Nursing Intervention for Prevention of Catheter-Associated Infections - Research Paper Example

Nursing Intervention for Prevention of Catheter-Associated Infections Catheter-associated infection is a serious problem in healthcare and is a majorcause of hospital-acquired infection. It has been estimated that about 10% of hospitalized patients require urinary catheterization. Urinary tract infections (UTI) following catheterization or other instrumentation are the most common hospital-acquired infections, accounting for approximately 30-40% of all secondary infections. The risk of acquiring bacteriuria (bacteria in urine) increases with time, from approximately 5% per day during the first week of hospitalization to nearly 100% in 4 weeks. It has been estimated that 1-4% of bacteriuric patients will ultimately develop clinically significant bacteraemia with a case fatality of 13-30%. In long-term care facilities, the vast majority of residents with indwelling urinary catheters are colonized with more than 50,000 colony-forming units of bacteria per mL of urine (Warren, Tenney, Hoopes, Muncie, & Anthony, 1982). Alternatives to indwelling catheters are intermittent catheterization with an associated infection risk ranging from 0.5-8%. Hospitalized patients are at a higher risk for catheter-associated bacteriuria; with possibility of Gram-negative bacteraemia increased 5-fold (Stamm, 1991). Therefore, it is important that urinary catheterization should be avoided, if possible, and only be used when there is a clear medical indication, and not purely just for the management of urinary incontinence. Regular review should be carried out regarding the patient's clinical need for continuing urinary catheterization. Prevention of bacterial infection is the best option, and strategies include the sterile insertion and care of the catheter, use of closed drainage systems, and allowing for the shortest period possible for catheterization. A generally accepted strategy against catheter-associated urinary tract infection (UTI) includes catheter removal (Warren J. , 2001) followed by short course antibacterial treatment (Harding, et al., 1991). Increased disconnection and reconnection of the catheter increases also the risk of contamination. Utilization of preconnected collecting tube units, disinfectant-impregnated catheters, and periurethral antimicrobial creams is also ideal (Bukowski, Betrus, Aquilina, & Perlmutter, 1998). The process of catherization has many sources of contamination even before the catheter is inserted (Damani, 2003). Catheter fluid could be non-sterile or prepared using less than the ideal sterilization procedure during manufacturing; although this event is rare in developed countries. Microorganisms that grow in the fluid are usually Gram-negative bacteria such as Klebsiella spp., Enterobacter spp. or Pseudomonas spp. Extrinsic sources of infection are introduced during insertion of the catheter, fluid administration; mostly coming from the hands of the health care professionals. Important sources of the microorganisms are, however, found at the insertion site and are usually bacteria that can be found on the patients' skin like staphylococci, and diphtheroids (Damani, 2003). The catheter may also be colonized by microorganisms, which form biofilms. Biofilm formation can be followed by local sepsis, or the microorganisms may be released into the bloodstream causing systemic infection (Costerton, Stewart, & Greenberg, 1999). Proper nursing intervention is the key to prevention of catheter-associated infections, since nurses are usually the ones who will insert the catheter and are in charge of patient care. Designated trained personnel should insert the catheter while supervision must be provided for trainees (Damani, 2003). Personnel must follow strict policies for insertion and maintenance of catheters. Patients should be monitored on a regular basis for signs of catheter related complications like tenderness at the site of infection, swelling, signs of infection and inflammation. Symptoms like fever and bloodstream infections should also be addressed immediately. Preventive measures that are necessary before insertion are the checking of solutions for growth of microorganisms, expiry dates and proper packaging e.g. visible turbidity, leaks, and particulates. Solutions and unused catheters must be stored unopened, and properly according to the manufacturer's recommendations. The catheter type also affects the chances of bacterial infection. Recommended types are polyurethane and silicone, which should be coated with antimicrobial or antiseptic preparations. Aseptic techniques should be followed during catheter insertion and later during manipulation (Damani, 2003). Hands, wrists, and lower arms must be soaped for at least 15 seconds; rinsed well and dried with a clean, sanitized towel. The faucet is closed, not with the bare hands, but wrapped in the towel before disposing properly. The hands are then disinfected with conventional alcohol-based disinfectants or other hand preparations prior to, and after catheter insertion. A 2% chlorhexidine or 0.5% alcoholic chlorhexidine-based preparation is preferred (Davies, Desai, Turton, & Dyas, 1987). Alternately, tincture of iodine, an iodophor, or an alcoholic povidone-iodine solution can be used for those who are sensitive to chlorhexidine. Chlorhexidine has been found to be a better disinfectant; it significantly reduced the incidence of microbial colonization of catheters compared with povidone-iodine (Maki, Ringer, & Alvarado, 1991). In addition, hand hygiene must be maintained before and after palpations of insertion sites, replacing dressings and catheters. The antiseptic preparation should also be applied to the site of insertion and allowed to dry before insertion of the catheter. If povidone iodine is used, then it should remain on the skin for at least 2 min or longer if it is not yet dry before inserting the catheter. Application of organic solvents like acetone or ether to the skin before insertion of catheters or during dressing change should be avoided. The importance of hand hygiene cannot be understated, because nurses can be major sources of infection. In a study of nursing staff in an intensive care unit, it was found that 17% of the staff had Klebsiella spp on their hands. Hand washing with chlorhexidine hand cleanser reliably gave 98-100% reduction in hand counts. The introduction of routine hand washing by staff before moving from one patient to the next was associated with a significant and sustained reduction in the number of patients colonized or infected with Klebsiella spp (Casewell & Phillips, 1977). Sterile gloves must be always worn and a 'no-touch' aseptic technique used. A second pair of gloves should be available should contamination occur. Use of protective clothing prevents staff from transferring infection, while at the same time protecting them from being infected with contagious diseases. Gloves and masks are part of the PPE or personal protective equipment. These are meant to protect the healthcare professional from infection. This has been shown in a study to determine factors that predispose or protect health professionals who worked on severe acute respiratory syndrome (SARS). Consistently wearing a surgical or particulate respirator mask while caring for a SARS patient protected the nurses from SARS infection (Loeb, et al., 2004). The peri-urethral area should be thoroughly cleaned with disinfectant making sure that the wiping motions are carried from front to back to prevent fecal bacteria from being transported to the urinary meatus which is the site of catheter entry. Sterile (water-soluble) lubricant should be applied on the catheter prior to insertion. When inserting the catheter, contact with non-sterile surfaces should be avoided. The catheter should be connected to a sterile, closed urinary drainage system (Damani, 2003). After the catheter is in place, the catheter system should be closed to postpone the onset of bacteriuria, and as soon as possible, the catheter is removed. If the catheter can be removed before bacteriuria develops, postponement becomes prevention (Warren J. , 2001). Inspection of the catheter and drainage system must be regularly performed and documented either in nursing or medical notes. The meatus should be cleaned regularly to prevent contamination. Daily routine bathing is all that is needed to maintain meatal hygiene. The urine drainage bag should be emptied regularly in order to maintain urine flow and to prevent reflux. Stagnant urine builds up microbial growth. Extreme care should be exercised when emptying the bag to prevent infection. As always, gloves must be worn and the hands must be disinfected after each procedure. The outlet of the bag must be wiped with alcohol swabs. The catheter is removed by gently withdrawing it from the body. The catheter is returned to its package, and disposed in containers for further decontamination before waste disposal (Rochester Medical, 2008). Hands should be thoroughly washed after this procedure. Each step from the preparation of the catheter, to its insertion, and finally its removal from the body are all avenues for inviting infection. However, evidence points that the use of simple and conventional procedures, if followed faithfully, could lead to decrease in catheter -associated infections. References Bukowski, T, Betrus, G, Aquilina, J & Perlmutter, A 1998, 'Urinary tract infections and pregnancy in women who underwent antireflux surgery in childhood', Journal of Urology, vol. 159, pp. 1286-1289. Casewell, M & Phillips, I 1977, 'Hands as a route for transmission of Klebsiella species', British Medical Journa , vol. 2, pp. 1315-1317. Costerton, J, Stewart, P & Greenberg, E 1999, 'Bacterial biofilms: a common cause of persistent infections', Science, vol. 284, pp. 1318-1322. Damani, N 2003, Manual of Infection Control Procedures. Cambridge: Cambridge University Press. Davies, A, Desai, H, Turton, S & Dyas, A 1987, 'Does instillation of chlorhexidine into the bladder of catheterized geriatric patients help reduce bacteriuria'' Journal of Hospital Infection, vol. 9, pp. 72-75. Harding, G, Nicolle, L, Ronald, A, Preiksaitis, J, Forward, J, Low, D, et al. 1991, 'How long should catheter-acquired urinary tract infection in women be treated' A randomized controlled study', Annals of Internal Medicin , vol. 114, no. 9, pp. 713-719. Loeb, M, McGeer, A, Henry, B, Ofner, M, Rose, D, Hlywka, D, et al. 2004, 'SARS among critical care nurses, Toronto', Emerging Infectious Diseases, vol. 10, no. 2, pp. 251-255. Maki, D, Ringer, M & Alvarado, C 1991, 'Prospective randomised trial of povidone-iodine, alcohol, and chlorhexidine for prevention of infection associated with central venous and arterial catheters', Lancet, vol.338, pp. 339- 343. Rochester Medical 2008, 'A guide to the proper use of intermittent catheters', RochesterMedical Corporation. Stamm, W 1991, 'Catheter associated urinary tract infections: epidemiology, pathogenesis and prevention', American Journal of Medicine, vol. 91, pp.65-71. Warren, J 2001, 'Catheter-associated urinary tract infections', International Journal of Antimicrobial Agent , vol. 17, pp. 299-303. Warren, J, Tenney, J, Hoopes, J, Muncie, H & Anthony, W 1982, 'A prospective microbiologic study of bacteriuria in patients with chronic indwelling urethral catheters', Journal of Infectious disease, vol. 146, pp. 719-723. Read More