated with indwelling catheter use include the following:

• Epididymitis caused by urethral and bladder inflammation or by scrotal abscesses seen in men. 
• Hematuria occurs in patients who have long-term catheters and is a possible sign of bladder cancer or kidney stones. Some bleeding may occur during catheter insertion, but, if the bleeding persists, urine cytology and a cystoscopy should be considered. A referral to a urologist may be indicated. 
• Bladder stones occur in at least 8% of patients with indwelling catheters and can form on the catheter or retention balloon. Therefore, patients with these catheters should be seen by a urologist annually. It is recommended that cystoscopy be performed to determine the environment within the bladder and the presence of stones or cancer. 
• Bladder cancer can occur in some patients with indwelling catheters for long periods of time. This has been seen in SCI patients. Monitoring for bladder cancer through yearly cystoscopy and urine cytology is recommended.Pain and discomfort can occur in addition to the morbidity and mortality caused by CAUTI.  In a study at a Veterans Affairs (VA) Medical Center, 42% of catheterized patients surveyed reported that the indwelling catheter was uncomfortable, 48% complained that it was painful, and 61% noted that it restricted their activities of daily living.  Of survey respondents, 30% stated that the catheter’s presence was embarrassing, and in unsolicited comments supplementing the structured questionnaires, 2 respondents noted that it “hurts like hell.”  Leakage of urine around the catheter (also called “catheter bypassing”) at the urethral meatus or suprapubic insertion site is a prevalent complication occurring in 25-65% of individuals with IUCs.  Bypassing is when the bladder forces urine out adjacent to the indwelling catheter because of one of a number of causes: irritation/inflammation resulting in bladder “spasms” or overactivity, catheter obstruction (from blood clots, stones, fecal impaction/constipation), improper catheter positioning, or drainage tube kinking. 
• Catheter expulsion or inadvertent dislodgment, defined as unintentional catheter removal, usually with the retention balloon inflated, can be a traumatic event.  Usual cause is deflation of the retention balloon.  Other causative factors include acute delirium or chronic dementia, which compromises the patient’s awareness of the rationale for catheterization and the consequences of removal.  Detrusor overactivity or “bladder spasms,” straining at stool, or excessive tension on the catheter can lead to inadvertent removal in certain cases.

References:

1. Alexaitis I, Broome B. Implementation of a nurse-driven protocol to prevent catheter-associated urinary tract infections. J Nurs Care Qual. 2014;29:245-52. DOI: 10.1097/NCQ.0000000000000041
2. Chatterjee S, Maiti P, Dey R, Kundu A, Dey R. Biofilms on indwelling urologic devices: microbes and antimicrobial management prospect. Ann Med Health Sci Res. 2014;4:100-4 DOI:  10.4103/2141-9248.126612
3. Clayton JL. Indwelling Urinary Catheters: A Pathway to Health Care-Associated Infections.  AORN J. 2017 May;105(5):446-452. doi: 10.1016/j.aorn.2017.02.013.
4. Cole S, Records A, Orr M, Linden S, Lee V. Catheter-associated urinary tract infection by pseudomonas aeruginosa is mediated by exopolysaccharide-independent biofilms. J Infect Immun. 2014;82:2048-58. DOI:  10.1128/IAI.01652-14
5. Cottenden A, Bliss D, Fader M, Getliffe K, Herrera H, Paterson J, et al. Management with continence products: In P. Abrams, L.  Cardozo, S. Khoury, A. Wein. (Eds.).  Incontinence: Proceedings from the 5th International Consultation on Incontinence (pp.149-254). Plymouth UK: Health Publications.
6. Davis NF, Bhatt NR, MacCraith E, Flood HD, Mooney R, Leonard G, Walsh MT. Long-term outcomes of urethral catheterisation injuries: a prospective multi-institutional study. World J Urol. 2019 Apr 24. doi: 10.1007/s00345-019-02775-x. [Epub ahead of print]
7. Dellimore KH, Helyer AR, Franklin SE. A scoping review of important urinary catheter induced complications. J Mater Sci Mater Med. 2013 Aug;24(8):1825-35. doi: 10.1007/s10856-013-4953-y.
8. Fuchs MA, Sexton DJ, Thornlow DK, Champagne MT. Evaluation of an evidence-based, nurse-driven checklist to prevent hospital-acquired catheter-associated urinary tract infections in intensive care units. J Nurs Care Qual 2011;26(2):101- 9. doi.org/10.1097/NCQ.0b013e3181fb7847.
9. Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA, HICPAC. Guideline for prevention of catheter associated urinary tract infections 2009. Infect Control Hosp Epidemiol. 2010;31:319-26. doi: 10.1086/651091.
10. Hollingsworth JM, Rogers MA, Krein SL, Hickner A, Kuhn L, Cheng A, et al. Determining the noninfectious complications of indwelling urethral catheters: a systematic review and meta-analysis. Ann Intern Med. 2013;159:401-10. DOI: 10.7326/0003-4819-159-6-201309170-00006.
11. Hooton TM, Bradley SF, Cardenas DD et al: Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. Clin Infect Dis 2010; 50: 625.
12. Kalisvaart JF, Katsumi HK, Ronningen LD, Hovey RM. Bladder cancer in spinal cord injury patients. Spinal Cord. 2010;48:257-61. DOI: 10.1038/sc.2009.118.
13. Kidd EA, Stewart F, Kassis NC, Hom E, Omar MI. Urethral (indwelling or intermittent) or suprapubic routes for short-term catheterisation in hospitalised adults. Cochrane Database Syst Rev. 2015;12:CD004203. DOI: 10.1002/14651858.CD004203.pub3.
14. Leuck AM, Wright D, Ellingson L, Kraemer L, Kuskowski MA, Johnson, JR. Complications of Foley catheters – Is infection the greatest risk? J Urol. 2012;187:1662-6. DOI: 10.1016/j.juro.2011.12.113. 
15. Magill SS, Edwards JR, Bamberg W, Beldavs ZG, Dumyati G, Kainer MA, et al. Emerging Infections Program Healthcare-Associated Infections and Antimicrobial Use Prevalence Survey Team. Multistate point-prevalence survey of health care-associated infections. N Engl J Med. 2014 Mar 27;370(13):1198-208. doi: 10.1056/NEJMoa1306801
16. Maki DG, Knaskinki, V, Tambyah PA. Risk factors for catheter-associated urinary tract infections: A prospective study showing the minimal effects of catheter care violations on the rise of CAUTI. Infect Control Hosp Epidemiol. 2000;21(2): 165.
17. Meddings J, Rogers MA, Macy M, Saint S. Systematic review and meta-analysis: reminder systems to reduce catheter-associated urinary tract infections and urinary catheter use in hospitalized patients. Clin Infect Dis. 2010;51:550-60. DOI: 10.1086/655133.
18. Menegueti MG, Ciol MA, Bellissimo-Rodrigues F, Auxiliadora-Martins M, Gaspar GG, Canini SRMDS, Basile-Filho A, Laus AM.  Long-term prevention of catheter-associated urinary tract infections among critically ill patients through the implementation of an educational program and a daily checklist for maintenance of indwelling urinary catheters: A quasi-experimental study. Medicine (Baltimore). 2019 Feb;98(8):e14417. doi: 10.1097/MD.0000000000014417.
19. Newman DK. Devices, products, catheters, and catheter-associated urinary tract infections. In D.K. Newman, J.F Wyman, V. W. Welch (Eds). Core Curriculum for Urologic Nursing (1st ed., pp1XXX). 2016, Pitman, NJ: Society of Urologic Nurses and Associates, Inc
20. Newman DK, Strauss R, Abraham L, Major-Joynes B. Unseen perils of urinary catheters. AHRQ WebM&M [serial online]. June 2015. Available at: http://webmm.ahrq.gov/case.aspx?caseID=352
21. Newman, DK & Strauss, R (2013). Preventing catheter-associated urinary tract infections.  UroToday Int J.  Oct, 6(5), art 64.
22. Nicolle LE. Catheter associated urinary tract infections. Antimicrob Resist Infect Control 2014;3:23, doi.org/10.1186/2047-2994-3-23.
23. Nickel JC, Costerton JW. Bacterial biofilms and catheters: A key to understanding bacterial strategies in catheter-associated urinary tract infection. Can J Infect Dis. 1992 Sep;3(5):261-7
24. Norsworthy AN, Pearson MM. From catheter to kidney stone: The uropathogenic lifestyle of proteus mirabilis. Trends Microbiol. 2017 Apr;25(4):304-315. doi: 10.1016/j.tim.2016.11.015.
25. Parry MF, Grant B, Sestovic M. Successful reduction in catheter-associated urinary tract infections: focus on nurse-directed catheter removal. Am J Infect  Control.  2013 Dec;41(12):1178-81. doi: 10.1016/j.ajic.2013.03.296.
26. Rebmann T, Greene LR. Preventing catheter-associated urinary tract infections: an executive summary of the Association for Professionals in Infection Control and Epidemiology, Inc., Elimination Guide. Am J Infect Control 2010;38(8):644-6. doi.org/10.1016/j.ajic.2010.08.003.
27. Russell JA, Leming-Lee T, Watters R.  Implementation of a nurse-driven CAUTI prevention algorithm.  Nurs Clin North Am. 2019 Mar;54(1):81-96. doi: 10.1016/j.cnur.2018.11.001.
28. Stickler DJ. Clinical complications of urinary catheters caused by crystalline biofilms: something needs to be done. J Intern Med. 2014;276:120-9. DOI: 10.1111/joim.12220
29. Stickler DJ. Bacterial biofilms in patients with indwelling urinary catheters. Nat Clin Pract Urol 2008, 5(11):598–608.
30. Thomas AZ, Giri SK, Meagher D, Creagh T. Avoidable iatrogenic complications of urethral catheterization and inadequate intern training in a tertiary-care teaching hospital. BJU Int. 2009;104(8):1109-12. doi: 10.1111/j.1464-410X.2009
31. Wilde MH, McDonald MV, Brasch J, McMahon JM, Fairbanks E, Shah S, et al. Long-term urinary catheter users self-care practices and problems. J Clin Nurs. 2013;22:356-67. doi: 10.1111/jocn.12042