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Campeau et al

Table 1. Common uses for chronic urinary catheters Table 2. Advantages of IC over indwelling urinary catheters
Bladder outflow obstruction Reduced risk of common indwelling catheter-related
Neurogenic lower urinary tract dysfunction complications (such as dislodged catheter, urethral erosion)
Management of urinary incontinence Reduced risk of UTIs
Patient preference Less of a barrier to intimacy and sexual activity
Healing of decubitus ulcer Potential for reduced lower urinary tract symptoms between
catheterizations
Disease management (e.g., urinary diversion, monitoring diuresis)
Adapted from Newman & Willson, 2011. 41 IC: intermittent catheterization; UTI: urinary tract
Adapted from Gammack, 2002. 70
infection.
gested that SPC is associated with a reduced risk of bacte- sis, prevention, and treatment of catheter-associated UTI
riuria and better patient satisfaction when compared with (CA-UTI) in 2010. This widely accepted guideline defines
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urethral catheters. Regular followup and surveillance con- CA-UTI as the presence of symptoms or signs compatible
5,6
tinue to be the backbone of this strategy in order to minimize with UTI with no other identified source of infection, along
associated morbidity and improve prognosis. with ≥10 colony-forming units (cfu)/ml of ≥1 bacterial spe-
3
cies in a single catheter urine specimen or in a midstream
1.2. IC urine specimen from a patient whose urethral, suprapubic, or
condom catheter has been removed within the previous 48
IC is accepted worldwide as a standard of care for patients hours. Signs and symptoms compatible with CA-UTI include
with incomplete bladder emptying. When IC was introduced the new onset or worsening of fever, rigors, altered mental
for SCI patients in the 1940s, nurses initially performed it status, malaise, or lethargy with no other identified cause;
using an aseptic technique, requiring sterile gloves, single- flank pain; costovertebral angle tenderness; acute hematuria;
use catheters, and disinfectant cleaning solution. In the pelvic discomfort; and in those whose catheters have been
1970s, Lapides suggested that sterility was not important for removed, dysuria, urgent or frequent urination, or suprapubic
preventing urinary tract infections (UTIs) and impractical for pain or tenderness. In patients with SCI, increased spasticity,
patients; he proposed clean IC (IC that includes only hand autonomic dysreflexia, or sense of unease are also compat-
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washing and regular genital hygiene). The bladder is drained ible with CA-UTI. The IDSA guideline does not recommend
regularly several times during the day, simulating the physi- interpretation of pyuria for defining CA-UTI, differentiating
ological bladder filling/emptying cycle. This can also prevent catheter-associated asymptomatic bacteria (CA-ASB) from
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adverse health outcomes, such as recurrent UTIs, urinary CA-UTI or serving as a threshold for antimicrobial therapy.
incontinence (UI), skin complications, and chronic kidney CA-ASB is defined by the ISDA as the presence of ≥10 cfu/
5
injury. Compared to indwelling catheters, IC can reduce the ml of ≥1 bacterial species in a single catheter urine speci-
risk of mechanical urethral erosion, bladder cancer/stones, men in a patient without symptoms compatible with UTI.
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and urosepsis (Table 2). The incidence of CA-ASB in those with indwelling catheters
Despite being preferable to an indwelling urinary cath- is 3–8% per day, with CA-ASB being nearly universal by 30
eter, IC can have challenges, such as pain, UTI, and urethral days. As such, the ISDA recommends against the routine
11
trauma. Recent studies reported urethral stricture rates in screening of CA-ASB, with the exception of selected clinical
IC users of 4–13%, even with the use of hydrophilic-coated situations, such as pregnant women.
10
catheters. Despite the medical advantages of IC, only 37% If there is clinical suspicion of CA-UTI, specimen collec-
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of patients remain on this form of bladder management tion should occur prior to antimicrobial therapy and proceed
over time. 9 according to method of bladder management. In general,
Factors such as catheter coating and design, reuse, and a catheterized urine specimen is preferable to voided sam-
who performs the catheterization make selection of the ideal ple, as it avoids contamination with periurethral microbes.
catheter difficult. The available literature does not provide Patients with indwelling catheters should have their catheter
convincing evidence regarding the effectiveness of any par- exchanged with immediate collection of a specimen follow-
ticular catheter design, technique, or strategy. ing insertion of the new catheter. This approach has been
demonstrated to enhance clinical improvement, minimize
2. Catheter-related complications symptoms duration, and reduce the frequency of infection
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relapse. In the setting of chronic urinary catheterization,
the level of colonization is commonly >10 cfu/mL; 13,14 there-
5
2.1 Catheter-associated infection fore, culture alone is inadequate for diagnosis of infection. In
general, a clinically significant UTI with a chronic indwell-
The Infectious Disease Society of America (ISDA) released ing catheter requires consideration of clinical symptoms and
international clinical practice guidelines for the diagno- severity of illness plus laboratory confirmation (urine culture

E282 CUAJ • July 2020 • Volume 14, Issue 7