Comparison of effectiveness of sterile vs. clean technique for indwelling catheter care in preventing urinary tract infection

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1 Comparison of effectiveness of sterile vs. clean technique for indwelling catheter care in preventing urinary tract infection Monika Dutta, Prem Verma, A.K. Mandal Abstract : Indwelling urinary catheterization is associated with a number of complications if emphasis is not given to preventive aspect as evidenced by the research studies. For instance urinary tract infection results in increased morbidity, extended hospital stay and enhanced hospital expenditure. Keeping in view all this a comparative study on sterile vs. clean technique for indwelling catheter care in preventing urinary tract infection was planned and carried out in selected wards of the Nehru Hospital, PGIMER, Chandigarh. Objective of the study was to compare the effectiveness of sterile vs. clean technique for catheter care in preventing urinary tract infection. 53 subjects were randomly distributed in two intervention groups i.e. group-i (sterile technique) and group-ii (clean technique). Catheter care in both the groups was provided consecutively for 5 days twice daily for the subjects who had shown their 1st urine culture being sterile within 24 hours of catheterization. In preventing indwelling catheter associated bacteriuria no significant difference in both the groups was observed (χ ,df=1, p>.05). Effectiveness in terms of preventing urinary tract infection could not be studied as none of the subject had met the CDC (Centre for disease control and prevention) criteria indicating urinary tract infection in both the groups. It was concluded that both the techniques are equally effective if carried out correctly. Based on the findings of this study a more extensive trial over a longer period of time can be carried out for establishing whether or not the organisms isolated ultimately associated with urinary tract infection. Key words : Catheter care, Sterile technique, Clean technique, Bacteriuria, Urinary tract infection. Correspondence at : Monika Dutta Public Health Nurse National Institute of Nursing Education, PGIMER, Chandigarh Introduction Despite the impassioned controversy over the merits of the indwelling urethral catheter, there are medically acceptable reasons for its use but nosocomial catheter associated urinary tract infection continues to be a common and serious problem in health care setting along with this nosocomial urinary tract infection results in increased morbidity, extended hospital stay and enhanced hospital expenditure. Above all there exists the personal 29

2 discomfort experienced by patients as well as the personal cost to them 1,2. Catheter associated urinary tract infection is a common infection often resulting in severe complications 3. It is interesting in this context to note that there is relatively little nursing research in this field 4. According to CDC a symptomatic urinary tract infection is diagnosed when patient has at least one of the following signs or symptoms with no other recognised cause: fever > 38 0 C, urgency, frequency, dysuria, or suprapubic tenderness and patient has a positive urine culture that is > 10 microorganisms per cc 5. Bacteriuria is the another term which is frequently used in association to urinary tract infection and defined as the presence of bacteria in the urine, which is normally free of bacteria, and implies that these bacteria are from the urinary tract and are not contaminants from skin, vagina or prepuce 6. Risk of bacteriuria associated with a urinary catheter depends on the method and duration of catheterization in certain populations like pregnant females, elderly or debilitated patients and patients with urologic abnormalities the risk of developing bacteriuria with a single short catheterization is more than 1 percent to 5 percent and in patients with indwelling urinary catheter the incidence of bacteriuria within 48 hours of catheterization without the benefit of closed collecting system is ninety percent and at 4 days ninety five percent have bacteriuria 7. Eighty percent of the nosocomial urinary tract infections are associated with the use of an indwelling urethral catheter. Incidence of infection in patients with indwelling catheter within 7 days was per cent whereas in long term catheterization > 28 days the prevalence approached 100 per cent 8,9. Nurses are largely responsible for the management of a patient s catheter and urine drainage system and therefore, have the responsibility in minimizing the risks of a patient acquiring infection 10. Management of patient s catheter is nurses responsibility. So they should come forward and use innovative ideas and procedures in to practice to find out the most effective technique for the prevention of urinary tract infection. It is always said that prevention is better than cure, hence catheter care is one of the preventive measures to minimize urinary tract infection. In Indian setup standard protocols for carrying out catheter care are not available. In Nehru hospital catheter care is considered as a sterile procedure. Use of antimicrobial solutions is done for cleaning the perineum, urethral meatus and catheter to reduce the likelihood of infection. Whereas in Western setup; clean technique of catheter care is recommended. Under this technique of catheter care cleaning of perineum, urethral meatus and catheter is done under clean conditions using soap and warm water 11. Keeping in view all this the present study was undertaken to compare the effectiveness of sterile vs. clean technique for catheter care in preventing urinary tract infection, as clean technique is cost effective and easy for patients to carry it out themselves. 30

3 Materials and Methods The present study was carried out in Nehru hospital of Post Graduate Institute of Medical Education and Research (PGIMER) Chandigarh. PGIMER is a central government owned autonomous institute. It was established in 1962 as a referral centre and tertiary level institute to provide diagnostic, therapeutic and rehabilitative services in various specialities and super specialities. The Nehru hospital, which is attached to PGIMER, Chandigarh is a tertiary care hospital with total bed strength of 1400 beds. Before starting the study a general survey was conducted in different wards of the Nehru hospital to know the number patients having indwelling urinary catheter and the areas of this hospital having maximum number of patients with urinary catheter. Findings of the survey revealed that at a given time approximately patients have indwelling urinary catheters in this hospital. Finally the units with maximum number of patients having indwelling urinary catheter were selected using purposive sampling method to conduct the study. Four emergency wards having patients with surgical, neurosurgical and urologic problems were taken. Under intensive care units Main ICU and Neuro-ICU were selected. Among general wards female surgical, female medical and gynae wards were taken. A set of tools for data collection comprised of identification data sheet, nursing assessment tool to detect urinary tract infection (questionnaire, observation check list, patient s record sheet and laboratory investigation proforma) and indwelling catheter care procedures for sterile and clean technique. Identification data sheet comprised of 8 items i.e. code no., C.R. No., age, sex, ward, bed no., date of admission and diagnosis. Nursing assessment tool to detect urinary tract infection comprised of four parts i.e. questionnaire, observation check list, patient record sheet and laboratory investigation proforma. Two procedures for catheter care were developed and modified for performing catheter care by using two different techniques i.e. sterile and clean. In both the procedures definition is followed by list of articles and procedural steps. Under sterile technique 9 articles (all sterile) and 15 steps were there and in clean technique numbers of articles were 8 (all clean) and procedural steps were 13. The content validation of all these tools and procedures was established by getting the valuable opinions from in nursing and surgery (urology) disciplines. As per the suggestions of experts modifications were made. A quasi-experimental design was adopted to carry out study in two intervention groups i.e. group-i (sterile catheter care technique) and group-ii (clean catheter care technique). The study was conducted in above selected wards of Nehru hospital, PGIMER, Chandigarh. Simple random sampling technique was used for assigning the subjects in intervention group-i and group-ii. Total 53 subjects were randomly distributed in group I (27 subjects) and group-ii (26 subjects). All the subjects were taken within 24 hours of catheterization and before starting the care urine for culture and sensitivity as well as for 31

4 microscopic examination was sent. Catheter care using both the techniques was provided consecutively for 5 days twice daily to the subjects whose 1 st urine culture was sterile. On 5 th day urine specimen for culture sensitivity as well as for microscopic examination was sent to know the effectiveness of catheter care. Simultaneously observations regarding urinary tract infection were daily recorded as per questionnaire, observation checklist and patient s record. Results The age of subjects enrolled in this study ranged from 16 to 85 years. The mean age for the subjects in intervention group-i is 46.74±10.4 whereas for subjects in intervention group-ii the mean age is 50.1 ±14 years. Nearly half of the subjects i.e. 11 (40.74%) in group-i and 13 (50%) in group- II were in the age group of 46 to 65 years. All the subjects included in the study were females. In group-i out of total 27 patients 5 (18.5%) were from intensive care units, 9 Table-1 : Characteristic of urinary catheter drainage system (33.3%) from emergency area and 13 (48.2%) from general surgical and medical wards. Out of 26 patients in group-ii 6 (23.1%) were from intensive care units, 8 (30.7%) from emergency area and 12 (46.2%) were from general surgical and medical wards. Both the groups were homogenous in respect to age, maintenance of closed drainage system, catheter fastening practices and soiled status of urinary catheter as per X 2 test (p>.05) (table-i). In intervention group-i closed drainage system was maintained in 22 (81.5%) subjects and in group -II and 20 (76.9%) subjects were with closed drainage system. Catheter fastening practices were poor in both the groups i.e. in group-i only 6 (22.2%) and in group-ii 9(34.6%) subjects had fastened catheter. In both the groups 7 subjects had soiled urinary catheter (contaminated with faeces, blood, discharged crust and talcum powder) i.e. 25.9% in group-i and 26.9% in group-ii. Variables Group-I (N=27) Group-II (N=26) Statistical test Results Closed drainage Maintained 22 (81.5%) 20 (76.9%) χ 2.165, d.f=1 system Not- maintained 05 (18.5%) 06 (23.1%) p-> 0.5 Soiled urinary Soiled 07 (25.9%) 07 (26.9%) χ 2.006, d.f=1 catheter Not- soiled 20(74.1%) 19 (73.1%) p-> 0.5 Catheter Fastened 06 (22.2%) 09(34.6%) χ 2.99, d.f=1 fastening Not-fastened 21(77.8%) 17(65.4%) p-> 0.5 practices Table-2 reveals that out of a total of 27 subjects in intervention group-i (sterile technique) only 4 (14.8%) subjects developed bacteriuria while the remaining 23 (85.2%) 32

5 were non-bacteriuric. Whereas in the intervention group-ii (clean technique) out of a total of 26 subjects 19 (73.1%) were nonbacteriuric and 7 (26.9%) showed the bacterial growth in urine culture. Statistically no significant difference in the effectiveness of two techniques of catheter care (sterile and clean) for preventing bacteriuria was observed as evidenced by χ 2 =1.17 d.f. 1 p>0.05. Table-2 : Comparing the effectiveness of sterile and clean technique of catheter care in preventing bacteriuria Type of technique Status of bacteriuria χ 2 Bacteriuric Non-bacteriuric Sterile technique (n=27) 4 (14.8%) 23 (85.2%) χ 2 =1.17 Clean technique (n=26) 7 (26.9%) 19 (73.1%) df.= 1 p>0.05. Table-3 depicts that more than half of the subjects i.e. 4 (57.1%) out of a total of 7 bacteriuria subjects in intervention group- II (clean technique) were in Emergency Ward- 1 which is a surgical unit followed by 2 in Table-3 : Ward wise presence of bacteriuria in both the groups Female Medical ward and one from NSICU. Whereas in group - I in four wards i.e. NSICU, Emergency Ward -3, Female Medical ward and Emergency Ward -4 one case from each area was bacteriuria case. Name of the ward No. of bacteriuric No. of bacteriuric subjects in group I (n=27) subjects in group II (n=26) NSICU 1(25%) 1(14.3%) Emg. Wd-3 1(25%) - FMW 1(25%) 2(28.6%) Emg.Wd-4 1(25%) - Emg.Wd-1-4(57.1%) Table-4 shows that out of 4 bacteriuric subjects 3 (75%) subjects have shown the growth of yeast in group I (sterile technique) whereas 3 (42.8%) subjects in group II (clean technique) showed the growth of E.Coli. Table-5 concludes that in both the groups a majority of subjects received antibiotics i.e. group I (sterile technique) 24(88.9%) subjects out of total 27 subjects and in group II( clean technique), 17 (65.4%) subjects out of total 26 subjects. The number of subjects who received antibiotic therapy were significantly higher in group I as compared to group II. as per χ 2 test (p<.05) 33

6 Table-4 : Proportion of pathogens isolated Name of the pathogen Intervention group-i Intervention group-ii (Sterile) n=4 (Clean) n=7 Yeast 3(75%) 1(14.29%) Citrobacter freundii 1(25%) - E.coli - 3(42.85%) Lactose and non-lactose ferments - 1(14.29%) Citrobacter diversus - 1(14.29%) Pseudomonas aeruginosa - 1(14.29%) Table-5 : Antibiotic therapy used in both the groups Intervention group Subjects received antibiotics Subjects not received antibiotics Group-I (N=27) 24 (88.9%) 03 (11.1%) Group-II (N=26) 17 (65.4%) 09 (34.6%) χ 2 = 4.2 df =1, p<.05 Table-6 depicts that E.coli and Citrobacter freundii showed resistance to the agents under all the four categories i.e. cephalosporines, aminoglycosides, quinolones and others. Pseudomonas strain was resistant to gentamycin, amikacin and Table-6 : Antibiotic resistance profile of the pathogens isolated ciprofloxacin under aminoglycosides and quinolones respectively. But Citrobacter diversus showed resistance to nalidixic acid, norfloxacin and ciprofloxacin falling under the category of quinolones Name of the isolated Cephalosporines Aminoglycosides Quinolones Others pathogens E.coli - Cefotaxime - Gentamycin - Nalidixic acid - Nitrofurantoin - Ceftazidime - Amikacin - Norfloxacin - Cefoperazone - Ciprofloxacin Pseudomonas - Gentamycin - Ciprofloxacin - Amikacin Citrobacter diversus - Nalidixic acid - Norfloxacin - Ciprofloxacin Citrobacter fruendii - Cefotaxime - Gentamycin - Nalidixic acid - Nitrofurantoin - Ceftazidime - Amikacin - Norfloxacin - Cefoperazone - Ciprofloxacin 34

7 Discussion A well-documented problem associated with the use of urinary catheter is development of urinary tract infection. The association between an indwelling urethral catheter and urinary tract infection is recognised by many nurses. The nurse is a member of the hospital team that is responsible for the care of urinary tract drainage of the patients with indwelling urethral catheters and thus she needs to be aware of the principles and problems of caring for such drainage systems and the effect that infection may have 2. There is still confusion about as what nursing practice for catheter care and for emptying drainage bag should be followed. The documented procedures are not comprehensive, lacking consistent recommendations and are not supported by research evidence 10,12. The present study was undertaken to compare the effectiveness of two catheter care techniques (sterile vs. clean) in preventing urinary tract infection as well as bacteriuria. Based on the objectives of the study subjects were selected and interventions carried out to compare the effectiveness of both the techniques in terms of occurrence of bacteriuria and urinary tract infection. The results of the study are discussed below. The present study findings suggest that both techniques of indwelling catheter care i.e. sterile and clean are equally effective in preventing bacteriuria as well as urinary tract infection. In a study on effectiveness of meatus care in prevention of bacteriuria it was reported that incidence of bacteriuria on 10 th day of catheterization was low in patients who received meatus care i.e. 16.6% as compared to those who had no metal care, it was 38.8% 13. Another study on comparative trial of oral antimicrobial regimen (Trimethoprim, Methenamine hippurate) and topical povidone-iodine for prevention of urinary tract infection documented that the group, which received Trimethoprim, most of the breakthrough infections that occurred were caused by Trimethoprim resistant organisms (usually E.coli). The incidence of infection was 71.4% while in other two groups the incidence of Trimethoprim resistant organisms was as low as 2.7% 14. In other studies where no regular intervention to prevent urinary tract infection was carried out the incidence of bacteriuria was quite high i.e. 34.4% reported in study done by Roe (1985) 48 hours of catheterization 15. Sedor and Mulholland (1999) 9 mentioned in their study that with single catheterization the infection rate is low approximately 1% but in patients with an indwelling catheter in place for less than seven days the rate of infection is 10% - 40% whereas >28 days prevalence approaches to 100%. In current study the incidence of bacteriuria in group I and in group II was low as compared to the incidence reported in the literature. This indicates that both the techniques of catheter care (sterile and clean) are definitely helpful in reducing the incidence of bacteriuria if carried out correctly. As statistically there is no significant difference in both techniques of indwelling catheter care (sterile vs. clean) in terms of preventing bacteriuria and urinary tract infection so the 35

8 clean technique can taught to the patients going home with urinary catheters. The clean technique of catheter care is cost effective as well as easy to carry out especially in home care settings. In the present study the percentage of subjects developed bacteriuria is quite low as per data documented in literature and here none of the subjects developed urinary tract infection. So it can be said that catheter care given to subjects under study could have reduced the number of colonized bacteria at periurethral site. Effectiveness of both the techniques cannot be compared in preventing urinary tract infection as none of the subject in both the groups fulfilled the CDC criteria for diagnosing urinary tract infection i.e. positive urine culture >10 5 microorganisms per cc and fever>38 0 C 5. From the study findings it was comprehended that most of the bacteriuric subjects in group-i were from emergency surgical unit, while in group II out of a total of 4 bacteriuric, 1 case each in NSICU, Emg. Wd- 3, FMW and Emg. Wd-4. Meers (1982) 16 has documented that among the hospital acquired infections, in urinary tract infection category, the maximum patients found with urinary tract infection were in medicine specialty (3.1%) and followed by surgery i.e. (2.6%). Saint (2000) 17 provided information about the general characteristics of 10 prospective studies which were used to estimate the cumulative incidence of bacteriuria in patients with indwelling catheters. Most of the patients evaluated in these studies have catheter in place for 2-10 days and have not received any intervention to prevent bacteriuria. Maximum incidence reported i.e 50% was in patients admitted in urology or surgery units followed by 38% in neurology, neurosurgery, urology, cardiac surgery and orthopaedic patients. Hence we can say that findings of the current study are somewhat consistent with the findings of the above studies but still depicts that maximum number of subjects were in general surgery speciality followed by neurosurgery. In the intervention group I the yeast growth was predominant, while in group II E.coli remained the main culprit in this study. Kadri, Gash & Rukhsana (2002) 18 in their recent study in a Kashmir hospital (India) analysed the microbiological pattern of urinary tract infection. Out of 324 urine samples which were positive for pathological bacteria revealed that 90.12% of the isolates were E.coli, followed by Klebsiella (7.72%) and Staphylococcus (1.24%). Clifford (1982) 2 conducted a study in six centres of UK hospitals, in this study both for inpatients and outpatients the major uropathogen was E.coli i.e. 47% and 64% respectively. Hence it can be said that the findings of above studies are consistent with the findings in intervention group II i.e. out of total 7 bacteriurics, 3 (42.85%) showed growth of E.coli. Majority of subjects in both the groups received antibiotics. In group I out of 27 subjects 24 (88.9%) were on antibiotics and this was significantly higher than in group II i.e. out of 26 subjects 17 (65.4%) received the same. Although there is no significant difference between two techniques of 36

9 indwelling catheter i.e. sterile and clean in terms of developing bacteriuria but still the number of bacteriurics are more in group-ii (clean technique). By looking at percentage of subjects who received antibiotics is more in group-i as compared to group-ii and that can be sited as the reason for more bacteriurics in group-ii (clean technique) in comparison to group-i (sterile technique). In this study antibiotic resistant strains of E,coli, Citrobacter freundii, Citrobacter aeuroginosa and pseudomonas were seen. Above mentioned study in Kashmir hospital (India) it was observed that 43.57% of the E.coli significantly exhibited resistance to commonly used antibiotics. In the present study also E.coli showed resistance to most commonly used antibiotics in hospital set up. In an epidemiological study on hospital acquired urinary tract infection out of 498 inpatients in medical and surgical units E.coli, Pseudomonas, Klebsiella and Candida accounted for over 90% of the isolates of hospital acquired urinary tract infection and 73.5% of these were resistant to all antibiotics (Kamat, Fereirra and Amonkare etal., 2009) 19. As nurses are largely responsible for management of a patient s catheter and urine drainage system, therefore have the responsibility in minimizing the risks of a patient acquiring infection 12. It seems paradoxical that, in these days of highly sophisticated medical care, we are unable to continuously drain the bladder without producing infection. As mentioned above different catheter care modalities like metal care or topical povidone-iodine application proved effective in reducing the incidence of bacteriuria. Same is true for this study as statistically both the techniques (sterile and clean) were found to be equally effective in preventing bacteriuria. Sterile technique requires professional competence as well as sterile articles, which in other terms make this procedure costlier as compared to clean technique of catheter care. So it can be suggested that at least the patients who are going home with indwelling urinary catheter can be guided to perform catheter care by using clean technique which is cost effective and easier for them to carry out as articles required here are clean and easily available at home care settings.. References 1. Given CD, Wenzel RP. Catheter- Associated Urinary Tract Infections in Surgical Patients: A Controlled Study on the Excess Morbidity. Journal of Urology 1980; 124: Clifford CM. Urinary tract infection A brief selective review. International Journal of Nursing Studies 1982; 19(4): Esquivel JG, Arreguin AG, Sandoval LB. etal. Urinary bacteria sensitivity and resistance in patients with chronic urinary catheters. The Internet Journal of Infectious Diseases 2009;7(1) Retrieved on journal/...internet _journal_of_ infectious _disesaes /...7/.../urinary_ bacteria_ sensitivity...urinary.../7.html 4. Maki DG, Hennekens CH, Bennett JV. Prevention of Catheter-Associated Urinary Tract Infection. Journal of American Medical Association 1972; 22(11): CDC/NHSN Centres for Disease Control and Prevention/National health care safety network. Available at 37

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