Spotlight on superbugs sparks concern over catheter use

In late May, health officials confirmed the arrival of a new antibiotic-resistant “superbug” present in a 49-year-old Pennsylvania woman. The news was alarming, but not unexpected, as doctors have long predicted that the over-use of antibiotics would someday result in strains of bacteria that can resist even the most powerful antibiotics available. It now appears that this dreaded scenario has become a reality for the first time in the United States.

Related: Antibiotic stewardship programs: 4 case studies

What is important to note is that the antibiotic-resistant bacteria was found in a urinary tract infection (UTI). That is key because UTIs are extremely common. Millions of patients are affected each year, and each year a growing number of UTIs are antibiotic-resistant.

UTIs put a significant strain on the healthcare system, thanks to patient re-admittance. One study pinned the annual cost to Medicare patients of 30-day re-admissions due to UTIs at $621 million, but the reality is that UTIs are frequently preventable.

Despite national attention on the issue-as well as the burden on the healthcare system-UTIs are still among the most common hospital-acquired infections (HAIs). The question is, why aren’t more people focused on the fact that most urinary tract infections are the result of catheter use?

While precise numbers are not available, it is believed that about one in four hospital patients has a catheter collecting their urine-putting them at risk of a potentially dangerous UTI.  Further, it has been estimated that up to 50% of these urinary catheters are unnecessarily placed. The alarm over the arrival of the new superbug offers good reason for overuse of catheters to be taken much more seriously.

What can doctors do to prevent catheter-associated UTIs?

Quite simply, the best way to prevent infections that result from catheter use is to take a measured look at the insertion of catheters in the first place. In a March report on antibiotic resistance, the Centers for Disease Control offers a clear directive to medical personnel: use catheters only when needed. Doctors typically prescribe high doses of antibiotics with catheter insertion as well as removal; overuse of antibiotics leads to antibiotic resistance and the development of antibiotic-resistant bacteria.

In my Oxford, Fla., practice, I’ve been focused on prevention of catheter-associated UTIs (CAUTIs) by exploring alternatives to the catheter whenever possible. For some, catheter insertion may be a necessary course of treatment. But for many others, a safer alternative, requiring less antibiotic exposure, is an option.

Alternative approach

Despite the clear link between urinary catheter use, UTIs and the costs involved in re-admissions, catheters remain the standard of care for patients who are unable to drain their bladder. The key to maximizing the use of alternatives to the catheter rests with education-specifically, educating physicians who are unaware of other options that can enhance patient care and reduce re-admissions.

In my practice, we have used a temporary prostatic stent as an alternative to catheters. It is particularly useful for the treatment of male patients suffering from chronic urinary retention as a result of prostate enlargement. Unlike a catheter, the stent allows a patient to naturally fill and empty his bladder. What’s more, the absence of the type of external component that is part of a catheter helps prevent bacteria from entering the body and significantly reduces the risk of urinary tract infections.

A male with a stent can conduct the full range of daily activities that is far more difficult with a leg bag and regular catheter maintenance. Consider how many older men enjoy golf as a recreational activity, for instance; catheter use and maintenance severely restricts the ability to spend four hours on a golf course. Sexual activity is restricted with a catheter, and even sound sleep is often compromised.

There are important benefits to using a prostate stent, and two of the benefits align perfectly with the CDC’s efforts to prevent healthcare-associated infections: a stent avoids infections related to the placement of a catheter, and a stent helps minimize antibiotic use. Reducing antibiotic exposure is a key component of the treatment protocol I have been implementing with many of my patients.

Next: Antibiotic reduction protocol

Antibiotic reduction protocol

My interest in removal of the catheter dates back several decades, and my focus on using a temporary prostate stent as an alternative course of treatment dates back several years-with positive patient outcomes, specifically as it pertains to infection rates.

I conducted a 10-month chart review in 2015, with data collected on 114 temporary prostatic stents placed in 37 patients (66 to 96 years old). Stents were in place for an average of 27 days at a time and included a range of profile groups: patients in chronic, subacute and temporary retention, and patients with and without history of passive drainage devices.

The results were eye-opening, as only two infections were realized among the 114 temporary prostatic stent placements. The standard method for measuring CAUTI rates is in UTIs per 1,000 days of catheter use, and the CDC’s National Healthcare Safety Network considers the baseline CAUTI rate to be 5 UTIs per 1,000 catheter days. My study concluded with 0.97 UTIs per 1,000 stent days-a strong indication that stent use reduces the risk of UTI.

How does this conclusion relate to antibiotic resistance? My standard protocol is to prescribe just one dose of antibiotics at the time of stent insertion, with no additional antibiotic necessary with the temporary prostatic stent in place or at the time of removal. With low risk for infection, most patients using the stent limit their antibiotic exposure, and reduce their likelihood of being impacted by antibiotic resistant bacteria.

Related: Antibiotic resistance: Impact on cost, outcomes

Conclusion

The CDC has been a prominent driver of education and outreach around protecting patients from antibiotic-resistant superbugs. It’s up to healthcare professionals involved in the treatment of patients to seek all possible avenues to ensure that patient exposure to superbugs is limited.

There is an undeniable link between catheter insertion, infections and antibiotic-resistant bacteria. But new, innovative approaches to treating male patients who are otherwise pegged for catheter insertion are changing the entire paradigm around CAUTIs. By re-thinking the use of catheters and considering alternatives whenever possible, both doctors and patients can help alleviate one of the biggest concerns related to hospital infections and superbugs.

Richard Roach, MD, is partner in Advanced Urology Institute, Oxford, Florida. His specialties include plasma vaporization for BPH, treatment of female stress incontinence and penile prosthesis for ED. He is also an expert in laser and laparoscopic surgery.