AMDA: Publications - Caring for the Ages

Diagnosing & Managing Urinary Tract Infections: Myths, Mysteries, & Realities (continued)

Dispelling UTI Myths: True or False?

UTIs are associated with all of the following:
     Daily fluid intake
     Bathing or showering
     Toileting hygiene
     Perineum care
     Frequency of voiding
     Type of underwear.
False. UTIs have no association with any of the above.

Cranberry juice helps minimize the risk of UTIs.
True. Cranberry-derived substances--including glycoproteins, fructose, and condensed tannins--prevent bacterial adherence, especially E coli, to urinary epithelial cells. Pathogens are flushed from the urinary tract and infection risk is then minimized. A minimum of 300 mg to 400 mg twice daily in tablet form or 8 oz to 16 oz of a >30% cranberry juice blend is needed for this therapeutic effect.

Asymptomatic bacteriuria must be treated if a culture was taken.
False. The need to treat asymptomatic bacteriuria in catheterized or non-catheterized elderly patients is not supported by current data. Antibiotic use may also promote growth of resistant uropathogens. A note however, should be written as to why treatment is not indicated.

Marked or frequent constipation increases the risk for UTIs.
True. In elders, marked or severe constipation has been noted to contribute to bladder instability and may encourage UTI by creating a degree of bladder outlet obstruction.

Vaginal estrogen deficiency is a factor promoting UTIs in elderly post-menopausal women.
True. It appears as if the intravaginal use of estrogen cream may be effective in reducing UTIs in elderly postmenopausal women. The importance of vaginal estrogen is becoming increasingly recognized, leading to therapeutic strategies other than using antibiotics. However, oral hormone therapy does not appear to reduce the frequency of UTI.

Meticulous catheter care will decrease the incidence of bacteriuria.
False. Despite meticulous catheter care, after 30 days of catheterization, there is a 95%-100% incidence of bacteriuria. However, good catheter care will decrease the incidence of infection. Obstruction of the catheter is problematic, but flushing is not routinely indicated unless the catheter is clogged by sediment.

It is necessary to repeat a urine culture after a course of antibiotics to show that the patient has responded to treatment.
False. It is not necessary to reculture after a course of antibiotics if the patient appears to be responding to the therapy. Polymicrobial bacteriuria often persists after a course of antibiotics and does not mean the treatment has failed.

The use of condom catheters reduces the risk of obtaining a UTI compared to an indwelling catheter.
Maybe. The frequency of UTIs with condom catheter use varies widely in published studies. One study found no association between the use of a condom catheter and infection unless the catheter was frequently manipulated by the patient (JAMA 1979;242:340-341). Other studies didn't show the same connection between manipulation and infection (South Med J 1983;76:579-582). One study showed a high occurrence of bacteriuria (89%) and UTI (40%) in men who were using condom catheters (J Am Geriatr Soc 1987;35:1063-1070). One study showed a greater risk of UTI with the use of a condom catheter than with indwelling catheters (Infec Control Hosp Epidemiology 1996;17:215-221).

Routine irrigation of an indwelling catheter reduces the risk of infection.
False. The effectiveness of this practice has not been proven in literature. One study showed that the instillation of hydrogen peroxide or antibiotic solutions may increase the risk due to the disruption of the mucosal barrier, selection of resistant organisms, and the possibility of bacteria introduction by breaking the closed drainage system (N Engl J Med 1978;299:570-573).

Perspectives on Catheters & Hospitals

A nurse from XYZ facility calls a hospital to conduct a readmission screen for her patient upon discharge from the hospital. She learns that the patient now has an indwelling catheter. The hospital floor nurse cannot give a justification for the catheterization, and says, "she came to the unit that way."

Sherrie Dornberger, RNC, President of the National Association of Directors of Nursing Administration in Long-Term Care, commented that "hospital nurses aren't trained to question the use of indwelling catheters the way LTC nurses are. More than 85% of our residents are readmitted from the hospital with an indwelling catheter."

AMDA President-Elect James E. Lett, MD, CMD, observed that while there may be consequences (regulatory and patient outcome) in LTC for leaving in a Foley catheter, it's expedient for hospital nurses. "They are facing the same staffing shortages as we are in LTC. Removing a Foley means more cleaning and changing, or more work to either toilet the patient or provide a bed pan."

William Jaquis, MD, Chief of the Department of Emergency Medicine at Sinai Hospital in Baltimore, MD, agreed that there is a problem in the system. "When we put an indwelling catheter in a patient, we do so with a view toward the clinically presenting condition--for example, the need for intake and output measurements in a patient with an acute exacerbation of chronic heart failure, or a culture in a case of suspected UTI. We will insert a Foley, not a straight catheter, because we don't know yet if the insertion will have to be repeated, and we want minimal invasion.

"However, if the patient is admitted to the floor, there generally isn't any follow up on the catheter. If it isn't needed, we don't have a lot of systems in place to communicate that.

"There is plenty of room for improvement," Dr. Jaquis continued. "What we need to do is set up a process to create some criteria for why we would put in a Foley in the first place, and make an effort in the front end to communicate that."

This article originally appeared in Caring for the Ages, October 2002; Vol. 3, No. 10, p. 18-21. Caring for the Ages is an official publication of the American Medical Directors Association, published by Elsevier. This article may not be reproduced in any form, print or electronic, without permission.

The opinions expressed by the authors are their own
and not necessarily those of AMDA or of Elsevier.