ARTICLE IN PRESS

American Journal of Infection Control ■■ (2018) ■■-■■

Contents lists available at ScienceDirect

American Journal of Infection Control American Journal of

Infection Control

j o u r n a l h o m e p a g e : w w w. a j i c j o u r n a l . o r g

Major Article

Efficacy of bladder irrigation in preventing urinary tract infections

associated with short-term catheterization in comatose patients:
A randomized controlled clinical trial
Farahnaz Ramezani MSN a, Mahnaz Khatiban PhD b,*, Farshid Rahimbashar MD c,
Ali Reza Soltanian d
a
School of Nursing and Midwifery, Hamadan University of Medical Sciences, Hamadan, Iran
b Mother & Child Care Research Center, Department of Medical Surgical Nursing, School of Nursing and Midwifery, Hamadan University of Medical
Sciences, Hamadan, Iran
c
Department of Anesthesiology, School of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran
d Modeling of Noncommunicable Disease Research Center, Department of Biostatistics and Epidemiology, School of Public Health, Hamadan University of

Medical Sciences, Hamadan, Iran

Key Words: Background: Bladder irrigation can be performed to prevent catheter-associated urinary tract infec-
Coma tions (CAUTI), but its efficacy has been not reported in short-term indwelling urinary catheterization. This
intensive care units clinical trial aimed to examine the efficacy of bladder irrigation with normal saline solution in prevent-
ing CAUTI in comatose patients admitted to intensive care units.
Materials and methods: Eligible patients were randomized to the experimental group or control group.
The experimental group received daily bladder irrigation with 450 cc sterile normal saline, in 3 150-mL
doses, for 3 consecutive days. Data on signs of CAUTI, including urine culture, axillary body temperature
(primary outcomes), and other urine and blood parameters (secondary outcomes) were obtained at base-
line and 5 days later.
Results: Results of group comparisons and logistic regression analysis that controlled for fluid intake showed
that the risk of CAUTI decreased by 99% in the experimental group compared with the control group (odds
ratio, 0.01; P < .001). Additional findings indicated a decrease in axillary body temperature and improve-
ments in urine appearance, urinary red cells and white cells, and erythrocyte sedimentation rates and
white-cell counts in the blood following bladder irrigation.
Conclusion: Daily bladder irrigation with normal saline during 3 days demonstrated efficacy in prevent-
ing CAUTI in comatose patients.
© 2018 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier
Inc. All rights reserved.

* Address correspondence to Mahnaz Khatiban, PhD, Mother & Child Care Research
Center, Department of Medical Surgical Nursing, School of Nursing and Midwifery,
Hamadan University of Medical Sciences, Hamadan, Iran.
E-mail address: mahnaz.khatiban@gmail.com (M. Khatiban).
FR and FR are currently affiliated with Besat Specialized and Super-Specialized
Hospital, Hamadan, Iran.
MK is currently affiliated with Mother & Child Care Research Center, School of
Nursing and Midwifery, Hamadan University of Medical Sciences, Hamadan, Iran.
ARS is currently affiliated with Modeling of Noncommunicable Disease Re-
search Center, School of Public Health, Hamadan University of Medical Sciences,
Hamadan, Iran.
Supported by the research and technology vice-chancellor at Hamadan Univer-
sity of Medical Sciences. The funding source had no role in the course of study,
research, or assembly of the manuscript.
Conflicts of interest: None to report.
In intensive care units, short-term indwelling urinary catheter-
ization is a fairly routine practice. It is done for 15%-25% of critically
ill adult patients1,2 to monitor urine output and guide fluid resus-
citation, as well as to facilitate daily patient care.3 Catheterization
has been shown to increase the risk of catheter-associated urinary
tract infections (CAUTIs). CAUTIs are manifested by positive urine
culture and at least 1 of these signs and symptoms: fever, supra-
pubic or costovertebral angle pain or tenderness, urinary urgency,
urinary frequency, and dysuria.4 It is estimated that 97% of UTIs re-
ported in hospitals occurred in catheterized patients.5 UTIs can
develop in less than a week following catheterization and are related
to several risk factors. Health care providers’ inappropriate

0196-6553/© 2018 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.ajic.2018.05.009
 ARTICLE IN PRESS
2 F. Ramezani et al. / American Journal of Infection Control ■■ (2018) ■■-■■
application of aseptic techniques during catheterization and poor
hand hygiene facilitate the transfer of external bacteria into the
bladder. Further, less-than-optimal management of the catheter and
drainage tube, along with immobility and incomplete bladder emp-
tying in comatose patients6 may lead to urinary stasis, which provides
a favorable medium for bacterial growth. The bacteria colonize the
internal lumen of the catheter and form a biofilm,7 which can lead
to CAUTI and catheter blockage.8 CAUTIs increase the burden of care,
length of intensive care and hospital stay, and the cost of care.9
Clinical guidelines recommend a range of strategies for reduc-
ing the risk of CAUTI associated with long-term indwelling urinary
catheterization. Bladder irrigation or washout has been advocated
as standard management of long-term catheters.10 However, a recent
Cochrane review11 found inconclusive evidence to support the ef-
fectiveness of bladder irrigation in preventing CATUI. It is plausible
that this finding is related to variability in the design and imple-
mentation of the irrigation protocol, including the types and volumes
of the solution used, the frequency and timing at which the irri-
gation procedure was done, and the specific techniques applied.
There is limited evidence of the influence of bladder irrigation on
the prevention of CATUI in critically ill, comatose patients with short-
term indwelling urinary catheters. This clinical trial was designed
to address this gap in knowledge.
The overall purpose of this clinical trial was to examine the ef-
ficacy of bladder irrigation on the prevention of CAUTIs in critically
ill, comatose patients catheterized for a short term (<30 days) and
receiving care in an intensive care unit. Critically ill patients are often
sedated or comatose and unable to report on the symptoms of UTI
(eg, pain and dysuria).12 Therefore, the objective signs of CAUTI were
assessed in this trial.
The specific trial objectives were to determine the effects of
bladder irrigation on primary outcomes, including urine colony
forming units per milliliter and patients’ axillary body tempera-
ture (°C). Secondary outcomes included urine parameters such as
urine specific gravity, pH, white blood cell (WBC) and red blood cell
(WBC) deposits, epithelial cells per high power field, and nitrite, as
well as blood parameters such as erythrocyte sedimentation rate
(ESR), WBCs, and RBCs.
MATERIAL AND METHODS
Design
A prospective, blinded, randomized controlled trial design was
used. Eligible patients were randomly assigned to the experimen-
tal group or control group as specified by the study group code
number written on a card placed in an opaque envelope. Partici-
pants in the experimental group received, in addition to usual care,
bladder irrigation following the protocol described in a later section,
whereas those in the control group were exposed to usual care,
which consisted of routine catheter care. Outcome data were col-
lected at the same time points in both groups: time 1, within 48
hours of catheterization (representing baseline), and time 2, 5 days
later (representing posttest); CAUTIs can develop with the 5-day time
period. Participants’ masking was maintained because they were
comatose. The outcome assessors and laboratory specialists were
blinded to the participants’ study group.
The trial was registered the Iranian Registry of Clinical Trials
(IRCT201702134578N6). It was conducted according to the prin-
ciples of the Declaration of Helsinki. The trial protocol was approved
by the Research Ethics Committee at Hamadan University of Medical
Sciences, Iran (IR.UMSHA.REC.1395.495) and the participating hos-
pital. Because patients were comatose, written informed consent
obtained from their family members.
Sample
Patients were eligible if they were aged 18 years or older, were
comatose, and had an indwelling urinary catheter within 48 hours
before the specimen collection resulted a positive urine culture of
≥103 CFU/mL.13 The exclusion criteria included a history of chronic
disease influencing kidney function (eg, diabetes, chronic kidney
disease, nephrosclerosis, acute or chronic glomerulonephritis, py-
elonephritis, immune deficiency disorders such as lupus
erythematosus, rheumatoid arthritis, urethral and/or bladder trauma,
current aminoglycoside therapy, and having an infection in other
body systems such as respiratory or wound infection). A patient’s
participation in the trial was terminated if his or her catheter was
removed for any reason, or if they were transferred to another hos-
pital unit.
The sample size calculation was informed by the results of a study
by Samimi et al 14 that compared the effects of 2 solutions
(chlorhexidine and normal saline [NS]) used in bladder irrigations
on the prevention of CAUTIs. Based on these results, the probabil-
ity of a positive urine culture was estimated at 73.2% in the control
group (p1) and at 50% in the experimental group (p2). Setting the
power at 80% and a 2-sided significance level (α) at 0.05, and ap-
plying the formula presented below, the number of participants
required in each study group was 24. To account for a possible 20%
dropout rate over the course of the trial, 30 participants were in-
cluded in each of the experimental and the control groups, for a total
of 60.
2
⎡ ⎤
⎢ Z1− α p (1 − p ) + Z1− β p1 (1 − p1 ) + p2 (1 − p2 ) ⎥
n= ⎣ 2 ⎦ ≅ 24
( p1 − p2 )2
Over the 7-month trial period (June-December 2017), all pa-
tients who were admitted to the participating intensive care unit
and were catheterized (n = 139), were screened for eligibility. Of those
meeting all eligibility criteria (n = 62), 60 were recruited, and their
family members provided written consent.
Treatment protocol
A 3-way indwelling urinary catheter was needed to prevent
backflow of urine into the bladder during irrigation.15 To maintain
comparability on catheter type, a 3-way catheter was used for all
patients in the control and experimental groups.
Usual care protocol
At the participating intensive care unit, usual care included
routine catheter care, as described in clinical practice guidelines.
It involved performing hand hygiene, wearing sterile gloves, main-
taining an uncontaminated area, using an aseptic technique and
sterile insertion technique, securing catheter to the patients’ thighs
with adhesive tape and below the level of the bladder, regularly emp-
tying the collecting bag, and changing indwelling catheters and the
drainage bags every 3 days or based on clinical indications such as
infection, obstruction, or leakage.
Bladder irrigation protocol
In addition to usual care, participants in the experimental group
received the bladder irrigation protocol, which involved these steps.
Skilled aseptic techniques were adhered to when inserting the cath-
eter at the start of the study. The bladder irrigation was done once
a day, in the evening, for 3 consecutive days. The irrigation solu-
tion was NS (0.9%). The volume used in the irrigation was estimated
on the basis of normal bladder capacity (400-600 cc) and normal
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F. Ramezani et al. / American Journal of Infection Control ■■ (2018) ■■-■■ 3

filling (150-300 cc), which triggers the urge to urinate.16 Accord-
ingly, the daily bladder irrigation was done with 450 cc, given in 3
doses (150 cc each) of NS kept at room temperature; each 150 cc
was injected into the bladder slowly, over a 10-minute period.17 The
catheter was clamped to keep the solution in the bladder for 10
minutes. The clamp was reopened to allow drainage of all the in-
jected solution, determined by measuring the volume of the drained
solution and comparing it with the volume of the instilled solu-
tion; the drained volume was equal to or greater than the volume
instilled.
Data collection
Data on participants’ demographic (eg, age and sex) and clini-
cal (eg, medical diagnoses) characteristics were obtained from their
medical records at time 1. A checklist was developed to guide the
collection of outcome data from the medical records. The check-
list included information on the specific outcome parameter and
instructions on what specific respective data to extract from the
records. The face and content validity of the checklist was con-
firmed by a panel of 14 experts, including 8 faculty members of the
medical-surgical nursing department, 3 intensive care nurses, 2 in-
tensive care unit specialists, and an infection specialist.
The primary outcomes were laboratory test results of the urine
culture, including presence and type of microorganism colony and
urine colony forming units per milliliter, and axillary body tem-
perature measured by a medical thermometer after calibration.
Axillary body temperature values ranging from 35.5°C-37.0°C in-
dicated normal temperature and those >37.0°C indicated the presence
of fever.18
The secondary outcomes were results of the laboratory test for
the blood parameters of ESR, WBCs, and RBCs. Values 10-19 mm/
hour (adult men) and 15-23 mm/hour (adult women) for ESR, 5.0-
10.0 (×103/μL) for WBCs, and 4.5-6.0 million/μL (adult men) and 4.2-
5.0 million/μL (adult women) on RBC; results of laboratory test for
the urine analysis parameters of appearance (clear), specific gravity
(normal, 1.002-1.035), pH (normal, 6-7.4), WBC (≤ 1) and RBC de-
posits (= 0), and epithelial cells (< 5) per high power field and nitrite
(negative) were considered as normal range.19
RESULTS
Table 1 presents the average values on the demographic and clin-
ical characteristics of participants in the experimental and control
groups. With randomization, the 2 groups did not differ on most
characteristics (P > .05), as shown in Table 1. However, the volume
of fluid intake through intravenous or nasogastric tube was signifi-
cantly larger in the control group than the experimental group
(P < .05). Linear and logistic regression analyses were performed to
examine the effects of bladder irrigation, controlling for the base-
line difference in fluid intake.
Primary outcomes
Urine colonization
The urine colony forming units for patients in the control and
experimental groups at time 1 (baseline) and time 2 (5 days later)
are shown in Figure 1. The χ2 test results indicated that the colony
forming units per milliliter was similar for both groups at time 1
(P > .05), but was significantly lower in the experimental group than
that in the control group at time 2 (P < .001). The McNemar test
showed a significant decrease in colony forming units in the ex-
perimental group at time 2 (P < .001). The result of the logistic
regression analysis demonstrated that the risk of infection in the
experimental group decreased by 99% compared with the control
group (odds ratio, 0.01; P < .001) when controlling for fluid intake
(Table 2).
Axillary body temperature
The Mann-Whitney U test results showed no statistically sig-
nificant difference in axillary body temperature between the
experimental and control groups at time 1 (P > .05), but revealed a
significant difference between the 2 groups at time 2 (P < .05). The
experimental patients’ axillary body temperature was within normal
range at time 2 compared with time 1 (P < .001). The linear regres-
sion analysis found that, after controlling for fluid intake, bladder
irrigation contributed to a decrease in temperature (t = −0.20; B =
−0.193; P < .05) (Table 2).

Table 1
Comparison of differences in demographic and clinical characteristics between the 2 groups of patients

Variable Control (n = 30) Experiment (n = 30) P value

Age, y* 60.53 ± 18.70 62.97 ± 15.33 > .05
Glasgow Coma Scale/Score* 7.33 ± 3.04 7.23 ± 1.98 > .05
Length of stay in intensive care unit, d* 8.97 ± 8.93 8.53 ± 7.03 > .05
Intravenous serum, mL/24 h* 2,383.33 ± 552.16 1,983.33 ± 700.78 < .05
Nasogastric feeding, mL/24 h* 1,096.67 ± 815.57 1,318.33 ± 750.57 > .05
Gender† > .05
Female 13 (43.3) 17 (56.7)
Male 17 (56.7) 13 (43.3)
History of diseases‡ > .05
No 11 (36.7) 9 (30)
Hypertension 19 (63.3) 19 (63.3)
Colon cancer 0 (0.0) 2 (6.7)
Diuretic medications† > .05
Yes 2 (6.7) 2 (6.7)
No 28 (93.3) 28 (93.3)
Antibiotic medications† > .05
Meropenem 7 (23.3) 13 (43.3)
Cefazolin 11 (36.7) 10 (33.3)
Ceftriaxone 6 (20.0) 3 (10.0)
Metronidazole 1 (3.3) 0 (0.0)
Cefepime 1 (3.3) 1 (3.3)

NOTE. Values are presented as mean ± standard deviation or n (%).

*Based on t test.
†Based on χ2 test.
‡
Based on Fisher exact test.
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The patients were assessed for eligibility

(n = 139).

Eligible patients (n = 62)

Excluded patients (n = 2, no consent)

Random
Allocation

Control group (n = 30 patients) Experimental group (n = 30 patients)

Baseline
Routine care Assessment Routine care + Bladder irrigation

Analysis (n = 30) Final Analysis (n = 30)

Assessment

Fig 1. Trial profile.

Table 2
Comparing differences in catheter-associated urinary tract infection variables between the 2 groups of patients before and after intervention

Variable Control (n = 30) Experiment (n = 30) P value P value

Urine, CFU/mL < .001 (Odds ratio, 0.01)
Baseline
< 100,000 12 (40.0) 4 (13.3) .05*
≥ 100,000 18 (60.0) 26 (86.7)
Day 5
< 100,000 7 (23.3) 28 (93.3) < .001*
≥ 100,000 23 (76.7) 2 (6.7)
P value .05† < .001†
Axillary temperature, °C .032 (t = −0.20;
Baseline 37.76 ± 0.43 37.77 ± 0.28 > .05‡ B = −0.193)
Day 5 37.67 ± 0.39 37.46 ± 0.25 < .05‡
P value > .05§ < .001§

NOTE. Values are presented as n (%) or mean ± standard deviation.

*Based on χ2 test.
†Based on McNemar test.
‡Based on Mann-Whitney U test.
§
Based on Wilcoxon test.

Secondary outcomes
Urine parameters
No statistically significant between-group differences in all urine
parameters were found at time 1. However, significant differences
were reported for urine appearance, WBC and RBC deposits, and pH,
by the Fisher exact test. Although the appearance of urine in most
patients was turbid at time 1, the number of patients who had turbid
urine decreased only in the experimental group at time 1 (P < .05)
(Table 3). Similarly, the RBC and WBC deposits in the urine and urine
pH decreased significantly in the experimental group, as found by
Fisher exact test and regression analysis. Bladder irrigation had no
effect on the other urine parameters, including epithelial cell
numbers, specific gravity, and urine nitrite level (P > .05) (Table 3).
Blood parameters
Although comparable at time 1, the experimental and control
groups differed at time 2 in the blood parameters of ESR, WBC, and
RBC. This difference was maintained after controlling for fluid intake
in the regression analysis (Table 4).
DISCUSSION
Overall, the trial’s findings suggest that bladder irrigation was
successful in preventing CAUTI in short-term catheterization of crit-
ically ill, comatose patients. Significant improvements were observed
in the primary outcomes, urine colony forming units, and axillary
body temperature, in patients who received bladder irrigation, using
450 cc NS, once a day, over a 3-day period. Significant improve-
ments were also found for 3 secondary outcomes; specifically urine
appearance, urinary RBC and WBC deposits, and erythrocyte sed-
imentation rates.
The results of the trial are comparable with those of 2 previous
studies17,20 despite differences in duration of catheterization, target
population, and bladder irrigation protocol. van den Heijkant et al20
conducted a small-scale study involving children catheterized
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Table 3
Comparing differences in categorical variables between the 2 groups of patients before and after intervention

Baseline Day 5

Variable Control Experiment Control Experiment

Urine appearance
Clear 1 (3.3) 0 (0.0) 2 (6.7) 5 (16.7)
Subturbid 2 (6.7) 2 (6.7) 2 (6.7) 9 (30.0)
Turbid 27 (90.0) 28 (93.3) 26 (86.7) 16 (53.3)
P value > .05* < .05*
Urine epithelial cell count (normal, 0-5/high power field)
≤5 29 (97.7) 25 (83.3) 28 (93.3) 30 (100)
>5 1 (3.3) 5 (16.7) 2 (6.7) 0 (0.0)
P value > .05* > .05*
Urine-specific gravity (normal, 1.002-1.035)
1,000-1,010 2 (6.7) 2 (6.7) 1 (3.3) 1 (3.3)
1,010-1,020 7 (23.3) 3 (10.0) 6 (20.0) 2 (6.7)
1,020-1,030 21 (70.0) 25 (83.3) 23 (76.7) 27 (90.0)
P value > .05* > .05*
Urine nitrite
Negative 28 (93.3) 28 (93.3) 28 (93.3) 30 (100)
Positive 2 (6.7) 2 (6.7) 2 (6.7) 0 (0.0)
P value > .05* > .05*
Colony type (urine culture)
Proteus mirabilis 2 (6.7) 3 (10.0) 1 (3.3) 1 (3.3)
Staphylococcus aureus 7 (23.3) 2 (6.7) 4 (13.3) 0 (0.0)
Providencia sp 6 (20.0) 9 (30.0) 7 (23.3) 4 (13.3)
Escherichia coli 9 (30.0) 5 (16.7) 9 (30.0) 3 (10.0)
Enterococcus 3 (10.0) 4 (13.3) 5 (16.7) 0 (0.0)
Streptococcus 1 (3.3) 1 (3.3) 1 (3.3) 0 (0.0)
Acinetobacter sp 1 (3.3) 1 (3.3) 1 (3.3) 2 (6.7)
Klebsiella 1 (3.3) 5 (16.7) 0 (0.0) 5 (16.7)
No growth 0 (0.0) 0 (0.0) 2 (6.7) 15 (50.0)

NOTE. Values are presented as n (%).

*Based on Fisher exact test.

Table 4
Comparing differences in numerical variables between the 2 groups of patients before and after intervention

Variable Control (n = 30) Experiment (n = 30) P value Linear regression model

Urine pH (normal, 6.0-7.4)
Baseline 5.9 ± 1.06 5.5 ± 0.82 ‖ > .05 t = −2.11
Day 5 5.4 ± 0.93 5.03 ± 0.13 B = –0.751
P value < .05* < .01* P = .04
Urine count of WBCs (leukocytes) (normal, < 2) t = 3.30
B = −7.877
P = .002
Baseline 16.07 ± 10.74 15.17 ± 9.81 > .05†
Day 5 13.8 ± 8.38 5.73 ± 5.21
P value > .05* < .001*
Urine count of red blood cells † (normal, 0) t = −4.52,
Baseline 19.8 ± 8.96 20.87 ± 9.74 > .05† B = −7.967
Day 5 16.77 ± 7.81 9.47 ± 6.96 P < .001
P value > .05* < .001*
Blood erythrocyte sedimentation rate, mm/h† t = −2.04
Baseline 46.9 ± 28.28 68.43 ± 30.37 < .01‡ B = −0.36
Day 5 42.91 ± 23.49 51.17 ± 26.92 P = .046
P value > .05§ < .001§
Blood WBCs, cells/μL t = 0.22
B = 205.1
P = .835
Baseline 1,3034.7 ± 1,6867.6 11,360.0 ± 3,888.3 > .05†
Day 5 9,793.33 ± 2,944.1 9,680.0 ± 4,083.1
P value > .05* < .001*

NOTE. Linear regression model after moderation effects of volume (in milliliters) of intravenous serum and nasogastric tube intake. Values are presented as mean ± stan-
dard deviation.
WBC, white blood cell.
*Based on Wilcoxon signed-rank test.
‡
Based on t test.
†Based on Mann-Whitney U test.
§Based on paired t test.
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following bladder surgery, and a bladder irrigation protocol using
50 cc NS or NS with acetylcysteine. The irrigation was performed
to prevent calculi formation and catheter obstruction. The find-
ings supported the benefits of bladder irrigation in preventing
recurrent UTIs and in reducing the incidence of calculi formation.20
Richter et al17 compared the effects of bladder irrigation done pre-
operatively to those of no irrigation in patients undergoing
prostatectomy. The irrigation protocol consisted of holding 50-
60 cc povidone-iodine solution in the bladder for 10-13 minutes,
which was found to be highly effective in reducing the incidence
of bacteriuria.17 In contrast, the trial’s findings are dissimilar to those
of a recent study that evaluated the efficacy of bladder irrigation
in community-dwelling persons with neurogenic bladder. The ir-
rigation was done twice daily for 8 weeks, using 30 cc sterile saline,
acetic acid, or neomycin-polymyxin solution. None of the 3 solu-
tions was efficacious in reducing the incidence of bacteriuria or
pyuria.21 The differences in our trial’s and this study’s findings can
be related to the differences in target population (chronic vs acute
condition, respectively); duration of catheterization (long vs short
term, respectively); and irrigation solution, amount, and frequency.
Although the results of a recent Cochrane review were incon-
clusive in supporting the effectiveness of bladder irrigation in
preventing CAUTIs,11 those of our trial are promising and encour-
age further research. It may be important to standardize the bladder
irrigation protocol to improve its consistent implementation and
hence the protocol’s influence on preventing deposits, calculi, and
clot retention that can lead to urine stasis and UTIs. Health care pro-
viders, including urologists, general practitioners, and advance
practice nurses appear to have limited knowledge of the benefits
of bladder irrigation.22 Knowledge translation initiatives are rec-
ommended to enhance their knowledge and skills in applying
bladder irrigation in short- and long-term catheterization.
The prospective, blinded, randomized trial design and the stan-
dardized bladder irrigation protocol are strengths of our trial and
enhance internal validity. The trial’s findings should be inter-
preted with caution in light of 3 possible limitations. Although
determined with power analysis, the sample size was small, lim-
iting the ability to detect significant between-group differences in
some secondary outcomes. The bladder irrigation was done using
a 3-way indwelling urinary catheter, limiting the applicability of the
irrigation protocol and the replicability of the findings with a 2-way
urinary catheter. Some of the primary (eg, body temperature) and
secondary (eg, ESR and blood cell count) outcomes examined in this
trial are also indicators of other infections, such as respiratory and
wound infections. Patients were carefully selected for this trial to
control for these potential confounds; however, it is plausible that
some participants could have acquired these infections during the
trial period, which can be responsible for the nonsignificant im-
provement in the parameters reported at time 2.
CONCLUSIONS
Our findings provide evidence supporting the effectiveness of
bladder irrigation in reducing colony forming units and fever in crit-
ically ill, comatose patients with short-term catheterization. Bladder
irrigation could also decrease urine turbidity, urinary WBC and RBC
deposits, and erythrocyte sedimentation rates that could be indi-
rectly associated with CAUTI. Bladder irrigation with NS, done once
a day, could be considered a promising, easy to implement, and cost-
effective intervention for preventing CAUTI in critical care settings.
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