Management Of urinary Tract Infection (UTI)

CONTINENCE
Management of urinary tract infection
(UTI) in the community
Marian DiVito
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to the rectum, bacteria from faecal
incontinence, sexual intercourse or
poor personal hygiene can easily
travel along the perineum into
the urethra and up to the bladder,
thereby causing UTIs.
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The following underlying factors
may also predispose individuals
to UTIs:
 An obstruction in the urinary
system, e.g. renal/ bladder stones,
benign prostatic hyperplasia
(prostate enlargement)
 Static ‘reservoir’ of urine due to
incomplete bladder emptying
(Getliffe and Dolman, 2003)
 Weakened immune system
(through conditions such as
diabetes, chemotherapy, etc
(Whittaker, 2009)
 Sexual intercourse (Bethel, 2012)
 The presence of a foreign body,
i.e. urinary catheter (Department
of Health [DH], 2003; National
Institute for Health and Clinical
Excellence [NICE], 2006)
 The presence of anatomical
abnormalities or trauma (i.e.
urethral stricture — narrowing of
the urethra caused by injury or
disease)
 Other common causes in women
include hormonal changes such
as the menopause (Nicolle, 2002).
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he Health Protection
Agency (now Public Health
England) defined urinary tract
infection (UTI) as ‘the presence
and multiplication of bacteria
in one or more structures of the
urinary tract with associated tissue
invasion’ (HPA, 2012). Urine is
stored in the bladder and is normally
sterile, however, UTIs can develop
when part of the urinary system
becomes colonised with pathogenic
bacteria. In non-catheterised
patients, bacteria mostly enter the
urinary system through the urethra
and, more rarely, through the
bloodstream.
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Continence  UTIs  Catheter care  Antibiotics
COMMON CAUSES OF UTI
©
UTI is more common in women than
men. Escherichia coli, usually found
in the colon, is the commonest cause
of UTIs in women and accounts for
a large proportion of uncomplicated
UTIs. Due to the shorter length of
the female urethra and its proximity
Marian DiVito, independent nurse prescriber
continence; nurse specialist at Your Healthcare
CIC (Community Interest Company),
Kingston Upon Thames
JCN 2014, Vol 28, No 3
A diagnosis of UTI is primarily
based on symptoms and known
as lower UTI or upper UTI (see
below for more information on both
types). It is important to exclude
any differential diagnosis that may
present with similar symptoms
of UTI.
Differential diagnosis in men
KEYWORDS:
18
DIAGNOSIS
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Urinary tract infection (UTI) is caused by the presence and
multiplication of bacteria in the urinary tract, with associated
tissue invasion. It is most common in women but can be more
complicated in male and catheterised patients. This article
highlights the importance of the correct diagnosis of UTI, which
will identify ‘red flags’ to aid community nurses’ choice of
management options and avoid the unnecessary prescription of
antibiotics. In addition, the author makes recommendations for
reducing catheter-associated UTIs (CAUTIs) in the community.
Conditions such as prostatitis
(inflammation, swelling or infection
of the prostate gland), epididymitis
(swelling of the tube that connects
a testicle with the vas deferens) and
urethritis (urethral inflammation)
should be considered as differential
diagnoses in men presenting
with acute dysuria (pain, or a
burning sensation during voiding)
or frequency of urination, and
appropriate diagnostic tests should
be considered.
Pain or discomfort in the
perineum, thighs or penis is a
common symptom of prostatitis
(Getliffe and Dolman, 2003). In
addition, sexually transmitted
diseases and cancer should also be
considered, especially if recurrent
UTIs are reported.
Differential diagnosis
in women
A differential diagnosis must be
considered in women presenting
with symptoms of UTI who also
have vaginal itchiness or discharge.
Peri- and postmenopausal women,
with declining oestrogen levels
may experience vaginal and vulval
changes that may result in vulvovaginal itching and dryness (NICE,
2014a). In addition, sexually
transmitted diseases and, more
rarely, cancer should also be
considered, especially if patients
report recurrent UTIs.
TIME FOR CHANGE
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It’s up to you to make a difference
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BARDEX I.C. Anti-Infective Foley Catheters
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with Bacti-Guard * Silver Alloy Coating and
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BARD Hydrogel are proven more effective
than conventional catheters in reducing
1
Catheter Associated Urinary Tract Infections
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BARDEX I.C. Foley Catheters shown in UK
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to reduce risk of CAUTIs by up to 71.2%
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• Encourages best practice
• Reduces risk of infection - Clinically proven anti-infection
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technology, a true closed system
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©
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contain everything required to either catheterise
or re-catheterise in one handy pack
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Telephone: 01293 527 888
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References: 1. Bard data on file 2. Coral Seymour (2006). Audit of catheter-associated UTI using silver alloy-coated Foley Catheters. British Journal of Nursing, 2006, Vol 15, No 11. Date of acceptance: April 2006.
3. Madeo M, Roodhouse AJ, (2009) Reducing the risks associated with urinary catheters. Nursing Standard. 23, 47-55.
Please consult product label and insert for any indications, contraindications, hazards,
warnings, cautions and directions
®
for use. *The Foley catheters included in the Bardex I.C. System contain Bacti-Guard silver alloy coating which is
licensed from Bactiguard AB. Bard and Bardex are registered trademarks of C. R. Bard, Inc., or an affiliate.
Bacti-Guard is a registered trademark of Bactiguard AB.
© 2014 C. R. Bard, Inc. All Rights Reserved. 0514/3584
CONTINENCE
Table 1: Type of infection/inflammation classified by site of colonisation (Grabe et al, 2002)
Location
Red Flag
Type of infection
Bacterial cystitis is inflammation of the bladder, usually caused by a
bladder infection
Prostatitis is inflammation of the prostate gland and can be bacterial or
non-bacterial
Epididymis and testes
Epididymo-orchitis is an inflammation of the epididymis (the coiled tube
that collects sperm from the testicle and passes it on to the vas deferens)
and/ or the testes. It is usually due to infection or a sexually transmitted
disease. It can be acute or chronic
Kidneys and renal pelvis
Pyelonephritis is an infection of the upper urinary tract (Bethel, 2012)
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treatment can do more harm than
good due to the adverse effects
such as rashes, gastrointestinal
symptoms and the development of
antibiotic resistance. Therefore, in
adult patients a diagnosis of UTI
should be based on a full clinical
assessment, including vital signs
(SIGN, 2006) and antibiotics only
prescribed when symptoms are
present (Table 2).
Bacteriuria
Asymptomatic bacteriuria
There is no evidence that the
treatment of asymptomatic
bacteriuria significantly reduces
the risk of symptomatic episodes.
Asymptomatic bacteriuria is the
presence of bacteria in the urine,
revealed by quantitative culture or
microscopy in a sample taken from
a patient without symptoms of
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Signs and symptoms of lower UTI
The signs and symptoms of lower
UTI (cystitis) include (NICE, 2014b;c):
 Dysuria
 Desire to pass urine frequently
or urgently
 Nocturia
 Dribbling incontinence (mainly
in men)
 Feeling of incomplete bladder
emptying
 Cloudy, bloody or bad-smelling
urine
 Confusion (new or worsening)
 Urinary incontinence (new
or worsening)
 Pain in the lower abdomen
 Mild fever (a high temperature
between 37–38°C to 98.6–101°F).
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Prostate
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Urethritis describes urethral inflammation and can be infectious or noninfectious. This is often caused by a sexually transmitted disease
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Urethra
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Signs and symptoms of upper UTI
The signs and symptoms of upper
UTI include (Scottish Intercollegiate
Guidelines Network [SIGN], 2003):
 Any of the symptoms of a lower
urinary tract infection
 A high fever (a temperature of
over 38°C or 101°F)
 Nausea or vomiting
 Shaking or chills
 Confusion — new or worsening
 Pain in the lower back or side that
is usually only one-sided.
The type of infection and
inflammation is classified by the site
of colonisation (Table 1).
MANAGEMENT OF UTI
There is evidence that antibiotic
20 JCN 2014, Vol 28, No 3
Haematuria (blood in the
urine) is considered a ‘red
flag’ (significant event that
requires immediate treatment).
The causes of haematuria
can be both insignificant
or point to life-threatening
malignant diseases, being
potentially glomerular (in the
kidneys, the glomerulus is
a network of capillaries that
help to filter blood), renal,
urological or haematological
in origin (Turner, 2008). When
haematuria is identified,
community nurses must send
a urine sample to a laboratory
for further analysis. If UTI has
been diagnosed and antibiotics
prescribed, the patient’s
symptoms must be reviewed
after seven days of completion
of antibiotics and a dipstick
urinalysis repeated. This is to
ensure that the therapy has
been effective and any UTI
eradicated. Patients must be
referred to a GP for review if
haematuria does not resolve
(refractory haematuria) despite
treatment. In women over 50
who present with microscopic
or macroscopic (visible with
naked eye) haematuria; or
women over 40 with persistent
or recurrent UTIs with
haematuria, a mid-stream
urine sample should be sent
for microscopy and their GP
informed without delay.
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Interstitial cystitis is inflammation of the bladder of unknown cause.
This is sometimes referred to as ‘painful bladder syndrome’. Patients may
present with symptoms similar to cystitis of urgency and frequency but with
additional discomfort in the bladder and pelvic area
Bladder
Haematuria...
Table 2: Suggested antibiotic treatments for UTI
Upper UTI and catheterised patients
Lower UTI
Co-amoxiclav 500/125mg three times per day for 14 days...
or...
Ciprofloxacin 500mg twice-daily for seven days if the patient is
allergic to penicillin
Trimethoprim 200mg twice-daily — women for three days and
men for seven days...
or...
Nitrofurantoin 50mg four times per day or 100mg modified
release twice daily — women for three days and men for
seven days*
* There is a temptation to extend treatment courses if the patient does not
improve, however, a lack of resolution of symptoms is more likely to be due to
resistance than insufficient length of treatment
Nurses should always refer to current guidelines for safe clinical practice
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For further information please contact the
CliniMed® Careline on 0800 036 0100
©
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The thought of catheterisation is a daunting one, but the procedure needn’t
be painful or traumatic. Instillagel anaesthetises the urethra whilst providing
broad-spectrum antimicrobial coverage that helps protect him against UTIs,
as well as giving essential lubrication. Tried and trusted for 25 years,
Instillagel is the triple action urethral gel that you can both rely on.
Anaesthetic - Antiseptic - Lubricant
Prescribing information: Composition: Each 100g of Instillagel
contains: Lidocaine Hydrochloride 2.0g, Chlorhexidine Digluconate
solution 0.25g, Methyl Hydroxybenzoate 0.06g, Propyl Hydroxybenzoate
0.025g. Uses: Catheterisation, cystoscopy. Exploratory and intraoperative investigations, exchange of fistula catheters, protection
against iatrogenic damage to the rectum and colon. Gynaecological
investigations. Dosage and administration: Unless otherwise prescribed
by a doctor: Urethral catheterisation: instil 6-11ml of gel into the urethra.
The anaesthetic effect begins after 3-5 minutes. Contraindications,
Warnings, Precautions and Interactions: Instillagel® must not be
used in patients with known hypersensitivity to the active ingredients
(amide-type anaesthetics, chlorhexidine and alkyl hydroxybenzoates)
or any of the excipients. It should not be used in patients who have
damaged or bleeding mucous membranes. Use with caution in patients
with impaired cardiac conditions, hepatic insufficiency and in epileptics.
Difficulty in swallowing may occur with an increased risk of aspiration
and biting trauma. Use with caution in patients receiving antiarrhythmic
drugs. Undesirable effects: In spite of the proven wide safety range
of Instillagel®, undesirable effects of lidocaine are possible where
there is severe injury to the mucosa; for example, anaphylaxis, fall in
blood pressure, bradycardia or convulsions. Presentations: Pre-filled
disposable syringes; for single use only. 6ml and 11ml; packs of 10.
NHS Price: 10 x 6ml £14.05, 10 x 11ml £15.76. Legal category: Pharmacy
P. Marketing Authorisation Number: PL 03377/0002. Marketing
Authorisation Holder: Farco-Pharma GmbH, Gereonsmühlengasse 1 - 11,
D-50670 Cologne, Germany. Further information is available from:
CliniMed Limited, Cavell House, Knaves Beech Way, Loudwater, High
Wycombe, Bucks. HP10 9QY. Tel: 01628 850100. Date: February 2012.
Information about adverse event reporting can be found
at www.mhra.gov.uk/yellowcard. Adverse events should
also be reported to Farco-Pharma on 0049221594061
CliniMed Ltd, a company registered in England number 01646927. Registered office: Cavell House, Knaves Beech Way, Loudwater, High Wycombe, Bucks HP10 9QY Tel: 01628 850100 Fax: 01628 527312
Email: enquiries@clinimed.co.uk or visit www.clinimed.co.uk. Instillagel® is a registered trademark of Farco-Pharma GmbH. CliniMed® is a registered trademark of CliniMed (Holdings) Ltd. ©2012 CliniMed Ltd. 1474/1211/1
CONTINENCE
2 – How would you go about
diagnosing UTI?
3 – Do you understand what a
differential diagnosis is?
4 – What is the main treatment option
in UTI?
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Cranberry products
The use of cranberry to prevent
urinary infections has been
recommended as a traditional
remedy by urologists and specialist
urology nurses for many years.
However, cranberry products are not
available on the NHS or regulated
properly and the concentration of
active ingredients is not always clear.
There is no evidence to support the
effectiveness of cranberry products
for treating symptomatic UTI.
Indeed, a recent systematic review
by Cochrane reported that the use
of cranberry appears to be less
effective than previous studies have
indicated for preventing UTIs and,
therefore, it was not recommended
(Jepson et al, 2012).
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Asymptomatic bacteriuria is
common, including in healthy
individuals, and treatment can
be more harmful than beneficial.
Therefore, only pregnant women
or men undergoing urological
interventions should be screened for
asymptomatic bacteriuria (Grabe et
al, 2008). Asymptomatic bacteriuria
is also common in older people and
those using urinary catheters —
however, as the name suggests it
does not cause any symptoms and
normally does not require treatment
(Grabe et al, 2008).
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lower or upper UTI and confirmed
by two consecutive samples
(Nicolle, 2003).
©
The exception would be patients
in certain at-risk groups such as renal
transplant patients and pregnant
women, where a mid-stream
specimen of urine must be collected
and sent for microscopy and culture
to ascertain the risks of deterioration,
then treated as appropriate.
Symptomatic bacteriuria
Symptomatic bacteriuria is an
infection of the upper part of
the urinary tract that includes
the kidneys and the ureters. The
presence of bacteriuria in urine is
revealed by quantitative culture or
22 JCN 2014, Vol 28, No 3
There is no need for dipstick
testing in patients who are
asymptomatic and a sample should
not be sent to for analysis in the
absence of UTI symptoms. However,
clinical judgment must be made in
patients unable to report symptoms
such those with learning disabilities
or dementia. Dipstick urinalysis
should not be used to diagnose UTI
in catheterised patients — pyuria
(urine containing pus) is common
in these patients and its level has no
predictive value.
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5 – How do you identify catheterassociated UTI (CAUTI)?
When patients present with
symptomatic bacteriuria, their GP
should be informed without delay
so that empirical treatment with
antibiotics can be started and a midstream urine sample sent for culture
and sensitivity to ensure the patient
is on the correct treatment. Very frail
or immuno-compromised patients
may require hospital admission as
may anyone who does not respond
to antibiotics within 24 hours and has
continuing symptoms of upper UTI.
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1 – What are the common causes of
urinary tract infection (UTI)
Dipstick urinalysis using a reagent
strip is a cheap and fast general
screening tool for a variety of medical
conditions. Proteinuria may indicate
renal impairment or uncontrolled
blood pressure and glycosuria
(glucose in the urine) may reveal
undiagnosed or uncontrolled diabetes
(Steggall, 2007).
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Answer the following questions
about this topic, either to test the
new knowledge you have gained or
to form part of your ongoing practice
development portfolio.
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Five-minute test
It is important to recognise
any evidence of upper UTI,
particularly symptoms suggestive
of pyelonephritis (kidney infection)
such as one-sided costovertebral
angle pain, fever, rigors or other
manifestations of systemic
inflammatory response. Upper UTI is
potentially more serious than lower
UTI due to a possibility of kidney
damage (Fulop, 2013).
ensure the patient is placed on the
correct antibiotic therapy. Although
there is no need to test low-risk
people, nurses may use this tool as
part of a first assessment/admission
assessment to obtain a baseline
reading.
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microscopy in a sample taken from
a patient with typical symptoms of
lower or upper UTI.
Patients taking warfarin should
avoid taking cranberry products as
they may enhance the anticoagulant
effect (British Medical Association/
Royal Pharmaceutical Society [BMA/
RPS], 2014).
Urine testing
The main value of urine culture is
to identify any bacteria and their
sensitivity to antibiotics and to
CATHETER-ASSOCIATED UTI
(CAUTI)
Catheterisation can be indwelling
(urethral or suprapubic) or
intermittent (Robinson, 2009). The
seminal work of Lapides et al (1972)
identified that residual urine in the
bladder and high bladder pressures
are common causes of UTIs, which
could be reduced by intermittent
catheterisation. These findings are
supported by the more up-to-date
findings of Shaw et al (2007) and
NICE (2012). Long-term Foley
indwelling catheters begin acquiring
bacteria soon after their introduction
and the longer they are in situ the
greater the likelihood of infection,
which increases by 6% each day
Red Flag
Admission...
Patients with catheters should
be admitted to hospital if they
develop fever, rigors, chills,
vomiting or confusion.
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Clinically proven1 innovation
TENA U-test
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For easy in-pad detection of
urinary tract infections
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• Specially designed for incontinent individuals
with symptoms
• Prevents unnecessary discomfort and intrusion
for individuals, maintaining dignity
• Results in reduced workload for carers and more
time for rewarding care
89%
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increases the comfort of individuals2
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On average
Contact your SCA Account Manager
or email hcmarketing@sca.com for
more information about TENA U-test
1. Krähenbühl et al.: Evaluation of a novel in-vitro diagnostic device for the detection of urinary tract infections in diaper
wearing children. Swiss Med Wkly. 2012;142:w13560. 2. Case study with 15 nursing home wards. Source: Qualitative
concept test study in Sweden and the Netherlands. 2011; Sponsor: SCA. 3. It takes one nurse one or two minutes to
place a TENA U-test in pad during pad change. In comparison, obtaining a urine sample fora dipstick test by taking the
resident to the toilet, manoeuvring him/her in bed, and if unsuccessful, inserting a catheter, can take one or two nurses
15–40 minutes. SCA, Extensive internal studies, 2011–2012
of nurses experienced
an improved working
environment 2
faster in comparison to procedures in
difficult cases that involve urine collection
with a cup, pot catheterisation and a dipstick3
CONTINENCE
 Option 2: take CSU sample;
remove catheter; start antibiotic
treatment; consider intermittent
assisted or self-catheterisation for
a few days before replacing
the catheter.
Table 3: ‘Golden rules’ for preventing UTI
Nurses must question the need for an indwelling catheter and review this at each catheter change
Nurses should consider the option of the patient/carer performing intermittent catheterisation, especially
where CAUTI is present
All catheterisations carried out by healthcare workers must follow an aseptic non-touch technique
(ANTT) procedure
Prevention
The meatus should be washed daily with soap and water
Nurses need to be up to date
with local and government
recommendations for best practice
evidence as they play an important
part in reducing CAUTIs (DH, 2003;
NICE, 2006; SIGN, 2012; HPA, 2012).
Use a catheter valve as a first choice as opposed to a free drainage bag when appropriate for the patient
Ensure that the closed urinary system is not broken except for good clinical reasons (i.e. changing the
drainage bag)
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Nurses should educate patients and carers on the benefits of effective hand decontamination, ANTT and
maintaining a closed system
Urine samples must be obtained from a sampling port (using ANNT)
Use appropriate sterile lubricants from a single-use container for male and females
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To prevent reflux, urine bags should be regularly emptied (when three-quarters full)
A link system for overnight drainage should be used, and the night bag disposed of each morning
Sterile bags should be used during the day and at night
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Bladder maintenance solutions/wash-outs must not be used to prevent CAUTIs
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Change in voiding patterns
Nausea
Vomiting
Malaise
Confusion.
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Management of CAUTIs
In the author’s experience, patients
with long-term indwelling catheters
should have a clean specimen
of urine (CSU) taken for culture
before the catheter is changed
and treatment with antibiotics for
symptomatic UTI is started:
 Option 1: take CSU sample;
remove catheter; start antibiotic
treatment with a new catheter
in situ
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Once the organisms have
attached to the catheter’s surface and
formed a biofilm, they can rapidly
multiply (Tenke et al, 2004; Stickler,
2008). Furthermore, biofilms can
cause catheter encrustation leading
to blockage, which results in trauma
and bladder pain on removal of the
catheter. While most catheterised
patients will never develop a systemic
inflammatory response to these
colonising pathogens (Nicolle et al,
2005), there is a risk that CAUTIs can
lead to septicaemia (Pellowe et al,
2005) and even death.




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Based on NICE guidelines (2012)
that the catheter is in place (Kambal
et al, 2004).
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Urine bags should be positioned below the bladder, but not in contact with the floor
ALL bags are single-use only
Diagnosis of CAUTIs
©
Fever is the most common
symptom of UTI in catheterised
patients. However, the absence of
fever does not appear to exclude
UTI (SIGN, 2012). Consequently,
clinical symptoms alone are not
recommended for predicting the
likelihood of symptomatic UTI in
catheterised patients — professional
judgement must also be used.
Symptomatic bacteriuria in
patients with catheters has the
following symptoms (SIGN, 2012):
 Fever
 Flank or suprapubic discomfort
24 JCN 2014, Vol 28, No 3
Indwelling catheterisation is a
procedure frequently undertaken
by nurses or delegated to carers/
patients by nurses after an initial
assessment — in this case NICE
(2012) has recommended that
patients and carers are educated
in catheter management and hand
decontamination techniques.
Nurses should always question
the reason for catheterisation, and if
appropriate, a trial without catheter
(TWOC) should be undertaken
(where a catheter that has been
inserted via the urethra is removed
from the bladder for a trial period
to determine whether the patient is
able to pass urine spontaneously).
It is the author’s experience that
patients are often discharged from
hospital with a catheter in place,
but the reasons for the original
catheterisation are not made clear to
community nurses.
NICE (2012) highlights that
‘indwelling urinary catheters are
the most common cause of urinary
tract infections’ and recommends
that any assessment should include
the reason for catheterisation. In
Expert commentary
Julian Spinks, GP with interest in continence, Kent
U
rinary tract infection in
men and women can vary
enormously in its impact
on patients, from minor illness in
the young adult to a major cause of
unplanned admissions to hospital
in the frail older person.
This article provides a concise
but comprehensive guide to the
diagnosis and management of
the condition and, at a time when
drug resistance is an increasing
problem, the section on prevention
is particularly timely.
CONTINENCE
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There is extensive literature,
although not yet any clear evidence,
to support the effectiveness of
catheter maintenance solutions
or the use of antiseptic-coated
catheters in the prevention of
blockages or reduction of CAUTIs.
It is evident that more research is
needed in this area of practice and
nurses should perform a thorough
holistic assessment to provide a
rationale for using these products.
Using a bladder infusion kit to
administer bladder maintenance
solutions via needle-free sample
ports, always using ANNT, is
recommended to maintain a closed
system and minimise the risk of
CAUTIs. In addition the author
recommends that any catheter
drainage bags used are sterile and
single-use only (Table 3).
A small quantitative study in two
hospitals suggested that the use of
KEY POINTS
Urinary tract infection (UTI)
is common in women but can
be complicated in male and
catheterised patients.

UTI develops when part of
the urinary system becomes
colonised with pathogenic
bacteria.

Escherichia coli, found in the
colon is the commonest cause
of UTIs in women and accounts
for a large proportion of
uncomplicated UTIs.
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article highlights the
importance of correct diagnosis/
differential diagnosis of UTI
to identify ‘red flag’ symptoms,
such as haematuria and avoid
the unnecessary prescription of
antibiotics.
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 This
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Community nurses should ensure
that UTIs are diagnosed according
to the presenting symptoms. UTIs
in women are common and often
caused by E. coli bacteria entering the
short urethra from the nearby rectum
and are normally asymptomatic.
In patients with no UTI symptoms
there is no need for dipstick testing
or antibiotic therapy in patients who
present with asymptomatic UTIs.
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Furthermore, it is crucial that
nurses eradicate poor clinical
practice such as washing drainage
night-bags and reconnecting them
later. All catheter bags are singleuse only and re-using catheter
bags that have been disconnected
— including seven-day bags, which
are also single-use — contravenes
manufacturers’ recommendations
(Medicines and Healthcare products
Regulatory Agency [MHRA], 2011).
CONCLUSION
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During catheterisation and
drainage system changes, effective
aseptic non-touch technique (ANTT)
is recommended to minimise the
risk of infection (NICE, 2012). The
change of a catheter bag or valve is a
procedure often delegated to carers,
but it still requires ANTT (RCN,
2012).
Although anaesthetic gel is
not recommended as a first-line
measure, it may be indicated for
patients who have had previous
traumatic and painful catheterisation
experiences. Professional judgment
must be used and potential allergies
and side-effects taking into
account as this a ‘prescription only
medication’.
C
If the catheter needs to remain
in situ, maintenance of a closed
drainage system is recommended as
avoiding unnecessary disconnections
is still the most effective way to
minimise CAUTIs (NICE, 2012).
an anaesthetic lubricant reduced the
incident of UTIs by 50% (Kambal et
al, 2004). However, the NICE (2012)
guidelines for infection control only
recommend the use of appropriate
lubricant from a sterile single-use
container for male and females to
minimise trauma and infection.
nd
view of the potential risks of the
procedure, a discussion between the
patient, GP and community nurse is
recommended and if safe, a TWOC
should be undertaken.
However, in men and catheterised
patients, UTIs can be complicated
and could lead to septicaemia or
even death. Identifying the right
diagnosis/differential diagnosis will
better enable the nurse to choose the
correct management options.
Similarly, comprehensive
assessment will help nurses
to identify ‘red flags’ such as
haematuria, which need urgent
referral.
The use of ANTT during
catheterisation and catheter care, the
maintenance of a closed drainage
system, and the use of sterile singleuse bags are recommended to
minimise CAUTIs.
Undoubtedly, avoidance of
unnecessary catheterisation
and prompt catheter removal
is the most effective method of
eradicating bacterial contamination
and preventing catheter-related
complications and community
nurses should closely monitor any
catheterised patients to ensure that
this invasive procedure does not
continue for longer than is absolutely
JCN
necessary.
REFERENCES
Bethel J (2012) Acute pyelonephritis: risk
factors, diagnosis and treatment. Nurs
Stand 27(5): 51–6
BMA/RPS (2014) British National Formulary:
59. BMA/RPS, London
DH (2003) Winning Ways: working together
to reduce healthcare associated infection in
England. DH, London
Fulop T (2013) Acute pyelonephritis.
Available at: http://emedicine.medscape.
com/article/245559-overview#a0101
(accessed 16 March, 2014)
Getliffe K, Dolman M (2003) Promoting
Continence: a clinical and research resource.
Bailliere, London
Grabe M, Bishop M, Bjerklund-JohansenT,
et al (2008) Guidelines on The Management
of Urinary and Male Genital Tract Infections.
European Association of Urology
Available at: http://www.uroweb.org
(accessed 21 May, 2014)
HPA (2012) UK Standards for Microbiology
Investigations. HPA, London
HPA (2013) Management of Infection Guidance
for Primary Care for Consultation and Local
Adaptation. Available at: http://www.
hpa.org.uk/Topics/InfectiousDiseases/
JCN 2014, Vol 28, No 3
25
CONTINENCE
le
Lt
d
Robinson J (2009) Urinary catheterisation:
assessing the best options for patients.
Nurs Stand 23(29): 40–5
Shaw C, Logan K, Webber I, Broome
L, Samuel S (2007) Effect of clean
intermittent self-catheterization on
quality of life: a qualitative study. J Adv
Nurs 61(6): 641–50
SIGN (2006) Management of Suspected
Bacterial Urinary Tract Infection in Adults:
A national clinical guideline, 88. SIGN,
Edinburgh
Steggall M (2007) Urine samples and
urinalysis. Nurs Stand 22(14/16): 42–5
Stickler D (2008) Bacterial biofilms in
patients with indwelling urinary catheters.
Nature Reviews Urology 5: 598–608
Tenke P, Riedl C, Jones G, Williams G,
Stickler D, Nagy D (2004) Bacterial
biofilm formation on urologic devices and
heparin coating as preventive strategy. Int J
Antimicrob Agents March(suppl 1): S67–S74
Tindall. Getliffe K, Dolman M (2007)
Promotion of Continence: a clinical research
resource. Elsevier, London
Turner B (2008) Haematuria: causes and
management. Nurs Stand 23(1): 50–6
Whittaker S (2009) Risk factors for
healthcare-associated bacteriuria and UTI.
Available at: www.continence-uk.co.uk/
journal/december_2009_contents.shtml
(accessed 20 May, 2014)
C
ar
e
Pe
op
NICE (2014b) Urinary Tract Infection (lower)
— women. Available at: http://cks.nice.
org.uk/urinary-tract-infection-lowerwomen#!diagnosissub:1(accessed 1 May,
2014)
NICE (2014c) Urinary Tract Infection (lower)
— men. http://cks.nice.org.uk/urinarytract-infection-lower-men#!diagnosissub
(accessed 1 May, 2014)
Nicolle E (2002) Urinary tract infection in
geriatric and institutionalized patients.
Curr Opin Urol 12(1): 51–5
Nicolle L (2003) Asymptomatic bacteriuria:
when to screen and when to treat. Infect
Dis Clin North Am J 17(2): 367–94
Nicolle L, Bradley S, Colgan R, Rice
JC, Schaeffer A, Hooton TM (2005)
Infectious Diseases Society of America
Guidelines for the Diagnosis and Treatment
of Asymptomatic Bacteriuria in Adults.
Available at: http://www.uphs.upenn.edu/
bugdrug/antibiotic_manual/idsauti-nosx.
pdf (accessed: 16 May, 2014)
Pellowe C, Pratt R, Loveday H, Harper P,
Robinson N, Jones S (2005) The Epic
Project: updating the evidence base for
national evidence-based guidelines for
preventing healthcare-associated infections on
the NHS hospitals in England. A report with
recommendations. J Hosp Inf 59(4): 373–74
RCN (2012) Catheter Care: RCN guidance for
Nurses. RCN, London
nd
InfectionsAZ/PrimaryCareGuidance
(accessed 20 May, 2014)
Jepson R, Williams G, Craig J (2012)
Cranberries for Preventing Urinary Tract
Infections (Review). The Cochrane Library.
Available at: http://onlinelibrary.wiley.
com/doi/10.1002/14651858.CD001321.
pub5/pdf (accessed 19 May, 2014)
Kambal C, Chance J, Cope S, Beck J (2004)
Catheter-associated UTIs in patients after
major gynaecological surgery. Profess Nurs
19(9): 515–18
Lapides J, Diokono A, Silber S, Lowe
B (1972) Clean, intermittent selfcatheterisation in the treatment of urinary
tract disease. J Urol 107(3): 458–61
MHRA (2011) Single-use Medical Devices.
Available at: http://www.mhra.gov.
uk/home/groups/dts-iac/documents/
publication/con2025015.pdf (accessed 16
May, 2014)
NICE (2006) Urinary Incontinence: the
management of urinary incontinence in
women. NICE, London
NICE (2012) Infection: prevention and
control of healthcare-associated infections
in primary and community care. Clinical
guideline 139. NICE, London
NICE (2014a) Clinical Knowledge Summary:
clinical topics. Available at: http://cks.
nice.org.uk/pruritus-vulvae#!diagnosis
(accessed 1 May, 2014)
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