CONTINENCE

Using an antimicrobial skin cleanser

before catheterisation
Tim Sandle
and they need to understand the
Community nurses caseloads may include a large number of infection risks of catheterisation
catheterised patients and catheter-related infection is a significant and how to combat them.
problem, with up to 90100% of those who are catheterised long-
term going on to develop a catheter-associated urinary tract This article looks at the microbial
infection (CAUTI). For community nurses, ensuring that their risks associated with catheterisation
skin and that of the patient has been cleansed before any catheter- in the community. It examines the
related intervention is paramount. This article looks at the use of findings of a new study, which looked
a new antimicrobial cleansing solution (octenilin; Schlke) and at an antimicrobial cleansing solution
whether its properties reduced the infection risk associated with (octenilin; Schlke) and whether its
catheterisation in the community. properties reduced the infection risk
associated with catheterisation.

KEYWORDS: CATHETERISATION
Continence Catheters Urinary tract infection Infection control
Many people transferring from
hospital to primary care will

M
anaging patients in the
community involves a
number of challenges
that differ significantly to those of
hospital-based healthcare. This is
particularly relevant to infection
control. In the hospital environment
the patients surroundings and
personal hygiene can, to a certain
extent, be managed. However, in
the community, these circumstances
are not so easily controlled. For a
range of patients, infection control
can be a particular challenge, for
example those with indwelling
catheters, leg ulcers or post-surgical
wound sites.
Tim Sandle, Head of Microbiology,
Bio Products Laboratory Limited, Watford
Nurses visiting patients homes
needs a certain skill-set to work
in an environment that may be
contaminated with household
refuse or pets, for example,
and where there may be issues
around showering and washing.
Community nurses caseloads
can include a large number of
catheterised patients with differing
issues. For example, blocked urinary
catheters are a significant problem
for district nurses (Evans and
Painter, 2001), and many end of life
patients have catheter-related needs
(Young and Conway, 2011).
Catheter-related infection is a
significant problem between
1030% of patients who are
catheterised for a short period
(24 days) develop bacteria in the
urine (bacteriuria), a figure that
rises to 90100% of those who are
catheterised long-term (Brusch,
2013). Similarly, approximately 80%
of hospital-related (including post-
discharge) urinary tract infections
(UTIs) are related to urethral
catheterisation (Brusch, 2013).
This means that catheter-related
infection can take up a significant
amount of community nurses time
have a urinary catheter still in
place (Seymour, 2007). Similarly,
many patients seen regularly by
community nurses, such as elderly
patients in nursing homes, will
have a long-term catheter in situ.
Therefore, community nurses need
to understand the basic principles
behind this common procedure.
The purpose of urinary
catheterisation is to drain urine from
the bladder into a collection device,
such as a catheter bag. The catheter
itself comprises a flexible tube,
usually manufactured from silicone,
which is inserted through the urethra
or sometimes via an abdominal
incision (suprapubic catheterisation).
In order to perform catheterisation,
the clinician guides the catheter into
the bladder permitting urine to flow
into the drainage device (Ghaffary et
al, 2013).
Urinary catheters can be in place
for either a short time or be used as
a longer-term measure.
Reasons for short-term
catheterisation might include:
Post surgery when anaesthetic
has interfered with bladder
function

30 JCN 2013, Vol 27, No 5

 CONTINENCE
In preparation for procedures
such as hysterectomy
To monitor urine output
To deal with temporary blockage
such as gall stones.
Long-term catheterisation is
often necessary in the following:
People who can no longer control
their bladder due to nerve damage
(neuropathic bladder)
To treat urinary incontinence
(loss of bladder control), for
example in patients with spinal
injury or late-stage dementia.
Community nurses are more
likely to see patients with long-
term catheterisation, although as
mentioned above, some patients
will be discharged from hospital
with a short-term catheter in place.
The risk of infection increases
the longer a patient is catheterised
and best practice dictates that
the procedure should be avoided
unless clinically essential and,
even then, should be removed as
soon as possible to avoid potential
complications including, infection,
bacteraemia, haematuria, urethritis
and bladder perforation (Saint et al,
2006; A Strategy for the Control of
Antimicrobial Resistance in Ireland
[SARI], 2006).
RISKS ASSOCIATED WITH
CATHETERISATION
UTIs are one of the commonest
healthcare-associated infections
(HCAIs) and up to 80% of these
are related to urinary catheters
(Lo et al, 2008). In common with
any invasive healthcare procedure,
catheterisation carries an infection
risk, in this case bacteriuria (a
bacterial infection of in the urine).
UTIs can have a number of causes:
The patients own colonic flora
coming into contact with
the urethra
Contamination from the
environment, such as other
patients, the healthcare
environment or bacteria in
the home
Cross-infection from the hands
of healthcare staff
The outer layers of the patients
own skin.
32 JCN 2013, Vol 27, No 5
Once bacteria enter the bladder,
they can multiply rapidly and in
more serious cases, symptoms
include (Chenoweth and Saint,
2011):
Dysuria
Frequency
Urgency
Pain
Fever.
There are a number of
steps that the community
nurse can take to reduce the
risk of catheter-associated
infections.
The presence of urinary catheters
and the length of time they remain
in situ are both contributory factors
to the development of what is
known as catheter-associated
urinary tract infection (CAUTI)
(Saint and Chenoweth, 2003), as are
contamination originating from the
patients skin, or that transferred
from the hands of healthcare staff.
CAUTI
CAUTI is a frequent and
problematic HCAI, which causes
discomfort and can result in serious
health problems if left undetected.
These infections often develop
because of inadequate skin cleansing
before the catheter is inserted, or
from cross-contamination from the
hands of healthcare workers, such
as community nurses (Pratt et al,
2007). It has often been debated
whether the use of an antimicrobial
on the skin before insertion could be
effective in reducing the likelihood
of infection.
Bacteria colonise a catheter and
form biofilms, which involve clusters
of cells covered in a protective matrix
of polysaccharide polymers (Kirker,
2009; Greener, 2011). Another
problem is that some of bacteria
may include antibiotic-resistant
pathogens, including Escherichia
coli, Klebsiella sp., Enterobacter sp.,
Proteus sp. and Citrobacter sp., and
Pseudomonas aeruginosa, which
makes them difficult to treat
(Sandle, 2013).
CAUTIs are common and
contribute up to 40% of all HCAIs
(Kennedy et al, 2013). Some
community patients are more at
risk, including:
Women
Older male patients in long-
term residential care
Those who are
immunocompromised
Patients with diabetes mellitus
(Infection Control Today, 2006).
REDUCING THE RISKS OF
CATHETERISATION IN THE
COMMUNITY
There are a number of steps that
the community nurse can take
to reduce the risk of catheter-
associated infections when caring
for patients at home or in a primary
care setting, such as a residential
facility. These include (Health
Protection Scotland, 2012):
Ensure that there is a regular
review of the need for the
indwelling urinary catheter
Remove if possible
Ensure the connection between
the indwelling urinary catheter
and the drainage system is not
interrupted, except to meet
clinical requirements (e.g. when
changing the bag)
Make sure regular meatal (area
around the urethra) hygiene is
performed
Make sure the drainage bag
is emptied when clinically
indicated; avoid touching
the drainage tap with any
environmental surface
Ensure hand hygiene is
performed and gloves are worn
before touching the indwelling
urinary catheter.
In terms of the last point
above, there is an ongoing debate
as to the use of soap and water
for hand hygiene and whether an
antimicrobial substance would
be more efficient. Some evidence
exists that antimicrobials contribute
to the elimination of CAUTIs
(Matsumoto et al, 1997; Pickard
et al, 2012) and the efficiency of
antimicrobials for skin cleansing
was demonstrated in a recent
study, using octenilin cleaning
solution.

Octenilin incorporates
octenidine dihydrochloride as its
active ingredient, which acts as
a broad-spectrum antimicrobial
and is suitable for use on skin,
mucous membrane and for wound
antisepsis. Octenilin also contains
ethylhexylglycerin (a conditioning
agent and preservative), which
reduces the skins surface tension,
providing optimal moistening and
cleansing, even on difficult-to-
reach areas.
STUDY INTO THE
ANTIMICROBIAL EFFECTIVENESS
OF A SKIN CLEANSER
For community nurses, being able
to ensure that their skin and that
of the patient has been adequately
cleansed before any catheter-
related intervention is paramount.
Community nurses can find
themselves dealing with different
patients in a variety of environments
and the ability to easily transport a
reliable antimicrobial could have a
major impact on patient care.
A recent study conducted in an
independent laboratory compared
an antimicrobial (octenilin cleaning
solution) with a standard hand-
washing procedure to reduce the
microbial content of the skin.
The study involved 30 skin tests
using different subjects for both
techniques. To safeguard the safety
of the subjects, the microorganism
chosen was Escherichia coli strain
K12 (which is safe to use in
humans). E.coli is representative
of the types of contamination that
could be associated with catheters
(Nicolle, 2005).
Before the study, the forearms
of all subjects were washed to
Table 1: A summary of the experimental data, showing the average values obtained for the
octenilin cleaning solution (study A) and saline studies (study B) compared with the control counts
Results
octenilin cleaning solution
Control counts
Mean counts from skin tests
Maximum count
Minimum count
Mean percentage reduction
ensure that most of the natural skin
bacteria were removed, then the E.
coli (less than 200 colony forming
units [CFUs] per arm) were applied
to the forearms and allowed to dry.
The study was repeated twice
during the first episode, the efficacy
of octenilin cleaning solution
was examined and the numbers
of remaining microorganisms
measured. For the second study,
saline (0.9% w/v solution) was
used before the numbers of
microorganisms were again
measured. Both solutions were
left in contact with the subjects
forearms for two minutes.
Before the study, the
forearms of all subjects were
washed to ensure that most
of the natural skin bacteria
were removed.
The microorganisms were
assessed using a contact agar plate
(the growth medium was tryptone
soya agar) and incubated for five
days at a temperature of 3035oC.
Following this, the numbers of
surviving colonies were calculated.
Before depositing the bacteria
onto the arm, the number of
bacterial cells were assessed. This
allowed any surviving bacteria,
post-treatment, to be compared to
a control count. The reduction in
bacteria from each of the subjects
forearms was then calculated by
comparison with the controls. The
comparative efficiency of both
octenilin cleaning solution and
saline were compared in relation
to the reduction in microorganisms
achieved by each solution (Table 1).
Study A: Study B:
0.9% saline solution
144 CFU 121 CFU
13 CFU 55 CFU
31 CFU 98 CFU
0 CFU 12 CFU
91% 55%
CONTINENCE
The study concluded that
octenilin cleaning solution had a
greater effect, eliminating 91% of
the known bacterial population,
compared with the saline rinse,
which removed 55%. The average
population of the control counts
varied a little, with the octenilin
receiving a higher challenge
while the differences were not of
great significance, the numbers
show the large extent to which the
bioburden on the forearms of each
subject were reduced.
CONCLUSION
Community nurses visit a large
variety of patients in a wide
range of settings and one of the
commonly encountered problems
is that of CAUTI. This article
has discussed the problems
associated with catheterisation in
the community, and highlighted
some of the measures that can
be taken by community nurses
to reduce the contamination risk,
including cleansing the skin before
catheterisation as well as during
any catheter-related intervention.
In an independent study, the
use of an antimicrobial solution
demonstrated superior microbial
reduction properties compared
with a saline rinse. Based on this,
it would be prudent for community
nurses to consider the use of an
antimicrobial before the insertion or
management of a catheter. JCN
REFERENCES
Brusch JL (2013) Catheter-Related Urinary
Tract Infection. Available online at:
http://emedicine.medscape.com/
article/2040035-overview (accessed 23
October, 2013)
Chenoweth CE, Saint S (2011) Urinary
tract infections. Infect Dis Clin North Am
25(1):10315
Evans E, Painter D (2001) Blocked urinary
catheters: nurses preventive role. Nurs
Times 97(1): 37
Ghaffary C, Yohannes A, Villanueva C,
Leslie SW (2013) A practical approach
to difficult urinary catheterizations. Curr
Urol Rep [epub ahead of print]
Greener M (2011) Octenidine:
antimicrobial activity and clinical efficacy.
Wounds UK 7(3): 748
JCN 2013, Vol 27, No 5 33
CONTINENCE

Health Protection Scotland (2012) by meatal disinfection. Dermatology 195

Preventing Catheter-associated Urinary
Tract Infections Community Settings.
Available online at: http://www.
documents.hps.scot.nhs.uk/hai/
infection-control/evidence-for-care-
bundles/key-recommendations/cauti-
community.pdf [accessed 22 October,
2012]
Infection Control Today (2006)
CAUTI. Available online at: http://
www.infectioncontroltoday.com/
articles/2006/06/cautis.aspx [accessed 22
October, 2013]
Seymour C (2007) Transferring patients
with a urinary catheter. Nurs Times
103(42): 524
Kennedy EH, Greene MT, Saint S (2013)
Estimating hospital costs of catheter-
associated urinary tract infection. J Hosp
Med 8(9): 51922
Kirker KR, Secor PR, James GA, et al
(2009) Loss of viability and induction
of apoptosis in human keratinocytes
exposed to Staphylococcus aureus biofilms
in vitro. Wound Rep Regen 17: 6909
Lo E, Nicolle L, Classen D, Arias KM,
Podgorny K, Anderson DJ, et al (2008)
Strategies to prevent catheter-associated
urinary tract infections in acute care
hospitals. Infect Control Hosp Epidemiol 29
(Suppl 1): S41S50
Matsumoto T, Sakumoto M, Takahashi
K, Kumazawa J (1997) Prevention of
catheter-associated urinary tract infection
Suppl 2: 737
Nicolle LE (2005) Catheter-related urinary
tract infection. Drugs Aging 22(8): 62739
Pickard R, Lam T, Maclennan G, et al
(2012) Types of urethral catheter for
reducing symptomatic urinary tract
infections in hospitalised adults requiring
short-term catheterisation. Health Technol
Assess 16(47): 1197
Pratt RJ, Pellowe CM, Wilson JA, et al
(2007) Epic 2: National evidence-based
guidelines for preventing healthcare-
associated infections in NHS hospitals in
England. J Hosp Infection 65S: S1S64
SARI (2006) Guidelines for the Prevention of
Catheterassociated Urinary Tract Infection.
HSE Health Protection Surveillance
Centre, Dublin
Sandle T (2013) Bacterial adhesion: an
introduction. J Validation Technol June
18. Available online at: http://www.
ivtnetwork.com/article/bacterial-
adhesion-introduction
Saint S, Chenoweth CE (2003) Biofilms
and catheter-associated urinary tract
infections. Infect Dis Clin North Am 17(2):
41132
Saint S, Kaufman SR, Rogers MA, Baker
PD, Boyko EJ, Lipsky BA (2006) Risk
factors for nosocomial urinary tract-
related bacteremia: a case-control study.
Am J Infect Control 34(7): 4017
Young J, Conway C (2011) Urinary catheter
use in end of life care. Nurs Times 107: 29
KEY POINTS
Community nurses caseloads
may include a large number of
catheterised patients.
Catheter-related infection can
take up a significant amount of
community nurses time and they
need to understand the infection
risks of catheterisation and how
to combat them.
Community nurses are more
likely to see patients with long-
term catheterisation, although
some patients in their caseloads
will be discharged from hospital
with a short-term catheter
in place.
The presence of urinary
catheters and the length of
time they remain in situ are
both contributory factors to
the development of catheter-
associated urinary tract
infection.
For community nurses, being
able to ensure that their skin
and that of the patient has been
adequately cleansed before any
catheter-related intervention
is paramount.

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