Pyelonephritis primary prevention

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Usama Talib, BSc, MD [2]

Overview

Preventative measures to avoid pyelonephritis include the measures for preventing a urinary tract infection which include voiding after intercourse, use of barrier contraception, increasing fluid intake and frequency of urination, cleaning the urethral meatus after intercourse and use of estrogen (among postmenopausal women). Single-dose prophylactic antimicrobial therapy prior to sexual intercourse may be administered to patients who have recurrent episodes of cystitis that are associated with sexual activity. Prevention of recurrence of cystitis may also be helpful in preventing development of pyelonephritis.

Primary Prevention

The following preventative measures may reduce the risk of urinary tract infections which are an important cause of pyelonephritis:[1][2]

The use of cranberry juice to prevent cystitis and thus pyelonephritis remains controversial. Cranberry Juice is thought to prevent the adherence of uropathogens to urothelial cells, but its benefit is yet to be proven.[8][9]

Catheter Associated UTI Prevention

Avoidance of Unnecessary Catheterization

  • Indications for indwelling catheters are:[10][11]
    • Significant urinary retention
    • Urinary incontinence when non-invasive measures are not indicated or fail
    • Monitoring urinary output
    • Anesthetized patients undergoing certain surgeries
  • Various educational techniques by using guidelines and spreadsheets about the indication and contraindication of catheterization has significantly decreased unnecessary use of catheters and thus associated UTIs.
  • Portable bladder ultrasonography to keep an eye on bladder volumes, help reduce unnecessary catheterization in patients post operatively.[12][13]

Discontinuation of Catheter

  • Catheter removal should be performed as early as possible when it is not required anymore. Early catheter removal can decrease the risk of attaining a urinary tract infection associated with catheterization

Prevention Before Catheter Insertion

Infection prevention
Recommendations and approved guidelines for catheterization, its replacement and protocol for the discontinuation, along with feedback about the rate of getting a UTI can help reduce catheter associated urinary tract infections.[14][15]

Alternatives to Indwelling Catheterization

  • Condom catheter:It is an alternative for short or long-term indwelling urinary catheters, to decrease the chances of attaining an infection in individuals who have normal post-voiding urine volumes.[16][17][18]
  • Intermittent catheterization: This technique is also utilized as a replacement for both short and long-term catheters to reduce the risk and related complications of catheter associated UTI.[19][20]It's commonly used with neurogenic bladder and spinal cord injuries.[21]
  • Suprapubic cathterization: It serves as another alternative for short duration indwelling catherterization to reduce the risk of catheter associated bacteriuria.[22] It is preferred over long duration indwelling catheterization for a decrease in bacteriuria and infections associated with catheters. It is also though to be more comfortable than the indwelling catheter and does not effect sexual function, but its utilization is restricted by the fact that it is an invasive technique and requires expertise of a specialized person.

Indwelling Catheter Insertion Technique
Aseptic measures should be ensured with utilization of sterile equipment. Although there is no clear difference in infection with clean (non-aseptic) technique, it is preferred because of the presence of multi-drug resistant organism in in-patient settings.[22]

Prevention after catheter insertion

  • Closed catheter system: A closed catheter system, which has distal ports for aspiration of urine by the help of a needle, is recommended to curtail catheter associated bacteriuria and UTI, and is utilized for short duration catheters, long duration catheters and suprapubic catheterization. It is significant in regard that it maintains the system closed and connected.[23]
  • Antimicrobial-coated catheters:Silver alloy catheters and antibiotic coated catheters have been considered for decreasing the risk and hampering the development of catheter associated bacteriuria. Thus they can utilized as a replacement for only short duration indwelling catherization.[24][25][26]
  • To prevent resistance to antimicrobial agents, utilization of systemic agents is not recommended for prophylaxis for catheterized patients, including candidates for surgery.[27]
  • Methenamine salts:They can be used for short duration indwelling catheters after gynecological procedures because of their usefulness in decreasing the risk of bacteriuria and UTIs.[28]
  • Povidone-iodine solution, silver sulfadiazine, polyantibiotic ointment or cream, or green soap and water are not proven to have protective effect with respect to catheter associated UTI.[29][30]
  • Surgical candidates with short duration catheterization can have a reduction in incidence of urinary tract infections associated with bacteriuria by bladder irrigaton.[31][32]Irrigaton is not considered useful for long duration catheterization because of the promotion of bacterial infections and the irritation of the mucosa of the urinary bladder.[33]
  • Utilization of antimicrobial agents in the drainage bags has not proven to be helpful.[34][35] There is insufficient data on the utilization of routine chatheter replacement.
  • Antimicrobial prophylaxis: Use of antimicrobial agents given systemicaly or by irrigation of the bladder at the time of the removal of catheter or when placing the catheter is not recommended, because of lack of evidence.[36]

References

  1. ↑ Raz, R.; Stamm, WE. (1993). "A controlled trial of intravaginal estriol in postmenopausal women with recurrent urinary tract infections". N Engl J Med. 329 (11): 753–6. doi:10.1056/NEJM199309093291102. PMID 8350884. Unknown parameter |month= ignored (help)
  2. ↑ H. H. Meyhoff, J. Nordling, P. A. Gammelgaard & R. Vejlsgaard (1981). "Does antibacterial ointment applied to urethral meatus in women prevent recurrent cystitis?". Scandinavian journal of urology and nephrology. 15 (2): 81–83. PMID 7036332.
  3. ↑ Aune A, Alraek T, Huo L, Baerheim A (1998). "[Can acupuncture prevent cystitis in women?]". Tidsskr Nor Laegeforen. 118 (9): 1370–2. PMID 9599500. (cf acupuncture group, x2 incidents in the sham group, x3 in the control group)
  4. ↑ Alraek T, Baerheim A (2001). "'An empty and happy feeling in the bladder.. .': health changes experienced by women after acupuncture for recurrent cystitis". Complement Ther Med. 9 (4): 219–23. PMID 12184349.
  5. ↑ Alraek T, Baerheim A (2003). "The effect of prophylactic acupuncture treatment in women with recurrent cystitis: kidney patients fare better". J Altern Complement Med. 9 (5): 651–8. PMID 14629843. (highlights need for considering different TCM diagnostic categories in acupuncture research)
  6. ↑ Alraek T, Soedal L, Fagerheim S, Digranes A, Baerheim A (2002). "Acupuncture treatment in the prevention of uncomplicated recurrent lower urinary tract infections in adult women". Am J Public Health. 92 (10): 1609–11. PMID 12356607.
  7. ↑ Katz AR (2003). "Urinary tract infections and acupuncture". Am J Public Health. 93 (5): 702, author reply 702-3. PMID 12721123 (no abstract).
  8. ↑ Hooton, TM. (2012). "Clinical practice. Uncomplicated urinary tract infection". N Engl J Med. 366 (11): 1028–37. doi:10.1056/NEJMcp1104429. PMID 22417256. Unknown parameter |month= ignored (help)
  9. ↑ Jepson R, Mihaljevic L, Craig J. "Cranberries for preventing urinary tract infections". Cochrane Database Syst Rev: CD001321. PMID 14973968.
  10. ↑ Saint, S.; Lipsky, BA. (1999). "Preventing catheter-related bacteriuria: should we? Can we? How?". Arch Intern Med. 159 (8): 800–8. PMID 10219925. Unknown parameter |month= ignored (help)
  11. ↑ Jain, P.; Parada, JP.; David, A.; Smith, LG. (1995). "Overuse of the indwelling urinary tract catheter in hospitalized medical patients". Arch Intern Med. 155 (13): 1425–9. PMID 7794092. Unknown parameter |month= ignored (help)
  12. ↑ Lukasse, M.; Cederkvist, HR.; Rosseland, LA. (2007). "Reliability of an automatic ultrasound system for detecting postpartum urinary retention after vaginal birth". Acta Obstet Gynecol Scand. 86 (10): 1251–5. doi:10.1080/00016340701621478. PMID 17851812. Unknown parameter |month= ignored (help)
  13. ↑ Slappendel, R.; Weber, EW. (1999). "Non-invasive measurement of bladder volume as an indication for bladder catheterization after orthopaedic surgery and its effect on urinary tract infections". Eur J Anaesthesiol. 16 (8): 503–6. PMID 10500936. Unknown parameter |month= ignored (help)
  14. ↑ Haley, RW.; Culver, DH.; White, JW.; Morgan, WM.; Emori, TG.; Munn, VP.; Hooton, TM. (1985). "The efficacy of infection surveillance and control programs in preventing nosocomial infections in US hospitals". Am J Epidemiol. 121 (2): 182–205. PMID 4014115. Unknown parameter |month= ignored (help)
  15. ↑ Goetz, AM.; Kedzuf, S.; Wagener, M.; Muder, RR. (1999). "Feedback to nursing staff as an intervention to reduce catheter-associated urinary tract infections". Am J Infect Control. 27 (5): 402–4. PMID 10511486. Unknown parameter |month= ignored (help)
  16. ↑ Ouslander, JG.; Greengold, B.; Chen, S. (1987). "External catheter use and urinary tract infections among incontinent male nursing home patients". J Am Geriatr Soc. 35 (12): 1063–70. PMID 3680838. Unknown parameter |month= ignored (help)
  17. ↑ Hebel, JR.; Warren, JW. (1990). "The use of urethral, condom, and suprapubic catheters in aged nursing home patients". J Am Geriatr Soc. 38 (7): 777–84. PMID 2115057. Unknown parameter |month= ignored (help)
  18. ↑ Saint, S.; Kaufman, SR.; Rogers, MA.; Baker, PD.; Ossenkop, K.; Lipsky, BA. (2006). "Condom versus indwelling urinary catheters: a randomized trial". J Am Geriatr Soc. 54 (7): 1055–61. doi:10.1111/j.1532-5415.2006.00785.x. PMID 16866675. Unknown parameter |month= ignored (help)
  19. ↑ Weld, KJ.; Dmochowski, RR. (2000). "Effect of bladder management on urological complications in spinal cord injured patients". J Urol. 163 (3): 768–72. PMID 10687973. Unknown parameter |month= ignored (help)
  20. ↑ Wyndaele, JJ. (2002). "Complications of intermittent catheterization: their prevention and treatment". Spinal Cord. 40 (10): 536–41. doi:10.1038/sj.sc.3101348. PMID 12235537. Unknown parameter |month= ignored (help)
  21. ↑ Warren, JW. (1997). "Catheter-associated urinary tract infections". Infect Dis Clin North Am. 11 (3): 609–22. PMID 9378926. Unknown parameter |month= ignored (help)
  22. ↑ 22.0 22.1 Carapeti, EA.; Andrews, SM.; Bentley, PG. (1996). "Randomised study of sterile versus non-sterile urethral catheterization". Ann R Coll Surg Engl. 78 (1): 59–60. PMID 8659977. Unknown parameter |month= ignored (help)
  23. ↑ Bryan, CS.; Reynolds, KL. (1984). "Hospital-acquired bacteremic urinary tract infection: epidemiology and outcome". J Urol. 132 (3): 494–8. PMID 6471184. Unknown parameter |month= ignored (help)
  24. ↑ Schumm, K.; Lam, TB. (2008). "Types of urethral catheters for management of short-term voiding problems in hospitalised adults". Cochrane Database Syst Rev (2): CD004013. doi:10.1002/14651858.CD004013.pub3. PMID 18425896.
  25. ↑ Drekonja, DM.; Kuskowski, MA.; Wilt, TJ.; Johnson, JR. (2008). "Antimicrobial urinary catheters: a systematic review". Expert Rev Med Devices. 5 (4): 495–506. doi:10.1586/17434440.5.4.495. PMID 18573048. Unknown parameter |month= ignored (help)
  26. ↑ Brosnahan, J.; Jull, A.; Tracy, C. (2004). "Types of urethral catheters for management of short-term voiding problems in hospitalised adults". Cochrane Database Syst Rev (1): CD004013. doi:10.1002/14651858.CD004013.pub2. PMID 14974052.
  27. ↑ Rutschmann, OT.; Zwahlen, A. (1995). "Use of norfloxacin for prevention of symptomatic urinary tract infection in chronically catheterized patients". Eur J Clin Microbiol Infect Dis. 14 (5): 441–4. PMID 7556234. Unknown parameter |month= ignored (help)
  28. ↑ Lee, BB.; Simpson, JM.; Craig, JC.; Bhuta, T. (2007). "Methenamine hippurate for preventing urinary tract infections". Cochrane Database Syst Rev (4): CD003265. doi:10.1002/14651858.CD003265.pub2. PMID 17943785.
  29. ↑ Burke, JP.; Garibaldi, RA.; Britt, MR.; Jacobson, JA.; Conti, M.; Alling, DW. (1981). "Prevention of catheter-associated urinary tract infections. Efficacy of daily meatal care regimens". Am J Med. 70 (3): 655–8. PMID 7011019. Unknown parameter |month= ignored (help)
  30. ↑ Burke, JP.; Jacobson, JA.; Garibaldi, RA.; Conti, MT.; Alling, DW. (1983). "Evaluation of daily meatal care with poly-antibiotic ointment in prevention of urinary catheter-associated bacteriuria". J Urol. 129 (2): 331–4. PMID 6834501. Unknown parameter |month= ignored (help)
  31. ↑ van den Broek, PJ.; Daha, TJ.; Mouton, RP. (1985). "Bladder irrigation with povidone-iodine in prevention of urinary-tract infections associated with intermittent urethral catheterisation". Lancet. 1 (8428): 563–5. PMID 2857910. Unknown parameter |month= ignored (help)
  32. ↑ Ball, AJ.; Carr, TW.; Gillespie, WA.; Kelly, M.; Simpson, RA.; Smith, PJ. (1987). "Bladder irrigation with chlorhexidine for the prevention of urinary infection after transurethral operations: a prospective controlled study". J Urol. 138 (3): 491–4. PMID 3625846. Unknown parameter |month= ignored (help)
  33. ↑ Elliott, TS.; Reid, L.; Rao, GG.; Rigby, RC.; Woodhouse, K. (1989). "Bladder irrigation or irritation?". Br J Urol. 64 (4): 391–4. PMID 2510901. Unknown parameter |month= ignored (help)
  34. ↑ Sweet, DE.; Goodpasture, HC.; Holl, K.; Smart, S.; Alexander, H.; Hedari, A. (1985). "Evaluation of H2O2 prophylaxis of bacteriuria in patients with long-term indwelling Foley catheters: a randomized controlled study". Infect Control. 6 (7): 263–6. PMID 3847401. Unknown parameter |month= ignored (help)
  35. ↑ Thompson, RL.; Haley, CE.; Searcy, MA.; Guenthner, SM.; Kaiser, DL.; Gröschel, DH.; Gillenwater, JY.; Wenzel, RP. (1984). "Catheter-associated bacteriuria. Failure to reduce attack rates using periodic instillations of a disinfectant into urinary drainage systems". JAMA. 251 (6): 747–51. PMID 6363727. Unknown parameter |month= ignored (help)
  36. ↑ Wazait, HD.; Patel, HR.; van der Meulen, JH.; Ghei, M.; Al-Buheissi, S.; Kelsey, M.; Miller, RA.; Emberton, M. (2004). "A pilot randomized double-blind placebo-controlled trial on the use of antibiotics on urinary catheter removal to reduce the rate of urinary tract infection: the pitfalls of ciprofloxacin". BJU Int. 94 (7): 1048–50. doi:10.1111/j.1464-410X.2004.05102.x. PMID 15541126. Unknown parameter |month= ignored (help)

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