A Critical Evaluation of Infection Control Practice

"A Critical Evaluation of Infection Control Practice"

 

INTRODUCTION

 

ICUs are the place in the hospital where the most severely ill patients are admitted, with the use of multiple invasive devices and frequent prescription of broad-spectrum antimicrobial agents. For these reasons, optimization of nursing-care procedures and adherence to antibiotic prescription rules are strongly recommended for the control of nosocomial infections. Most patients in these units require an indwelling urinary catheter to monitor diuresis. A closed drainage system is strongly recommended to prevent catheter-associated urinary tract infections. However, to our knowledge, no comparative trial comparing open and closed drainage systems has been conducted in ICU patients.

This paper aims to examine the current practices of ICUs in hospitals in the procedure of catheterization and the role of the nurses. It also aims to provide recommendations after researching into the current conditions and infection control procedures.

 

BODY

 

            Nosocomial infections (NIs) are hospital-born infections and now concern 5 to 15% of hospitalized patients and can lead to complications in 25 to 33% of those patients admitted to intensive care units (ICUs) (2004). Infection after urinary catheterization is one example.

Each year, urinary catheters are inserted in more than 5 million patients in acute-care hospitals and extended-care facilities. Urinary tract infections are the second most common nosocomial infections in ICUs in Europe and the first in the United States (2001). Catheter-associated urinary tract infection (CAUTI) is the most common nosocomial infection in hospitals and nursing homes, comprising [is greater than] 40% of all institutionally acquired infections. Nosocomial bacteriuria or candiduria develops in up to 25% of patients requiring a urinary catheter for [is greater than or equal to] 7 days, with a daily risk of 5%. CAUTI is the second most common cause of nosocomial bloodstream infection, and studies by Platt et al. and Kunin et al. suggest that nosocomial CAUTIs are associated with substantially increased institutional death rates, unrelated to the occurrence of urosepsis ( 2001).

For centuries, the urethral catheter system consisted of a tube inserted through the urethra into the bladder and drained into an open container. The closed catheter system was developed in the 1950s and is still in use today (2000).

UTIs are the most common nosocomial infection, accounting for 40% of all hospital-reported infections and affecting approximately 600,000 patients annually. Catheter insertion is the primary risk factor for nosocomial UTIs. Women and elderly patients are at increased risk for catheter-associated UTIs, but several other risk factors exist. Pre-existing chronic illness, malnutrition, diabetes, renal insufficiency, and insertion of the catheter outside the operating room or late in hospitalization are each associated with increased risk of UTIs. (1,3) In addition to causing morbidity, UTIs also contribute directly to mortality in approximately 0.1% of patients annually in the United States. UTIs also add to the costs of care by prolonging hospitalization by 1 to 4 days and increasing the direct costs of treatment by an estimated $593 to $680 per infection (2005).

They may involve a urosepsis, which carries a mortality rate that may be as high as 25 to 60%. They often occur in patients with an indwelling urinary catheter. The lumen and external surfaces of the catheter are the routes for bacterial entry into the bladder. For preventing infection, the maintenance of a closed sterile drainage system is described as the most successful method. A closed drainage system was described for the first time in 1928, and its benefit was appreciated much later (2001).

Although most CAUTIs are asymptomatic, rarely extend hospitalization, and add only $500 to $1,000 to the direct costs of acute-care hospitalization, asymptomatic infections commonly precipitate unnecessary antimicrobial-drug therapy. CAUTIs comprise perhaps the largest institutional reservoir of nosocomial antibiotic-resistant pathogens, the most important of which are multidrug-resistant Enterobacteriacae other than Escherichia coli, such as Klebsiella, Enterobacter, Proteus, and Citrobacter; Pseudomonas aeruginosa; enterococci and staphylococci; and Candida spp (2001).

Excluding rare hematogenously derived pyelonephritis, caused almost exclusively by Staphylococcus aureus, most microorganisms causing endemic CAUTI derive from the patient's own colonic and perineal flora or from the hands of health-care personnel during catheter insertion or manipulation of the collection system. Organisms gain access in one of two ways (Figure 1). Extraluminal contamination may occur early, by direct inoculation when the catheter is inserted, or later, by organisms ascending from the perineum by capillary action in the thin mucous film contiguous to the external catheter surface. Intraluminal contamination occurs by reflux of microorganisms gaining access to the catheter lumen from failure of closed drainage or contamination of urine in the collection bag (2001)

Catheterization of the bladder involves introducing a rubber or plastic tube through the urethra and into the bladder. The catheter provides a continuous flow of urine in patients who are unable to control micturition or those with obstructions. It also provides a means of assessing urine output in hemodynamically unstable clients. Because bladder catheterization carries the risk of urinary tract infections, blockage, and trauma to the urethra, it is preferable to rely on other measures for either specimen collection or management of incontinence (2004).

            The use of urinary catheters should be avoided whenever possible. Clean intermittent catheterization, when practical, is preferable to long- term catheterization. Suprapubic catheters offer some advantages, and condom catheters may be appropriate for some men. While clean handling of catheters is important, routine perineal cleaning and catheter irrigation or changing are ineffective in eliminating bacteriuria. Bacteriuria is inevitable in patients requiring long-term catheterization, but only symptomatic infections should be treated. Infections are usually polymicrobial, and seriously ill patients require therapy with two antibiotics. Patients with spinal cord injuries and those using catheters for more than 10 years are at greater risk of bladder cancer and renal complications; periodic renal scans, urine cytology and cystoscopy may be indicated in these patients ( 2000).

Once the decision has been made to use an indwelling urinary catheter, efforts should be made to minimize problems.

 

Recommendations

 

            Build up of secretions or encrustation at the catheter insertion site is a source of irritation and potential infection. The nurses, in order to avoid such a situation, must provide perineal care and hygiene at least twice daily or as needed for a patient with a retention catheter. Soap and water are effective in reducing the number of organisms around the urethra. The nurse must not accidentally advance the catheter up into the bladder during cleansing or risk introducing bacteria.

            In addition to routine perineal care and hygiene, many institutions recommend that clients with catheters receive special care at least three times a day and after defecation or bowel incontinence to help minimize discomfort and infection.

            All patients with catheter should have a daily fluid intake of 2000 to 2500 ml if permitted. This can be met through oral intake or intravenous infusion. A high fluid intake produces a large volume of urine that flushes the bladder and keeps catheter tubing free of sediment.

            Maintaining a closed urinary drainage system is important in infection control. A break in the system can lead to introduction of microorganisms. Sites at risk are the site of catheter insertion, the drainage bag, the spigot, the tube junction, and the junction of the tube and the bag.

            In addition, the nurse has the responsibility to monitor the patency of the system to prevent pooling of urine within the tubing. Urine in the drainage bag is an excellent medium for microorganism growth. Bacteria can travel up drainage tubing to grow in pools of urine. If this urine flows back to the patient’s bladder, an infection will likely develop.

            Suggestions for ways to prevent infections in catheterized patients are the following:

• Follow good hand hygiene techniques.
• Do not allow the spigot on the drainage system to touch a contaminated surface.
• Only use sterile technique to collect specimens from a closed drainage system.
• If the drainage tube becomes disconnected, do not touch the ends of the catheter or tubing. Wipe the end of the tubing and catheter with an antimicrobial solution before reconnecting.
• Ensure that each client has a separate receptacle for measuring urine to prevent cross contamination.
• Prevent pooling of urine in the tubing and reflux of urine into the bladder.
• Avoid raising the drainage bag above the level of the bladder.
• If it becomes necessary to raise the bag during transfer of a patient to a bed or stretcher, clamp the tubing or empty the tubing contents to the drainage bag first.
• Provide for drainage of urine from the tubing to the bag by positioning the tubing.
• Empty the drainage bag at least every 8 hours. If large outputs are noted, empty more frequently.
• Encourage fluid intake, if it is not contraindicated. Inclusion of cranberry juice has been shown to decrease the adherence of bacteria to the bladder wall and to catheter lumen.
• Remove the catheter as soon as clinically warranted.
• Tape or secure the catheter appropriately for the patient.
• Perform routine perineal hygiene per agency policy and after defecation r bowel incontinence.

 

            Good health depends in part on a safe environment. Practices or techniques that control or prevent transmission of infection help to protect individuals, especially patients and health care workers from disease. Patients in all health care settings are at risk for acquiring infections because of lower resistance to infectious microorganisms, increased exposure to numbers and types of disease-causing microorganisms, and invasive procedures.

            In acute care or ambulatory care facilities, patients can be exposed to pathogens, some of which may be resistant to most antibiotics. By practicing infection prevention and control techniques, health care workers can avoid spreading microorganisms to patients and fellow health care workers.

            In all settings, the patients and their families must be able to recognize source of infections and be able to institute protective measures. Patient teaching should include information concerning infections, modes of transmission, and methods of prevention.

The first major advance for preventing CAUTI since the wide-scale adoption of closed drainage 35 years ago is the development of catheters with antiinfective surfaces. These advances should not be considered the final answer, however. Other technologies that should be pursued include new, more potent antiinfective materials; microbe-impervious antireflux valves; urethral stents; conformable (collapsible) urethral catheters; and vaccines for enteric gram-negative bacilli and staphylococci. Antiseptics are far more likely than antibacterials to confer greater resistance to surface colonization and not to select for infection with antimicrobial-drug resistant bacteria or yeasts. New surface technologies that release far greater quantities of ionic silver or other antiinfective agents into the aqueous environment contiguous to the catheter surface might even prevent CAUTIs caused by intraluminal contaminants (2001).

Prevention of catheter-associated UTIs is more effective, particularly for indwelling catheters, than relying solely on antimicrobial agents. (8) The most effective practice interventions for reducing catheter-associated UTIs include identifying patients who no longer need indwelling catheters, considering other catheterization options or alternatives to catheterization, and providing patient and caregiver education when long-term indwelling catheterization is needed (2005).

Reducing the time a patient is catheterized can be accomplished by systematic reminders to review the duration of catheterization for each patient. An interventional study in which physicians were reminded daily to remove unnecessary catheters significantly reduced the number of catheter days from 7 to 4.6 (P<0.001), which reduced the rate of catheter-associated UTIs from 11.5 to 8.3 per 1000 catheter-days (P=0.009). This intervention also resulted in a 69% decrease in the monthly cost of antibiotics for catheter-associated UTIs. Reminders to remove unnecessary catheters can be issued by the nursing staff or by computerized ordering systems (2005).

In addition to practice intervention, the choice of catheters and related equipment can also reduce UTIs substantially. Other methods of catheterization should he considered before inserting an indwelling catheter. Catheterization options are based on the reason for catheterization and the expected duration of need. Other options include condom catheters for males, suprapubic catheters for patients who require long-term indwelling drainage, and intermittent catheterization for patients with spinal cord injuries. (3,7) Patients who must use an indwelling catheter should have a closed catheter system with a small catheter (14 to 18 French with a 5-cc balloon). Manufacturer's recommendations for inflation and deflation, system maintenance, securing the catheter, and properly positioning the drainage bag below the patient's bladder should be followed. Preventing encrustation and blockage are also very important. Following these steps and properly maintaining closed drainage catheter systems has been shown to substantially reduce the risk for UTI (2005).

 

 

CONCLUSION

 

            Patient safety should be the number one concern before, during and after each procedure in any hospital. A detailed knowledge of the epidemiology, based on adequate surveillance methodologies, is necessary to understand the pathophysiology and the rationale of preventive strategies that have been demonstrated to be effective. In my area of work, the principles of general preventive measures such as the implementation of standard and isolation precautions should be reviewed.

Urinary catheterization can cause many health problems. Alternatives to catheterization should be used whenever possible. Reduction of catheter-associated UTIs is based primarily on preventive infection control practices. The cornerstones of effective prevention include thorough adherence to the guidelines promoted by the CDC for hand hygiene, correct insertion, handling, positioning, and maintenance of catheters; avoidance or limited use of long-term indwelling catheters; and possibly selection of catheters that are designed to deter biofilm growth. Following appropriate practice and product interventions, it is possible to significantly reduce the number of catheter-associated UTIs. This, in turn, reduces hospital stays and associated costs of treatment.

The greatest hope for a major reduction in CAUTI and indeed all nosocomial infections is likely to be vaccines against important nosocomial multidrug-resistant pathogens, such as the enteric gram-negative bacilli and staphylococci.

The success of the nurse who practices infection-control techniques is measured by determining whether the goals for reducing or preventing infection are achieved. A comparison of the client’s response, such as absence of fever or development of wound drainage, with expected outcomes determines the success of nursing interventions.

 

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