A 40-year-old man is evaluated prior to being discharged from the hospital to a physical rehabilitation center. The patient was brought to the emergency department 2 weeks ago after his motorcycle collided with a truck. He was thrown 3 m (10 ft) away and sustained multiple rib and thoracic vertebrae fractures. The patient had no sensation or motor function below the T10 spinal level. Surgical stabilization of the fractures was performed, but there was no neurologic recovery. The spinal injury is also complicated by neurogenic bladder requiring urinary catheterization. Which of the following is most likely to reduce the risk of infection associated with urinary catheter use in this patient?
Catheter-associated urinary tract infection (CA-UTI) is a common complication of urinary catheter use and can be caused by:
CA-UTI is most effectively prevented by avoiding unnecessary catheter use and minimizing the duration of catheterization. However, in patients with neurogenic bladder, long-term catheter use is required. In these patients, clean intermittent catheterization (CIC), which involves periodic insertion and removal (eg, every 4-6 hours) of a clean urinary catheter and can often be performed by the patient, is usually the initial treatment. CIC interrupts the extraluminal and intraluminal mechanisms of infection and, compared with the use of indwelling catheters, is associated with a significantly lower risk of CA-UTI. Indwelling catheters (changed monthly) can be considered if patients or their caregivers cannot perform CIC but are associated with an increased risk of UTI, stricture, and bladder spasm; suprapubic tube placement is another option.
(Choice A) Bladder irrigation with antibacterial solutions can lead to the emergence of resistant bacteria and may increase the risk of UTI due to the killing of nonpathogenic bacteria.
(Choices C and D) The application of antibacterial creams to the urethral meatus or antibacterial washes to the external genitalia has not been found to be helpful in decreasing the risk of CA-UTI.
(Choice E) In patients using a urinary catheter, antibiotics should be administered only in the setting of a proven UTI. Prophylactic antibiotics may increase the risk of development of resistant organisms and have not been reliably demonstrated to decrease the risk of CA-UTI.
Educational objective:
Clean intermittent catheterization is an effective measure for reducing the risk of catheter-associated urinary tract infection in patients with neurogenic bladder.