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International Journal of Nursing Studies 45 (2008) 352–361

www.elsevier.com/locate/ijnurstu

Relationship between catheter care and catheter-associatedurinary tract infection at Japanese general hospitals:

A prospective observational study

Toshie Tsuchidaa, Kiyoko Makimotoa,�, Shinobu Ohsakob, Miyoko Fujinoc,Midori Kanedad, Taeko Miyazakie, Fusae Fujiwaraf, Tomoyuki Sugimotog

aDepartment of Nursing, Osaka University, 1-7 Yamadaoka, Suita city, Osaka 565-0871, JapanbItami Municipal Hospital, JapancOsaka Sennin Hospital, JapandSumitomo Hospital, Japan

eTakatsuki Red cross Hospital, JapanfToyonaka Municipal Hospital, Japan

gDepartment of Biomedical Statistics, Osaka University, Japan

Received 7 February 2006; received in revised form 2 October 2006; accepted 19 October 2006

Abstract

Background: The risk factors for catheter-associated urinary tract infections (CAUTIs) that are associated with

catheter care have not been examined in detail by prospective studies or randomised clinical trials.

Objectives: To examine the patterns of catheter care and to identify the CAUTI risk factors associated with catheter

care.

Design: Prospective observational study.

Methods: Between January and December 2004, 555 adult patients who were catheterised for X3 days in five general

hospitals in Japan were surveyed. One researcher collected the following data twice a week: catheter insertion method,

catheter management, and signs and symptoms of urinary tract infections. The relative risk exceeding 1 by the Poisson

regression were selected for Cox proportional hazard analysis in order to calculate adjusted risks. In addition, expected

reductions in the incidence of CAUTIs by elimination of the risk factors were estimated using the population

attributable risk percent.

Results: The mean duration of catheterisation was 25 days. The overall incidence of CAUTIs was 3.9 cases per 1000-

device days; the incidence of CAUTIs ranged from 0.6 to 7.2 cases per 1000-device days among the five hospitals. Only

fecal incontinent patients were analysed since they accounted for 94% of the CAUTI cases. In the univariate analysis,

the silver-alloy catheter, which contains antimicrobial property, emerged as a potential risk. Since silver-alloy catheters

were used in only one hospital, silver-alloy catheter care was compared with that of the other types of catheter, and a

significantly higher percentage of inappropriate care was observed. In the final Cox model, two variables remained:

‘non-pre-connected closed system (standard system)’ (RR 2.35, 95%CI 1.20–4.60, p ¼ 0.013) and ‘no daily cleansing of

the perineal area’ (RR 2.49, 95%CI 1.32–4.69, p ¼ 0.005). The population attributable risk percent suggested that the

use of a ‘pre-connected closed system’ and ‘daily cleansing of the perineal area’ could reduce the incidence of CAUTIs

by nearly 50%.

e front matter r 2006 Elsevier Ltd. All rights reserved.

urstu.2006.10.006

ing author. Tel./fax: +81 6 6879 2541.

esses: tosie@a2.mbn.or.jp (T. Tsuchida), kmakimot@sahs.med.osaka-u.ac.jp (K. Makimoto).

ARTICLE IN PRESST. Tsuchida et al. / International Journal of Nursing Studies 45 (2008) 352–361 353

Conclusions: Our investigation identified fecal incontinence as the major risk factor for CAUTIs in the study

population. However, attributable risk percent indicates that the implementation of two basic elements of catheter care

could reduce CAUTIs by nearly 50%. The hospital using silver-alloy catheters had the highest CAUTI rates, strongly

suggesting the hazards of relying on the antimicrobial property of silver and the resultant laxity in care.

r 2006 Elsevier Ltd. All rights reserved.

Keywords: Catheter-associated urinary tract infection; Daily cleansing of the perineal area; Fecal incontinence; Nursing care; Pre-

connected closed drainage system

What is a already known about the topic?

�

Major risk factors of catheter-associated bacteriuria

can be reduced by following recommended guidelines

in catheter care.

�

Catheter care guidelines to minimise the occurrence

of CAUTIs based on randomised clinical trials,

prospective studies and expert opinions have yet to

be implemented and evaluated.

What this paper adds

�

Fecal incontinence was the major risk factor for

CAUTIs in long-term users of indwelling urethral

catheters.

�

‘Daily cleansing of the perineal area’ could substan-

tially reduce the incidence of CAUTIs in fecal

incontinent patients.

�

Silver-alloy catheters could not protect fecal incon-

tinent patients from CAUTIs when inappropriate

catheter care was provided.

�

Pre-connected closed system may reduce CAUTIs in

fecal incontinent patients who were catheterised for

X10 days.

�

Attributable risk percent should be considered as a

useful tool for estimating cost effectiveness and

prioritising interventions.

1. Introduction

Among healthcare-associated infections, catheter-as-

sociated urinary tract infections (CAUTIs) are char-

acterised by one of the highest rates of occurrence

(Saint, 2000; Platt et al., 1982; Rudman et al., 1988). In

the past three decades, evaluation of new devices to

prevent CAUTIs has been the major focus of CAUTI

prevention research. Although all CAUTI prevention

guidelines (Centers for Disease Control and Prevention,

1981; Department of Health, UK, 2001) have empha-

sised the importance of catheter care, there is little

evidence of their effectiveness in reducing CAUTIs.

Since the invention of the Folley catheter, a closed

drainage system is considered to be the major innova-

tion in catheter management and has been used in Japan

since the 1970s. The pre-connected closed system was

developed to reduce intra-luminal contamination and

has been reported to lower mortality (Platt et al., 1982).

However, Degroot-Kosolcharoen et al. (1988) showed

that it did not reduce the occurrence of bacteriurea.

Coated catheters with antimicrobial properties such as

silver-alloy catheters, were developed to reduce intra-

luminal and/or extra-luminal contamination but are

seldom used in Japan because of their higher cost. This

type of catheter is reported to be effective in reducing

bacteriurea in meta-analyses (Saint et al., 1998, 2002)

and a recent Cochran review (Brosnahan et al., 2006),

but not in another study (Niel-Weise et al., 2002). A

recent systematic review showed that older studies (prior

to 1995) tended to show significant results with regard to

silver-alloy catheters, while its effects were less notice-

able in the later studies. This may be due to the changes

in patient population and better catheter management

(Johnson et al., 2006). Although the effect of silver-alloy

catheter is recognisable in the randomised controlled

trials, most of these studies were poor in quality

(Brosnahan et al., 2006).

In contrast to the evaluation of new devices, catheter

care itself drew little attention in the CAUTI prevention

research. Moreover, the reported catheter care proce-

dures that were designed to minimise the occurrence of

CAUTIs are mostly expert opinions on topics such as

positioning of urinary drainage bags and fluid intake.

Prospective studies or randomised clinical trials that can

validate these opinions have not yet been conducted

(Wilde, 2003; Department of Health, UK, 2001). The

only randomised control trials on catheter care were

those that studied the effect of disinfection on perineal

area using disinfectant or antibiotic cream two or three

times daily (Classen et al., 1991a, b; Huth et al., 1992;

Burke et al., 1981). The results of these studies showed

that such meatal care did not reduce catheter-associated

bacteriuria in short-term catheterised patients.

In Japan, the duration of catheterisation for surgical

patients has been shortened after the introduction of

clinical path, which include the removal of urinary

catheters within 48 h after the surgery. However,

catheterised patients who are not managed according

to the clinical path draw little attention with regard

to catheter management. Only a few small scale

ARTICLE IN PRESST. Tsuchida et al. / International Journal of Nursing Studies 45 (2008) 352–361354

epidemiological surveys on catheter care or UTIs were

reported in Japan. According to a questionnaire survey

of staff nurses in northern hospitals in Japan (Yamada

et al., 2001), the prevalence of daily perineal cleansing

was 50%, and 30% of them used disinfectants or

antimicrobial ointments for the perineal area. The

contents of Japanese UTI prevention guidelines were

similar to those of the Western ones. However, the

guidelines do not provide specific information on

catheter care such as the type of lubricant to be used,

volume of water to be used to inflate the balloon.

The aim of this study was to examine the patterns of

catheter care and identify the CAUTI risk factors that

are associated with catheter care in several general

hospitals in Japan through a prospective observational

study. In addition, the expected reductions in the

incidence of CAUTIs by elimination of the risk factors

were estimated by calculating the population attributa-

ble risk percent.

2. Methods

2.1. Design

A prospective observational study was conducted to

survey catheter care practice and to examine risk factors

in catherized patients for X3 days.

2.2. Subjects and setting

Five general hospitals having over 300 beds in the

Kansai area of Japan participated in the study. Patients

who were eligible for enrolment in the study were: (1)

adult patients who agreed to participate and (2) those

who had been using a urethral catheter for X3 days.

Patients who were excluded were: (1) those who had a

CAUTI at the start of the study and (2) those with a

urethral catheter in place at admission.

2.3. Data collection

Between January and December 2004, one researcher

visited five hospitals twice weekly in order to collect

data. Table 1 shows the list of variables for which

information was collected. These were based on the

Western prevention guidelines (Department of Health,

UK, 2001; Centers for Disease Control and Prevention,

USA, 1981) and a systematic review (Saint and Lipsky,

1999). The standard data collection sheets were used to

collect data shown in Table 1. The signs and symptoms

of UTI observed and recorded by the staff nurse as part

of their routine were abstracted from medical records;

the researcher also assessed the patient for CAUTI twice

weekly. Information related to catheter insertion for

each patient was provided by staff nurses who filled out

the questionnaire. The researcher observed and collected

data on catheter care procedures in all the eligible

patients. Catheter care at each participating hospital was

observed 3 h a day twice weekly for the 1-year study

period, totalling 300 h of direct observation.

The researcher collected urine samples (2ml) through

a sampling port, which was wiped with 70% ethanol.

Dipsticks (Uropapers, Eikenkagaku Co., Tokyo, Ja-

pan) were used to test urine for leukocyte esterase,

nitrate and haemoglobin. Urine cultures were procured

at the request of the attending physician when the

physician suspected UTI.

2.4. Definition of UTI

The following criteria listed by the Centers for Disease

Control and Prevention (CDC) were used to define

symptomatic urinary tract infections (Garner et al.,

1988).

Criterion 1. At least one of the following signs or

symptoms (fever, urgency, frequency, dysuria, suprapu-

bic tenderness) and a positive urine culture (X105).

Criterion 2. At least two of the following signs or

symptoms (fever, urgency, frequency, dysuria, suprapu-

bic tenderness) and positivity for at least one of the

seven categories including dipstick test, pyuria, urine

culture, etc.

2.5. Data analysis

The incidence of CAUTIs was tabulated as per 1000

device-days. The relative risks of all the variables were

calculated, and potential confounders were examined by

cross tabulation. ANOVA was used to assess the

difference between the means when the distribution

was approximately normal; if the distribution was

skewed, the Kruskal–Wallis test was used for assess-

ment.

The Scheffe test was used for a post hoc test. The

relative risk and 95% confidence interval were estimated

for each variable by Poisson regression using Stata 9

(Orikasa, 2002).

All variables with relative risk greater than 1.1 were

subsequently entered into the Cox proportional hazard

regression model. SPSS ver.11.0 was used to perform all

analyses except for calculation of 95% CI in univariate

analysis.

The attributable risk percent was used to estimate the

potential reduction in the percentage of CAUTIs among

the exposed group if the exposure were to be removed.

For the variables retained in the final model, the

population attributable risk percent was used to

estimate the percent reduction in the incidence of

CAUTIs in the participating hospitals if the exposure

were to be eliminated (Kahn and Sempos, 1989).

ARTIC

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Table 1

Collected variables

Categories Data collection source Variables Recommendation based on the guidelines and

reviews

Demographic data Medical record Age, sex, diagnosis at admission, medical history

Insertion of the catheter Questionnaire of the staff nurses Reasons for catheterisation, Relieve urinary tract obstruction, aid in urologic

surgery and measurements of urinary output, etc

Type of lubricant, Single use

Volume of water to inflate the balloon, Filled per manufacture directions

Observation by the researcher Material of the catheter,

Size of the catheter, Small a catheter as possible or 14 or 16 Fr

Type of drainage system, Closed drainage system

Signs and symptoms of

CAUTIs

Medical record Temperature, urine culture, urinalysis,

Observation by the researcher Urgency, frequency, dysuria, suprapubic

tenderness, testing by means of reagent strips,

Conditions of the patient Medical record Fluid intake, , 1/2 ounce/pound/day or 2000–3000 ml/day

fecal incontinencea, activity level, antibiotic use

Catheter management Medical record Frequency of cleansing of perineal areac, catheter

irrigation,

Daily routine bathing or showering

Not to be performed as a routine infection

prevention measure

Type of urine collection containerb, Separate and clean container

placement of drainage bag and tube, Below the level of the bladder and not contact with

the floor or do not allow drainage tubing to fall

below the drainage bag

Observation by the researcher Maintenance of drainage systemd, Not be disconnected

catheter securement, Thigh for female patient and upper thigh or lower

abdomen for menCatheter leakage

Recommendation written by italic is based on review articles.aFecal incontinence: use of a diaper for excretion regardless of the level of consciousness.bUrine collection container: a container that is used to collect urine from a drainage bag.cCleansing of the perineal area: cleansing with warm water and plain soap. Daily or after every excretion or two to three times a week.dMaintenance of drainage system: the connection between the catheter and connecting tube was marked with a line. When the line was not straight, the system was considered to

be disconnect.

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1355

ARTICLE IN PRESST. Tsuchida et al. / International Journal of Nursing Studies 45 (2008) 352–361356

Because the event rate was not known before the

initiation of the study in long-term catheter users, we

used the article by Harrell et al. (1996) which suggests

that 10 events are required for one variable. In addition,

we looked for similar prospective studies with Cox

proportional hazard analysis in which approximately

500 subjects were analysed (Johnson et al., 1990).

2.6. Ethical considerations

This study was approved by (1) the Human Subject

Committee of the Osaka University, Graduate School of

Medicine and (2) the ethical committees of all the five

participating hospitals. The research nurse and chief

nurse of the unit jointly explained to eligible patients

about the research. Patients were advised of their right

to withdraw from the study at any point, and that their

participation status would not affect the care they

received. The names of the facilities and patients’ names

were coded for data entry so that patients’ names could

not be identified.

3. Results

3.1. Demographic profile and catheter use

A total of 555 patients agreed to participate in the

study, and two patients declined to participate. The

mean length of stay in the participating wards of the five

hospitals ranged from 19 to 29 days, and the mean

occupancy rate ranged from 80% to 92%. The mean

catheter utilisation was 17% with a range of 11–20%.

These differences in the means among five hospitals were

not statistically significant. The participating wards

served the departments of internal medicine (30%),

orthopedics (29%), neurology (14%) and neurosurgery

(14%).

Table 2

Patient demographic characteristics, duration of chatheterisation and

5 Japanese hospitals

Hospital Male to female

ratio

Mean age7S.D Duration of

Mean7S.D

A (n ¼ 180) (1:1.7) 78711 22719�

B (n ¼ 77) (1:1.9) 72717 31749

C (n ¼ 33) (1:1) 75711 40740

D (n ¼ 85) (1:2.1) 73714 21736*

E (n ¼ 180) (1:1.2) 70714 25723

Total (n ¼ 555) (1:1.5) 74714 25731

�v.s. Hospital C by post hoc test; po.05.

Table 2 shows the patient demographic character-

istics, duration of catheterisation and CAUTI rates of

the patients who were catheterised for X3 days. The

mean duration of catheterisation was 25 days and the

total number of device-days during the study period was

13,783. The age distribution did not differ significantly

among the five hospitals; however, the male-to-female

ratios differed by as much as a factor of two. There were

significant differences in the duration of catheter use

among the five hospitals. The subjects in whom the

catheter placement exceeded 100 days had been diag-

nosed with cerebrovascular diseases (n ¼ 6), plastic

surgery following burns or decubitus ulcer (n ¼ 2),

transcervical fracture (n ¼ 2), pneumonia and respira-

tory management problems following cardiac arrest

(n ¼ 2) and cirrhosis (n ¼ 1).

3.2. Catheter care and incidence of CAUTI

All the participating hospitals used either a closed

drainage system or a pre-connected closed system; the

pre-connected system was used in 42% of the study

subjects. The catheters were regularly changed at 2–4-

week intervals in all the participating wards. The most

common reason for catheter placement was output

monitoring (45%); this was followed by bed rest (20%),

urinary incontinence (15%), protection of wounds in the

perineal and sacral areas (9%) and ischuria (7%).

The CAUTI incidence differed by a factor of 12

(Table 2). Of a total of 54 subjects with CAUTIs, 19 met

the definition criterion 1 for CAUTI and 35 met the

definition criterion 2 for CAUTI. Of the 54 CAUTI

cases, 51 had fecal incontinence. The CAUTI rate in

subjects with fecal incontinence was 4.3/1000 device-

days, while it was 1.9/1000 device-days in subjects

without fecal incontinence (po0.001). For bed-ridden

patients, bed-bath was provided daily, and full bath was

provided once or twice weekly. The perineal area was

CAUTI rates among patients with X3 days of catheterisation in

catheterisation (days) CAUTI rate (1000

device-days)Median Min–max

15 3–118 4.3

14 3–355 4.3

19 3–163 7.2

10 3–301 0.6

17 3–172 3.9

15 3–355 3.9

ARTICLE IN PRESST. Tsuchida et al. / International Journal of Nursing Studies 45 (2008) 352–361 357

cleansed with soap and water daily in 56% of the

subjects.

3.3. Urine culture

The physician had ordered 94 urine cultures; of these,

57% cultures were positive. A urine culture was advised

when a patient displaying at least one of the following

symptoms: fever of unknown origin (n ¼ 9), suprapubic

pain (n ¼ 9), passing cloudy/murky urine (n ¼ 22) and

reason not specified (n ¼ 54). Additional urine samples

(167) were taken to test the validity of our surveillance

(manuscript in preparation). Among the pathogens

responsible for CAUTI, the percentage of Enterococcus

spp. (32%) was the highest, followed by Escherichia coli

(20%), Pseudomonas aeruginosa (13%), Candida spp.

(13%) and others in patients without antibiotic therapy.

3.4. Comparison of best and worst catheter care practice

Due to the 12-fold difference in the CAUTI incidence

among the hospitals, catheter care was compared

between hospitals with the highest and the lowest

CAUTI rates. Significantly higher percentages of

inappropriate care were observed in the hospital with

the highest rate than those in the hospital with the lowest

rate; clamping the drainage tube (50% vs. 4%,

respectively, po0.001), drainage system disconnected

(65% vs. 40%, po0.001), drainage bag in contact with

the floor (36% vs. 6%, po0.001), drainage bag and tube

Table 3

Relative risks of CAUTI exceeding 1.1 in the univariate analysis

Factors RR

Urine collection container (common v.s. individual) 1.4

Material of catheter (silver-alloy v.s. latex/silicon) 2.0

Size of catheter (^8Fr v.s. %16Fr) 2.6

Lubricant (multiuse v.s. single use) 1.6

Disinfectant for peritoneal area before insertion (0.02%

aqueous chlorhexidine v.s. povidone iodine)

2.6

Drainage system (non-preconnected v.s. pre-connected closed) 1.3

Fecal incontinence (yes v.s. no) 2.8

Daily cleansing of perineal area with tap water and regular soap

(no v.s. yes)

1.5

Catheter irrigation (yes v.s. no) 1.3

Catheter securement (no v.s. yes) 1.3

Table 4

Result of Cox proportional hazard regression model for cases with fe

Risk factors RR

Non-preconnected cloed system 2.35

No daily cleansing of perineal area 2.49

placed higher than the patient’s bladder (63% vs. 38%,

po0.001) and no daily cleansing of perineal area (86%

vs. 25%, po0.001). The percentage of fecal incon-

tinence, the use of closed drainage system and antibiotic

use between these two hospitals did not differ signifi-

cantly.

3.5. Multivariate analysis

Relative risks were tabulated for all the 28 variables

related to catheter care. Of those 28 variables, 18

demonstrated a relative risk of less than 1 and were not

statistically significant. The variables that showed

relative risks of 41.1 are presented in Table 3. Of these

10 variables, the use of silver-alloy catheters and fecal

incontinence were not entered into the multivariate

analysis. First, silver-alloy catheters were used in only

one of the five participating facilities, and could not be

used as a confounder. Second, subjects with fecal

incontinence accounted for 94% of those having

CAUTIs and for 87% of the total device-days. Thus,

only the fecal incontinent subjects were analysed in the

Cox proportional hazard analysis.

Eight variables were entered into the Cox model, and

the following two variables were retained: ‘non-pre-

connected closed system’ and ‘no daily cleansing of

perineal area’ (Table 4). When these two variables were

examined using Kaplan Meier curves, ‘non-pre-con-

nected closed system’ reached statistical significance on

the 10th day after insertion, and ‘no daily cleansing of

95% confidence interval p-value

7 0.82–2.69 0.17

2 0.77–4.53 0.11

9 0.83–6.72 0.06

2 0.65–3.51 0.23

4 0.31–10.05 0.23

8 0.76–2.60 0.27

3 0.92–14.19 0.05

7 0.88–2.82 0.10

0 0.40–3.25 0.56

4 0.66–2.99 0.41

cal incontinence

95% confidence interval p-value

1.20–4.60 0.013

1.32–4.69 0.005

ARTICLE IN PRESS

Demonstrating the difference

between two drainage systems

Demonstrating the difference

between two perineal care groups

P<0.05 on the day of 7 after insertion P<0.05 on the day of 10 after insertion

Fig. 1. Kaplan-Meier curves.

Table 5

The percentage of inappropriate catheter care between the two catheter material groups based on over 300 h of direct observation in

each participating hospital during one-year study period

Inappropriate catheter care Silver-alloy catheter (%) Latex/silicon cathether (%) p-value

Clamping the drainage tube 59.1 13.7 o.001

No catheter securement 95.6 76.5 o.001

No daily cleansing of perineal area 84.0 37.1 o.001

Drainage bag in contact with the floor 40.0 21.3 o.001

Drainage bag and tube placed higher

than the patient’s bladder

62.5 46.9 o.001

Catheter size ^18Fr 7.5 3.6 o.001

Drainage system disconnected 67.8 57.9 o.01

Catheter irrigation 10.0 8.9 o.05

T. Tsuchida et al. / International Journal of Nursing Studies 45 (2008) 352–361358

perineal area’ reached the significance level on the 7th

day after insertion (Fig. 1).

3.6. Type of catheter and catheter care

Although silver-alloy catheters contain anti-microbial

properties, the hospital using silver-alloy catheters had

the highest rate. Therefore, silver-alloy catheter care was

compared with that of the other types of catheters, and a

significantly higher percentage of inappropriate care was

observed in the case of the former rather than in the

latter (Table 5). At the hospital concerned, the silver-

alloy catheters were changed every 3 weeks, whereas the

latex/silicon catheters that were used in the past were

changed every 2 weeks; the rationale behind this

discrepancy is that the silver-alloy catheters are believed

to possess antimicrobial properties.

3.7. Population attributable risk percent

The population attributable risk percent was calculated

for the two variables retained in the final Cox model. The

use of a pre-connected closed system was estimated to

result in a 26% reduction in the incidence of CAUTIs,

and the implementation of daily cleansing of the perineal

area would result in a 20% reduction in the incidence of

CAUTIs in the participating hospitals (Table 6).

4. Discussion

Our study examined the association between catheter

care and CAUTIs, and the results indicate that fecal

incontinence and catheter care are major determinants

in the occurrence of CAUTIs during long-term indwel-

ling urethral catheter use.

ARTICLE IN PRESS

Table 6

Potential reduction in CAUTIs by interventions

Prevalence of exposure

(%)

Attributable risk percent

(%)

Population attributable risk

percent (%)

Use of preconnected closed

drainage system

57 38 26

Daily cleansing of perineal area 42 38 20

T. Tsuchida et al. / International Journal of Nursing Studies 45 (2008) 352–361 359

Although this was an observational study, daily

cleansing of the perineal area seems to be highly effective

for the prevention of CAUTIs in subjects with fecal

incontinence. Data on daily cleansing was evaluated in

an old study (Burke et al., 1981), in which daily

cleansing showed no beneficial effect on the incidence

of bacteriurea. Our study population was extremely

different from that in Burke’s study in which fecal

incontinent patients were probably not included. One-

third of the CAUTI pathogens revealed in this study

were related to fecal contamination and coincidentally,

the percentage is close to the population attributable

risk percent (25%) of daily cleansing of the perineal

area.

The effectiveness of a pre-connected closed system in

preventing CAUTIs was significant after being adjusted

for daily perineal cleansing. Evidence on the efficacy of a

pre-connected system is scarce. A pre-connected system

was evaluated in male surgical and medical patients in

the US. (DeGroot-Kosolcharoen et al., 1988). The

incidence of bacteriurea was low (2%) and over 50%

of bacteriurea cases occurred within 1 week of catheter-

isation, suggesting that the manipulations related to

catheter insertion played a major role in the develop-

ment of bacteriuria (DeGroot-Kosolcharoen et al.,

1988). The discrepancy between the two study results

can be explained by the heterogeneity of the study

populations and the difference in outcome measures.

The use of silver-alloy catheters, which were reported

to be effective in reducing bacteriurea by meta-analyses

and systematic reviews (Saint et al., 1998, 2002;

Brosnahan et al., 2006), turned out to be a risk factor.

Silver-alloy catheters were used in only one of the five

participating facilities; hence, the risk of improper

catheter care could not be examined along with the

adjustment for the type of catheters. A significantly

higher percentage of improper catheter care such as

‘clamping the drainage tube’ or ‘drainage bag in contact

with the floor’ was observed in the facility in question;

this type of care theoretically increases the risk of

catheter contamination (CDC, 1981; Smith, 2003). It

appears that silver-alloy catheters are not effective

unless proper catheter care is provided, and their

effectiveness in long-term catheter use in patients with

fecal incontinence remains to be proven.

Reasons for catheter insertion were inappropriate in

35% of the patients included in the current study; this

value is comparable to those of the other studies (Jain et

al., 1995; Bouza et al., 2001). As the risk of CAUTI

significantly increased after 7 days of catheterisation,

minimising the use of urinary catheter is essential for

reducing the CAUTI incidence. Although the guideline

suggests the immediate removal of the catheter when its

use is no longer indicated, there is a tendency to

maintain non-surgical patients with low morbility on

catheters for an extended period as shown in this study.

The effectiveness of various prevention strategies was

estimated by means of the population attributable risk

percent. The use of a pre-connected closed system and

daily cleansing of the perineal area can be expected to

reduce the incidence of CAUTIs in the participating

hospitals by nearly 50%. While the attributable risk

percent has not been used for healthcare-associated

infection prevention, it could serve as a useful tool for

estimating cost effectiveness and prioritising multiple

interventions.

4.1. Implication for nursing practice

The first prevention guideline for hospital-acquired

UTI was published 25 years ago (CDC, 1981). Since

then, numerous review articles have been published as a

reminder of the importance of basic catheter care

(Godfrey and Evans, 2000; Hampton, 2004). Never-

theless, compliance for the prevention guideline has been

low (Zimakoff et al., 1995; Bouza et al., 2001). An

European UTI survey that involved 141 hospitals in 14

countries showed that the global preventable errors in

urinary catheter management was 53.1%, and open

drain or violated closed drain was found in 36.8% of the

catheterised patients (Bouza et al., 2001).

Nurses have been taught the principles of infection

control; however, they may not be able to interpret and

implement these principles into practice. Therefore,

translation of the prevention guideline into clinical

practice is required. Infection control nurses should

observe catheter care and provide specific catheter care

procedures in each hospital. One of the typical violations

of the recommended care observed in this study was that

when a catheterised patient was transferred from a bed

ARTICLE IN PRESST. Tsuchida et al. / International Journal of Nursing Studies 45 (2008) 352–361360

to a wheelchair, the urinary bag was hanged at the side

of the wheel chair, thereby placing it at a level higher

than that of the patient’s bladder. Transferring knowl-

edge regarding avoidance of common errors may be

insufficient to change the erroneous practices. Periodic

audit is probably necessary to check the reasons for

catheterisation (Brennan and Evans, 2001) and to

improve the compliance to basic catheter care.

4.2. Limitation of the study

Symptomatic CAUTIs were used as the outcome

measure in the current study because of their clinical

significance; nevertheless, bacteriurea may be a more

sensitive measure of outcome than symptomatic CAU-

TIs to examine different types of catheter care proce-

dures that lead to microbial contamination. The

majority of our study subjects were 70 years of age

and over and were less likely to have a body temperature

greater than 38 1C, which is a criterion for symptomatic

urinary tract infections (Travis and Lampley-Dallas,

1997; Brown, 2002; Melillo, 1995). Signs and symptoms

of CAUTIs were assessed and recorded by staff nurses in

each hospital. Ideally, a researcher would have assessed

patients for CAUTIs every day. Nevertheless, the

development of fever or other symptoms of CAUTIs

always prompted attending physicians to carry out a

differential diagnosis for CAUTI. Thus, it is unlikely to

miss symptomatic CAUTIs based on two sources of

data collection, i.e., research nurse’s assessment for

CAUTIs twice weekly and medical records.

The frequency of obtaining urine cultures may be less

than optimal in this study although no comparable data

on the frequency of urine cultures are available in the

literature. Furthermore, catheter management in Japan

is different from that in the Western countries, where

regular replacement of catheters is not recommended.

However, it is unclear whether a regular catheter change

could reduce the risk of CAUTIs in fecal incontinent

patients; this issue needs to be addressed in future

research.

5. Conclusion

Our investigation identified fecal incontinence as the

major risk factor for CAUTIs in long-term indwelling

urethral catheter users in five participating general

hospitals in Japan. However, attributable risk percent

indicates that the implementation of a ‘pre-connected

closed system’ and ‘daily cleansing of the perineal area’

could reduce CAUTIs by nearly 50% in patients with

fecal incontinence. The hospital that used silver-alloy

catheters had the highest CAUTI rates; this strongly

suggests the hazards of relying on the antimicrobial

property of silver and the resulting laxity in care.

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