PREVENTION OF URINARY INFECTION IN GYNAECOLOGY

epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England

National evidence-based guidelines for preventing healthcare-associated infections (HCAI) in National Health Service (NHS) hospitals in England were originally commissioned by the Department of Health and developed during 1998-2000 by a nurse-led multi-professional team of researchers and specialist clinicians. Following extensive consultation, they were first published in January 2001(1) and updated in 2007.(2) A cardinal feature of evidence-based guidelines is that they are subject to timely review in order that new research evidence and technological advances can be identified, appraised and, if shown to be effective for the prevention of HCAI, incorporated into amended guidelines. Periodically updating the evidence base and guideline recommendations is essential in order to maintain their validity and authority. The Department of Health commissioned a review of new evidence and we have updated the evidence base for making infection prevention and control recommendations. A critical assessment of the updated evidence indicated that the epic2 guidelines published in 2007 remain robust, relevant and appropriate, but some guideline recommendations required adjustments to enhance clarity and a number of new recommendations were required. These have been clearly identified in the text. In addition, the synopses of evidence underpinning the guideline recommendations have been updated. These guidelines (epic3) provide comprehensive recommendations for preventing HCAI in hospital and other acute care settings based on the best currently available evidence. National evidence-based guidelines are broad principles of best practice that need to be integrated into local practice guidelines and audited to reduce variation in practice and maintain patient safety. Clinically effective infection prevention and control practice is an essential feature of patient protection. By incorporating these guidelines into routine daily clinical practice, patient safety can be enhanced and the risk of patients acquiring an infection during episodes of health care in NHS hospitals in England can be minimised.

Novel antiseptic urinary catheters for prevention of urinary tract infections: correlation of in vivo and in vitro test results

Urinary catheters are widely used for hospitalized patients and are often associated with high rates of urinary tract infection. We evaluated in vitro the antiadherence activity of a novel antiseptic Gendine-coated urinary catheter against several multidrug-resistant bacteria. Gendine-coated urinary catheters were compared to silver hydrogel-coated Foley catheters and uncoated catheters. Bacterial biofilm formation was assessed by quantitative culture and scanning electron microscopy. These data were further correlated to an in vivo rabbit model. We challenged 31 rabbits daily for 4 days by inoculating the urethral meatus with 1.0 x 10(9) CFU streptomycin-resistant Escherichia coli per day. In vitro, Gendine-coated urinary catheters reduced the CFU of all organisms tested for biofilm adherence compared with uncoated and silver hydrogel-coated catheters (P < 0.004). Scanning electron microscopy analysis showed that a thick biofilm overlaid the control catheter and the silver hydrogel-coated catheters but not the Gendine-coated urinary catheter. Similar results were found with the rabbit model. Bacteriuria was present in 60% of rabbits with uncoated catheters and 71% of those with silver hydrogel-coated catheters (P < 0.01) but not in those with Gendine-coated urinary catheters. No rabbits with Gendine-coated urinary catheters had invasive bladder infections. Histopathologic assessment revealed no differences in toxicity or staining. Gendine-coated urinary catheters were more efficacious in preventing catheter-associated colonization and urinary tract infections than were silver hydrogel-coated Foley catheters and uncoated catheters.

epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England

National evidence-based guidelines for preventing healthcare-associated infections (HCAI) in National Health Service (NHS) hospitals in England were commissioned by the Department of Health (DH) and developed during 1998-2000 by a nurse-led multi-professional team of researchers and specialist clinicians. Following extensive consultation, they were published in January 2001. These guidelines describe the precautions healthcare workers should take in three areas: standard principles for preventing HCAI, which include hospital environmental hygiene, hand hygiene, the use of personal protective equipment, and the safe use and disposal of sharps; preventing infections associated with the use of short-term indwelling urethral catheters; and preventing infections associated with central venous catheters. The evidence for these guidelines was identified by multiple systematic reviews of experimental and non-experimental research and expert opinion as reflected in systematically identified professional, national and international guidelines, which were formally assessed by a validated appraisal process. In 2003, we developed complementary national guidelines for preventing HCAI in primary and community care on behalf of the National Collaborating Centre for Nursing and Supportive Care (National Institute for Healthand Clinical Excellence). A cardinal feature of evidence-based guidelines is that they are subject to timely review in order that new research evidence and technological advances can be identified, appraised and, if shown to be effective in preventing HCAI, incorporated into amended guidelines. Periodically updating the evidence base and guideline recommendations is essential in order to maintain their validity and authority. Consequently, the DH commissioned a review of new evidence published following the last systematic reviews. We have now updated the evidence base for making infection prevention and control recommendations. A critical assessment of the updated evidence indicated that the original epic guidelines published in 2001 remain robust, relevant and appropriate but that adjustments need to be made to some guideline recommendations following a synopsis of the evidence underpinning the guidelines. These updated national guidelines (epic2) provide comprehensive recommendations for preventing HCAI in hospitals and other acute care settings based on the best currently available evidence. Because this is not always the best possible evidence, we have included a suggested agenda for further research in each section of the guidelines. National evidence-based guidelines are broad principles of best practice which need to be integrated into local practice guidelines. To monitor implementation, we have suggested key audit criteria for each section of recommendations. Clinically effective infection prevention and control practice is an essential feature of protecting patients. By incorporating these guidelines into routine daily clinical practice, patient safety can be enhanced and the risk of patients acquiring an infection during episodes of healthcare in NHS hospitals in England can be minimised.

Postoperative prophylaxis with norfloxacin in patients requiring bladder catheters

The effect of once daily doses of 200 mg oral norfloxacin on the occurrence of catheter-associated bacteriuria (greater than 1000 CFU/ml) and pyuria was studied in 105 post-operative gynaecologic patients. Norfloxacin was given from the second day after surgery until catheter removal. Bacteriuria developed in 32 of 51 (63%) control patients compared to 8 of 54 (15%) patients receiving norfloxacin (p less than 0.001). Pyuria was present in 22 of 51 (43%) control subjects versus only 3 of 54 (5%) patients treated with norfloxacin (p less than 0.001). Bacteria isolated from control patients comprised species of Enterobacteriaceae (40%), Staphylococcus (35%), and Streptococcus (17%); seven isolates were resistant to multiple antibiotics reflecting their nosocomial origin. In contrast, strains isolated from norfloxacin-treated patients comprised non-fermenting gram-negative rods (79%, usually Alcaligenes or Acinetobacter spp.) and faecal streptococci (12%). It is concluded that once daily doses of 200 mg oral norfloxacin are effective in reducing the rate of catheter-associated bacteriuria and pyuria following reconstructive gynaecologic surgery.

Bladder irrigation with povidone-iodine in prevention of urinary-tract infections associated with intermittent urethral catheterisation

Bladder irrigation with povidone-iodine in the prevention of urinary-tract infections after single or intermittent urethral catheterisation was investigated in a controlled study. In the control group (36 patients) the catheter was removed after urethral catheterisation and emptying of the bladder, and in the trial group (42 patients) 50 ml povidone-iodine 2% was instilled and allowed to drain immediately before removal of the catheter. The incidence of bacteriuria was 28% in the control group and 4% in the povidone-iodine group. After the introduction of bladder irrigation with povidone-iodine in the orthopaedic department of Leiden University Hospital the incidence of hospital-acquired bacteriuria fell from 6.9% to 3.7%.

Genitourinary infections in the patient at risk: extrinsic risk factors

The indwelling urinary catheter is an essential part of modern medical care. It is widely used to relieve temporarily anatomic or physiologic urinary obstruction, to facilitate surgical repair of the urethra and surrounding structures, to provide a dry environment for comatose or incontinent patients, and to permit accurate measurement of urinary output in severely ill patients. Unfortunately, when poorly managed, the indwelling catheter may present a hazard to the very patients it is designed to protect. It is the leading cause of nosocomial induced urinary tract infections and the most common prediposing factor in fatal gram-negative sepsis in hospitals. Catheters drain the bladder, but they obstruct the urethra, producing other major problems such as urethral strictures and epididymitis. Advances in catheter care since the introduction of closed drainage are reviewed. The best means of prevention is the avoidance of use when unnecessary and prompt removal when the need no longer exists. This practice is of particular importance in long-term care institutions. Alternate methods include intermittent catheterization in the paraplegic patient, condom drainage in the nonobstructed patient, and direct drainage of the bladder through the skin. Most recent studies have attempted to improve care of the indwelling catheter by either prevention of periurethral infection (the most common route of acquisition) or sterilization of the drainage bag to prevent ascending infection and cross infection. Thus far, these methods have been unsatisfactory. A new approach to designing drainage systems is clearly needed. Finally, all studies failed to demonstrate the ability of systemic antimicrobial therapy to eradicate catheter-associated infections other than temporarily. Instead, excessive use of antibiotics has led to the emergence of resistant strains that may be spread to other patients through contaminated urine.

Urinary tract infections

The urinary catheter is a fact of medical life. It is a valuable instrument when used for proper indications and when aseptic management is enforced. When improperly used, it is the major source of serious gram-negative infection in hospitalized patients. Male patients who require long-term drainage should be first tried on condom catheter drainage if there is no obstruction to flow or significant residual urine. Condom drainage, however, may lead to severe maceration of the penis if daily changing and cleansing is not done. Indwelling urethral catheters must be attached to a good system of closed drainage whether or not infection is present. Continuous bladder irrigation with neomycin-polymyxin solutions is a useful adjunct once closed drainage is established and working well. Suprapubic catheters are of special value for long-term use because they do not obstruct or irritate the urethra. The development of percutaneous methods of suprapubic drainage should improve and increase the use of this method.

Continuous irrigation of the bladder after prostatectomy: its effect on post-prostatectomy infection

The incidence of post-prostatectomy bacteriuria was measured in patients having no continuous bladder irrigation postoperatively, in those irrigated for 24 hours with chlorhexidine 1/5,000, and in those irrigated with normal saline. The infection rate after saline irrigation was greater than after chlorhexidine, but the infection rates after chlorhexidine irrigation and drainage alone were similar. The infection rate was higher in older patients, in those treated with retropubic rather than transurethral prostatectomies, in those who had postoperative catheters for more than 4 days, and in those admitted in acute retention of urine. The increase in infection rate associated with acute retention was seen only in the group treated with drainage alone postoperatively. Chlorhexidine irrigation appears to reduce the infection rate in these cases.

Evaluation of a vented drainage system in prevention of bacteriuria

A vented urinary drainage system was compared to an otherwise identical non-vented system in a prospective, randomized, double-blind study. Among the 316 female patients evaluated there was a significant reduction in the rate of bacteriuria after 10 days using the vented system (66 per cent in the non-vented group versus 26 per cent in the vented group, p less than 0.05), while no significant difference could be demonstrated among the 190 male patients. We used urine hemoglobin as an indicator of mucosal trauma that might predispose to bacteriuria and no significant difference could be shown between the 2 drainage systems.

New developments in the diagnosis and treatment of urinary tract infections

Not long ago it was customary to expect an atmosphere of confrontation and controversy when urologic surgeons and infectious disease physicians met at conferences and symposia. Even more often each group exhibited an attitude of "benign neglect" towards the other. Times have changed in large part because of the efforts of the leadership group in urology. The establishment of an Advisory Board for this Journal, drawn from non-urological disciplines, is one example of the effort being made to draw together all concerned with urinary tract infections and pyelonephritis. I have been asked to review some practical up-to-date matters relating to the diagnosis and treatment of urinary tract infections and pyelonephritis from the point of view of an infectious disease physician. However, it may be helpful to begin with a synthesis of current concepts of the natural history of urinary tract infection, since the need for early diagnosis and the tactics for treatment depend largely on our expectations for the patient. This synthesis requires definition of terms that are acceptable to a wide variety of disciplines. The review would then focus on new methods for screening and office diagnosis, antimicrobial sensitivity tests, localization of infection and indications for urologic investigation, particularly in relation to vesicoureteral reflux. New developments in treatment of urinary tract infections will be discussed. Special attention will be given to areas in which we are ignorant and require more information. Last, I will direct my attention to the problem of the urinary catheter, hoping to arrive at a synthesis of the situation which will tell it like it is but avoid overstating the case.

Postoperative urinary tract infection and its prevention in gynecology

During recent years, the occurrence and significance of bacteriuria has received much attention. The sequelae of asymptomatic bacteriuria may be far ranging and serious. The difficulty of eradicating chronic pyelonephritis imposes upon physicians the responsibility of preventing situations that predispose patients to its development.Some of the methods for dealing with this problem have been enumerated. The first is, of course, to catheterize only when necessary. Carefully done intermittent catheterization carries a smaller risk of infection than does the use of an indwelling catheter.When the decision to use a catheter has been made the procedure should then be undertaken with a proper size catheter and the most careful technique possible.Good technique is self evident but often neglected. From bladder to bottle continuous and unbroken asepsis must be maintained. An attempt at initially disinfecting the urethra by the use of solutions and lubricants containing antibiotics is worthwhile and safe.