Diagnosis, Prevention, and Treatment of Catheter - Keck School of ...

i. Data are insufficient to make a recommendation as towhether condom catheterization is preferable to short-term orlong-term indwelling urethral catheterization for reduction ofCA-UTI.ii. Data are insufficient to make a recommendation as towhether condom catheterization is preferable to short-term orlong-term indwelling urethral catheterization for reduction ofCA-bacteriuria in those who are cognitively impaired.17. Intermittent catheterization should be considered as analternative to short-term (C-I) or long-term (A-III) indwellingurethral catheterization to reduce CA-bacteriuria and an alternativeto short-term (C-III) or long-term (A-III) indwellingurethral catheterization to reduce CA-UTI.18. Suprapubic catheterization may be considered as an alternativeto short-term indwelling urethral catheterization toreduce CA-bacteriuria (B-I) and CA-UTI (C-III).i. Data are insufficient to make a recommendation as towhether suprapubic catheterization is preferable to long-termindwelling urethral catheterization for reduction of CA-bacteriuriaor CA-UTI.ii. Data are insufficient to make a recommendation as towhether intermittent catheterization is preferable to suprapubiccatheterization for reduction of CA-bacteriuria or CA-UTI.Intermittent Catheterization TechniqueRecommendations19. Clean (nonsterile) rather than sterile technique may beconsidered in outpatient (A-III) and institutional (B-I) settingswith no difference in risk of CA-bacteriuria or CA-UTI.20. Multiple-use catheters may be considered instead of sterilesingle-use catheters in outpatient (B-III) and institutional(C-I) settings with no difference in risk of CA-bacteriuria orCA-UTI.21. Data are insufficient to make a recommendation as towhether one method of cleaning multiple-use catheters is superiorto another.22. Hydrophilic catheters are not recommended for routineuse to reduce the risk of CA-bacteriuria (B-II) or CA-UTI (B-II).23. Data are insufficient to make recommendations onwhether use of portable bladder scanners or “no-touch” techniquereduces the risk of CA-UTI, compared with standardcare.Evidence SummaryAlternatives to indwelling urethral catheterization include intermittentcatheterization, suprapubic catheterization, and theuse of external collection devices, including condom catheters,diapers or pads.Indications and limitations of intermittent catheterization.Guttman and Frankel [155] in 1966 described intermittentcatheterization using sterile technique in patients with neurogenicbladders. Lapides et al [156] later demonstrated in observationalstudies that the clean (nonsterile) technique wassafe and associated with a low incidence of complications. Intermittentcatheterization is widely viewed to be associated withfewer complications, compared with indwelling urethral catheterization,including fewer instances of CA-bacteriuria, pyelonephritis,epididymitis, periurethral abscess, urethral stricture,vesicoureteral reflux, hydronephrosis, bladder and renal calculi,bladder cancer, and autonomic dysreflexia [22, 24, 157, 158].In a 38-month prospective observational study involving 128patients with acute spinal cord injuries, the incidence rates per100 person-days for CA-bacteriuria and CA-UTI, respectively,were 5 and 2.72 cases for men with indwelling urethral catheters(128 patients), 2.95 and 0.41 cases for men with clean intermittentcatheterization (124 patients), 2.41 and 0.36 cases formen with condom catheters (41 patients), and 0.96 and 0.34cases for women with suprapubic catheterization (10 patients),respectively [25]. Although there are no randomized, controlledtrials that have compared long-term catheterization methods(intermittent urethral catheterization, indwelling urethral orsuprapubic catheterization, and external catheter for men) inmanaging voiding problems in patients with [159] or withoutneurogenic bladders, clean intermittent catheterization has becomethe standard of care for appropriate women and menwith spinal cord injuries [16]. In addition, clean intermittentcatheterization is a more commonly used alternative in menwith bladder atonia and elderly patients who need assistancewith voiding [21, 77, 160].In contrast to patients with long-term catheterization, patientswith short-term catheterization have been the subject ofrandomized trials of catheterization techniques. A recent Cochranereview of randomized or quasi-randomized trials thatcompared catheterization methods in patients who underwentshort-term bladder drainage (14 days duration) found 2 trials(both involving patients who underwent surgical procedures)that compared indwelling urethral catheterization with intermittentcatheterization [161]. The meta-analysis showed thatsignificantly more cases of CA-bacteriuria occurred in the indwellingurethral catheterization group (RR, 2.90; 95% CI,1.44–5.84).Intermittent catheterization is not commonly used for shorttermcatheterization, however, because of the educational, motivational,and staff-time requirements necessary for its implementationand because of discomfort in sensate patients. Otherlimitations to intermittent catheterization include the inabilityor unwillingness of patients to perform frequent catheterizationbecause of comorbid conditions or discomfort, or abnormalurethral anatomy, such as stricture, false passages, or bladderneck obstruction. Upper extremity impairment because of cervicalspinal cord injury or other abnormality, obesity, and spas-Downloaded from http://cid.oxfordjournals.org/ by guest on November 29, 2011642 • CID 2010:50 (1 March) • Hooton et al