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International Journal of Nursing Studies 45 (2008) 352361 www.elsevier.com/locate/ijnurstu

Relationship between catheter care and catheter-associated urinary 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
a

Department of Nursing, Osaka University, 1-7 Yamadaoka, Suita city, Osaka 565-0871, Japan b Itami Municipal Hospital, Japan c Osaka Sennin Hospital, Japan d Sumitomo Hospital, Japan e Takatsuki Red cross Hospital, Japan f Toyonaka Municipal Hospital, Japan g Department 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 ve 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 1000device days; the incidence of CAUTIs ranged from 0.6 to 7.2 cases per 1000-device days among the ve 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 signicantly higher percentage of inappropriate care was observed. In the nal Cox model, two variables remained: non-pre-connected closed system (standard system) (RR 2.35, 95%CI 1.204.60, p 0.013) and no daily cleansing of the perineal area (RR 2.49, 95%CI 1.324.69, p 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%.
Corresponding author. Tel./fax: +81 6 6879 2541.

E-mail addresses: tosie@a2.mbn.or.jp (T. Tsuchida), kmakimot@sahs.med.osaka-u.ac.jp (K. Makimoto). 0020-7489/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2006.10.006

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Conclusions: Our investigation identied 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; Preconnected 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 substantially reduce the incidence of CAUTIs in fecal incontinent patients. Silver-alloy catheters could not protect fecal incontinent 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-associated urinary tract infections (CAUTIs) are characterised 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 emphasised 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 intraluminal 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 signicant results with regard to silver-alloy catheters, while its effects were less noticeable 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 procedures that were designed to minimise the occurrence of CAUTIs are mostly expert opinions on topics such as positioning of urinary drainage bags and uid 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

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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 specic information on catheter care such as the type of lubricant to be used, volume of water to be used to inate 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 attributable risk percent.

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 (2 ml) through a sampling port, which was wiped with 70% ethanol. Dipsticks (Uropapers, Eikenkagaku Co., Tokyo, Japan) 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. Denition of UTI The following criteria listed by the Centers for Disease Control and Prevention (CDC) were used to dene symptomatic urinary tract infections (Garner et al., 1988). Criterion 1. At least one of the following signs or symptoms (fever, urgency, frequency, dysuria, suprapubic tenderness) and a positive urine culture (X105). Criterion 2. At least two of the following signs or symptoms (fever, urgency, frequency, dysuria, suprapubic 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 KruskalWallis test was used for assessment. The Scheffe test was used for a post hoc test. The relative risk and 95% condence 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 nal 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).

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 ve 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 lled out

Table 1 Collected variables Categories Data collection source Variables Recommendation based on the guidelines and reviews T. Tsuchida et al. / International Journal of Nursing Studies 45 (2008) 352361

Demographic data Insertion of the catheter

Medical record Questionnaire of the staff nurses

Age, sex, diagnosis at admission, medical history Reasons for catheterisation, Type of lubricant, Volume of water to inate the balloon, Material of the catheter, Size of the catheter, Type of drainage system, Temperature, urine culture, urinalysis, Urgency, frequency, dysuria, suprapubic tenderness, testing by means of reagent strips, Fluid intake, , fecal incontinencea, activity level, antibiotic use Frequency of cleansing of perineal areac, catheter irrigation, Type of urine collection containerb, placement of drainage bag and tube,

Relieve urinary tract obstruction, aid in urologic surgery and measurements of urinary output, etc Single use Filled per manufacture directions Small a catheter as possible or 14 or 16 Fr Closed drainage system

Observation by the researcher

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Signs and symptoms of CAUTIs

Medical record Observation by the researcher

Conditions of the patient Catheter management

Medical record Medical record

1/2 ounce/pound/day or 20003000 ml/day Daily routine bathing or showering Not to be performed as a routine infection prevention measure Separate and clean container Below the level of the bladder and not contact with the oor or do not allow drainage tubing to fall below the drainage bag Not be disconnected Thigh for female patient and upper thigh or lower abdomen for men

Observation by the researcher

Maintenance of drainage systemd, catheter securement, Catheter leakage

Recommendation written by italic is based on review articles. a Fecal incontinence: use of a diaper for excretion regardless of the level of consciousness. b Urine collection container: a container that is used to collect urine from a drainage bag. c Cleansing of the perineal area: cleansing with warm water and plain soap. Daily or after every excretion or two to three times a week. d Maintenance 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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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 ve 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 identied.

Table 2 shows the patient demographic characteristics, 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 signicantly among the ve hospitals; however, the male-to-female ratios differed by as much as a factor of two. There were signicant differences in the duration of catheter use among the ve hospitals. The subjects in whom the catheter placement exceeded 100 days had been diagnosed with cerebrovascular diseases (n 6), plastic surgery following burns or decubitus ulcer (n 2), transcervical fracture (n 2), pneumonia and respiratory management problems following cardiac arrest (n 2) and cirrhosis (n 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 24week 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 denition criterion 1 for CAUTI and 35 met the denition 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 devicedays, 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

3. Results 3.1. Demographic prole 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 ve 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 1120%. These differences in the means among ve hospitals were not statistically signicant. 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 CAUTI rates among patients with X3 days of catheterisation in 5 Japanese hospitals Hospital Male to female ratio (1:1.7) (1:1.9) (1:1) (1:2.1) (1:1.2) (1:1.5) Mean age7S.D Duration of catheterisation (days) Mean7S.D A (n 180) B (n 77) C (n 33) D (n 85) E (n 180) Total (n 555) 78711 72717 75711 73714 70714 74714 22719 31749 40740 21736* 25723 25731 Median 15 14 19 10 17 15 Minmax 3118 3355 3163 3301 3172 3355 4.3 4.3 7.2 0.6 3.9 3.9 CAUTI rate (1000 device-days)

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

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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 9), suprapubic pain (n 9), passing cloudy/murky urine (n 22) and reason not specied (n 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. Signicantly 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 oor (36% vs. 6%, po0.001), drainage bag and tube
Table 3 Relative risks of CAUTI exceeding 1.1 in the univariate analysis Factors Urine collection container (common v.s. individual) Material of catheter (silver-alloy v.s. latex/silicon) Size of catheter (^8Fr v.s. %16Fr) Lubricant (multiuse v.s. single use) Disinfectant for peritoneal area before insertion (0.02% aqueous chlorhexidine v.s. povidone iodine) Drainage system (non-preconnected v.s. pre-connected closed) Fecal incontinence (yes v.s. no) Daily cleansing of perineal area with tap water and regular soap (no v.s. yes) Catheter irrigation (yes v.s. no) Catheter securement (no v.s. yes)

placed higher than the patients bladder (63% vs. 38%, po0.001) and no daily cleansing of perineal area (86% vs. 25%, po0.001). The percentage of fecal incontinence, the use of closed drainage system and antibiotic use between these two hospitals did not differ signicantly. 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 signicant. 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 ve 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-preconnected closed system and no daily cleansing of perineal area (Table 4). When these two variables were examined using Kaplan Meier curves, non-pre-connected closed system reached statistical signicance on the 10th day after insertion, and no daily cleansing of

RR 1.47 2.02 2.69 1.62 2.64 1.38 2.83 1.57 1.30 1.34

95% condence interval 0.822.69 0.774.53 0.836.72 0.653.51 0.3110.05 0.762.60 0.9214.19 0.882.82 0.403.25 0.662.99

p-value 0.17 0.11 0.06 0.23 0.23 0.27 0.05 0.10 0.56 0.41

Table 4 Result of Cox proportional hazard regression model for cases with fecal incontinence Risk factors Non-preconnected cloed system No daily cleansing of perineal area RR 2.35 2.49 95% condence interval 1.204.60 1.324.69 p-value 0.013 0.005

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Demonstrating the difference between two perineal care groups

Demonstrating the difference between two drainage systems

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 Clamping the drainage tube No catheter securement No daily cleansing of perineal area Drainage bag in contact with the oor Drainage bag and tube placed higher than the patients bladder Catheter size ^18Fr Drainage system disconnected Catheter irrigation Silver-alloy catheter (%) 59.1 95.6 84.0 40.0 62.5 7.5 67.8 10.0 Latex/silicon cathether (%) 13.7 76.5 37.1 21.3 46.9 3.6 57.9 8.9 p-value o.001 o.001 o.001 o.001 o.001 o.001 o.01 o.05

perineal area reached the signicance level on the 7th day after insertion (Fig. 1).

3.7. Population attributable risk percent The population attributable risk percent was calculated for the two variables retained in the nal 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).

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 signicantly 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 silveralloy 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.

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 indwelling urethral catheter use.

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T. Tsuchida et al. / International Journal of Nursing Studies 45 (2008) 352361 Table 6 Potential reduction in CAUTIs by interventions Prevalence of exposure (%) Use of preconnected closed drainage system Daily cleansing of perineal area 57 42 Attributable risk percent (%) 38 38 Population attributable risk percent (%) 26 20 359

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 benecial effect on the incidence of bacteriurea. Our study population was extremely different from that in Burkes study in which fecal incontinent patients were probably not included. Onethird 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 signicant after being adjusted for daily perineal cleansing. Evidence on the efcacy 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 catheterisation, suggesting that the manipulations related to catheter insertion played a major role in the development 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 ve participating facilities; hence, the risk of improper catheter care could not be examined along with the adjustment for the type of catheters. A signicantly higher percentage of improper catheter care such as clamping the drainage tube or drainage bag in contact with the oor 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 signicantly 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 rst 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). Nevertheless, 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 specic 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

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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 patients bladder. Transferring knowledge regarding avoidance of common errors may be insufcient 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 signicance; nevertheless, bacteriurea may be a more sensitive measure of outcome than symptomatic CAUTIs to examine different types of catheter care procedures 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 nurses 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.

References
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5. Conclusion Our investigation identied fecal incontinence as the major risk factor for CAUTIs in long-term indwelling urethral catheter users in ve 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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