Catheter Irrigation Solution - source to buy? - Indwelling Urinary Catheter Encrustations - etiology & prevention

[Guest guest]

I'm in search of a foley catheter irrigation solution.See below regarding the problem and treatment of catheter encrustation.Anyone have a source for ordering?Specifically...Suby G solution

Optiflo G solutionUrotraineret alMost of these seem to be available in the UK, but I can't seem to find a source in the US.Anyone else using a different solution for encrustations and catheter irrigation?

thanks Locke, MD---------- Forwarded message ----------

Date: Tue, Nov 2, 2010 at 12:47 PMSubject: Indwelling Urinary Catheter Encrustations - etiology & preventionTo: Hospice IDG <HOTV-IDGgooglegroups>, Hospice PAQIC <HOTV-PAQICgooglegroups>

Recent

discussion about recurrent encrustations on a patient's indwelling catheter.

Here

is what I could find.

 

It

sounds like irrigation with an acidic solution is helpful - Suby G or

Renacidin

 or Mandelic acid

 

Possibly

acidifying the urine helps - although some bacteria thrive on acidic urine and

this might worsen that situation.

 

All

silicone catheter might prevent encrustation compared to other catheters -

latex, etc.

 

Anyone

else with ideas?

 

Locke

=================================

This

is probably the most succint discussion section...

 

http://www.o-wm.com/content/indwelling-catheter-management-from-habit-based-evidence-based-practice

 

 Catheter

encrustation.

Catheter

encrustation occurs in up to 50% of long-term catheterized patients and can

lead to emergency room visits and frequent catheter changes.27

Encrustation

is caused by infection of the urinary tract by Proteus mirabilis or other urease-producing

bacteria.

The

activity of the urease raises the urinary pH (>7), causing precipitation of

calcium and magnesium phosphates that attach to biofilm on the catheter inner

and outer surfaces.33

Studies

have shown that antibiotics or antiseptic solutions are ineffective at

eradicating biofilms.42

Patients are classified as either “blockersâ€(patients who consistently and

repeatedly develop encrustations, resulting in decrease urine flow) or

“non-blockers.â€27,35

 Acidifying the urine with cranberry juice or pills or vitamin C has not been

shown to delay or decrease encrustation and blockage; however, a recent study

found that increasing fluids decreased time until blockage.43

In addition, studies have shown that acidic irrigant solutions instilled into

the bladder can dissolve encrustations, although further studies are needed

regarding optimal volume and frequency and the effects on bladder mucosa.27

In patients with frequent blockage due to encrustations, a prescription citric

acid bladder irrigant solution (Renacidin®, Guardian Laboratories, Hauppauge,

NY) may be instilled into the bladder to dissolve encrustation.

 

   Current recommendations or management of encrustation and blockage

include the following:

     • Inspect and palpate the catheter for signs of

encrustation

     • Schedule catheter changes based on blockage history (ie,

usual time to blockage)

     • Increase fluid intake

     • Keep extra catheter kits available

     • Perform two sequential bladder washouts with <50 cc

acidic bladder irrigant solution instilled by gravity no more than every other

day.27

 

 

===================================

 

Causes

of Encrustation

 

The cycle of encrustation stems from

infection of the urine by a urease producing

bacteria. When the urine and catheter

are colonised by bacteria capable of producing the

enzyme urease, urinary urea is split

resulting in the release of ammonia, which causes a rise

in the urinary pH (Getliffe 2002). As

the micro-organisms colonise the catheter surface

they multiply and form a living layer or

‘biofilm’, which thickens as the multiplication continues.

Under these conditions crystals of

calcium phosphate and magnesium ammonium

phosphate form and become trapped in the

catheter surface and can eventually block the

catheter. The main cause of catheter

encrustation is the formation of Struvite

(magnesium ammonium phosphate) and

calcium phosphate deposits. This process can

happen very quickly (34-48 hours in

vitro).3

Following catheterisation bacteria gain

access to the catheterised bladder either via the

inner lumen of the catheter or the

periurethral space outside the catheter. Maintaining a

continuous sterile closed drainage

system is vital to minimise bacterial migration through

the catheter lumen.

The use of hydrophilic catheter coatings

and more recently Silver Alloy coatings can also

minimise bacterial migration and

adherence as Silver ions inhibit bacterial adherence to the

catheter surface, minimising the

migration of pathogens into the bladder.

Recurrent blockage of urinary catheter

is a common problem in around 50% of long term

catheterised

patients.2,4

 

=========================================

http://www.biomedhtc.org.uk/strategy & modulation.htm

 

Modulation of catheter encrustation by

increasing fluid intake with citrate-containing drinks

The pH at which calcium

and magnesium crystals precipitate from urine is known as the nucleation pH (pH

n). Normally the voided urinary pH (pH v)is below its pH n. When P. mirabilis

infects the urinary tract however, its urease activity can elevate the pH v

above the pH n, crystals form and the catheter encrusts. Many long-term

catheterised patients drink very little and consequently their urine samples have

a very low pH n values.

Research work has shown

that it is possible to manipulate pH n of

urine simply by increasing fluid intake and supplementing the diet with citrate

containing drinks such as orange or lemon juice.

In this way the pH n can be raised above the urinary pH which normally results

from P. mirabilis infection.

A small clinical study has demonstrated that citrated drinks are effective at

raising the pH n within patients undergoing long term catheterisation and

funding is being sought to do a larger clinical study.

Suller MT, VJ,

Mathur S, Feneley RC, Greenman J, Stickler DJ. Factors modulating the pH at

which calcium and magnesium phosphates precipitate from human urine. Urol Res

2005 Aug;33(4):254-60

Stickler DJ, SD.

Modulation of crystalline Proteus mirabilis biofilm development on urinary

catheters. J Med Microbiol 2006 May; 55 (Pt 5): 489-94

 

===================================================

http://www.continence-uk.com/essentials_2008/Continence_Essentials_2008_Catheter_Encrustation.pdf

 

=======================================================

http://www.ijaaonline.com/article/PIIS0924857900003484/fulltext

 

Catheter

associated urinary tract infection and encrustation

 

4.2. Catheter

encrustation 

A variety of

methods are currently used in the management of catheter encrustation and

blockage. Catheter replacement and altering the type or size of the catheter,

increasing fluid intake, dietary modification of the urine with cranberry juice

or acidification with vitamin C, bladder washouts with saline, acidic or

antiseptic solutions, and antibacterial treatment of the associated urinary

tract infection have all been investigated. The high incidence of recurrent

catheter blockage and the variety of management methods suggest that the

solution to the problem had not been found. Indeed, surveys of nursing staff

responsible for catheter management have revealed diverse opinions and

uncertainties about the most appropriate method for the management of the

blocked catheter as a result of the unsatisfactory clinical experience with the

current methods of management.

The length of

time catheters can safely remain in situ prior to removal for blockage is

variable, not only between patients who are blockers, but also between catheter

episodes for the same patient. In over 60% of blockers a pattern was

identifiable and Norberg et al. [18] have recommended

monitoring three to five catheter episodes to identify a characteristic pattern

of ‘catheter life’ in order that re-catheterization can be planned to precede

the predicted development of blockage. However, the underlying cause has not

been resolved and catheter replacement is only a short-term solution to relieve

the obstructed system as rapid encrustation usually occurs.

A high

fluid intake is frequently recommended for catheterized patients [5] but, in practice, it is

difficult to maintain a high diuresis over a prolonged period by increasing

water intake and urinary solute concentration is not correlated with the degree

of encrustation [19].

Oral

intake of cranberry juice or vitamin C have been recommended [19] but prevention of struvite precipitation

by maintaining a low urinary pH is difficult in the presence of

urease-producing micro-organisms.

Furthermore, the addition of hydrogen ions in the presence of urease causes

more urea to be converted into ammonia and restores the alkaline conditions.

Inhibitors of urease were found to be more effective in lowering the pH in P.

mirabilis infected urine but the side effects were unacceptable to the

patients receiving them [20].

A variety of

bladder washouts are currently available on the market containing saline,

antiseptic or a weak acidic solution.

The daily instillation of the acidic Suby G solution

was shown to be effective in controlling encrustation in vitro [21] and dissolved struvite

crystals in suspension but was ineffective in removing crystals entrapped

within the biofilm [22] and in vivo [23].

Dilute

acid solutions can remove the protective surface layer of mucus in the bladder [24] and increase exfoliation of

bladder mucosal cells [25].

An antiseptic bladder washout containing chlorhexidine produced only minor and

temporary effects on P. mirabilis infections in vitro [17]. A prospective, randomized

controlled trial showed that chlorhexidine washouts produced no significant

reduction in bacteriuria and resulted in an alteration in the microbial flora,

with the tendency for P. mirabilis to become the predominant organism,

which is counterproductive. An increased risk of infection accompanies frequent

breaking of the closed drainage system and bacteraemia may be facilitated by

bacterial invasion as a result of chemical cystitis or mechanical damage [26].

The use of

antimicrobial agents to prevent urinary infection in the presence of a urethral

catheter is controversial. Even when long-term low-dose antimicrobials were

administered, bacterial growth could be identified in 76% of patients. The

bacterial biofilm protects the organism from antimicrobial agents, and thus

treatment of patients with indwelling catheters can be very difficult.

Long-term anti-microbial treatment of patients with indwelling catheters should

be avoided in order to prevent antibiotic resistance acquired by the permeation

of a low dose of an anti-microbial across the bacterial biofilm [27]. Pre-catheterization

anti-microbial prophylaxis is useful but only provides protection for 3–4 days.

To reduce the incidence of infection, aseptic insertion and maintenance of a

closed urinary drainage system play a significant role but do not eliminate the

risk, which increases with each additional day of urethral catheterization.

Ideally, infected patients should be separated from uninfected patients to

prevent cross-contamination, and patients who can perform clean intermittent

self-catheterization should be taught the technique instead of having a

long-term indwelling catheter.

Further

scientific research is required to prevent ‘crisis management’, which has been

the current practice, and to move on to well-informed, planned strategies

derived from improved knowledge of this multifactorial phenomenon. More work is

required in this field, which has received little attention in the past and

together with a co-ordinated multidisciplinary approach and adequate resources,

the problem, which is responsible for reducing the quality of life in the

affected patients and an unacceptably high complication rate with spiralling

management costs, may yet be solved.

 

=======================================

http://www.health.qld.gov.au/qscis/PDF/Complications_of_SCI/catheter_blockages.pdf

 

Encrustation

·  Encrustation is the development of

crystals in the catheter tubing

·  There are two types of encrustration.

These are:

-  Struvite (magnesium ammonium

phosphate)

-  Apatite (calcium phosphate)

·  Calcium salts are a large component

of catheter encrustations

·  Struvite, not developed from a

biofilm, is reversible. It is only reversible

if the urine is low in phosphate,

magnesium and calcium salts or

the urine is acidified.

·  Non blockers have a wider safety

margin between their normal urine

pH and that at which crystallization occurs

(~1.4 variance in pH)

·  The phosphate precipitates as either

calcium or magnesium phosphate

in alkaline urine which starts at pH

values of 6.7 and peaks at

pH of 7.5

Prevention:

·  Antibiotic therapy is not effective

with encrustation

·  Long term antibiotic use can lead to

developing resistant bacteria

·  Encrustations are less pronounced on

silicone and hydrogel catheters

·  Acidic bladder washouts may assist

with clearing struvite build up but

isn’t helpful when a urease producing

organism is present

·  Moderate the intake of magnesium and

calcium in the diet. Magnesium

is found in diet beverages, herbal teas

and fruit juices. A high

calcium diet also contains more

potassium, phosphate and magnesium

which

precipitate in the urine leading to encrustation

 

Alkaline Urine

·  The normal pH averages 6.0 but can

range from 4.5—8.0.

·  There is considerable encrustation at

pH>6.8

·  The activity of urease is dependent

on pH . Urease is more active in an

acid pH causing more urea to convert

into ammonia

·  Ammonia in solution is alkaline

·  Ammonia also damages the protective

layer of urothelial cells which

defend against infection

·  Urease producing bacteria are:

·  Proteus mirabilis, ella

morganii, Provedencia stuartii,

Klebsiella pneumoniae, Proteus rettgeri,

Proteus vulgaris,

Staphylococcus aureus

·  Urease producing bacteria also lead

to a higher risk for stone formation

·  There is no evidence to suggest a

balanced diet and moderate intake

of food groups has any bearing on urine

pH

·  Medications and oral solutions such

as antacids, effervescents and

diet drinks (both which contain citrate)

can cause the urine to be more

alkaline

Prevention:

·  Take a measurement of the urine pH

·  Acidifying therapy with vitamin C can

help prevent alkaline urine

·  Take a micro-urine to detect any

urease producing bacteria

·  If a urease producing organism is

present, alkaline therapy such as

citrates

or sodium bicarbonate may reduce crystallisation

 

 

==================================

 

http://onlinelibrary.wiley.com/doi/10.1046/j.1464-410x.2000.00343.x/full

 

The

dissolution of urinary catheter encrustation

1.     

K.A. Getliffe1,

2.     

S.C. 2,

3.     

M. Le 2

Article first

published online: 27 AUG 2008

 

Objectives To identify the optimum

volume of acidic bladder washout solution to dissolve catheter encrustations

and to compare the effectiveness of different bladder washout delivery devices.

Materials and methods Urinary catheter

encrustation was generated in vitro using a model of the catheterized

bladder adapted from previous work. An acidic bladder washout solution (Suby G)

was applied via the catheter in the model and retained for 15 min. The

amount of encrusting material dissolved was measured by colorimetric analysis

of the magnesium and calcium content of the solution returned after the washout

procedure. The relative effectiveness of different volumes of washout solution

and different washout delivery devices (Optiflow, Bard Ltd, Crawley; UroTainer,

B/Braun Medical Ltd, Aylesbury; and a bladder syringe) in dissolving catheter

encrustations was compared to the ‘standardized’ conditions commonly used in

practice.

Results There was no statistically

significant difference between washouts with 100 mL and washouts with

50 mL for any of the delivery devices tested. Gentle agitation with

50 mL Suby G did not significantly improve the dissolution of encrustation

but the total amount of material dissolved when two washouts with 50 mL

Suby G were used sequentially was significantly better than a single washout

with either 100 mL or 50 mL.

Conclusions Under controlled laboratory conditions, smaller volumes of acidic

bladder washout solution (50 mL) are as effective as the 100 mL

commonly used in practice, but two sequential washouts with 50 mL are more

effective than a single washout. The newly designed Optiflow delivery device is

at least as effective as the other devices tested. This study provides new

evidence which may contribute to decision-making by practitioners in relation

to cath-eter care.

 

==============================

http://www.ijaaonline.com/article/S0924-8579(02)00095-X/abstract

 

Uropathogens

and urinary tract concretion formation and catheter encrustations

Top of Form

Hans Hedelin

Bottom of Form

Abstract 

Infection stones (ammonium

magnesium phosphate) and catheter encrustations have a common cause—urease

producing microorganisms. With their rapid growth and frequent recurrences,

infection stones are among the most troublesome of urinary system stones. For

many patients with a long-term indwelling catheter, encrustations can be a

severe problem. Urine composition is important, because, urine calcium enhances

the crystallization process and urine citrate inhibits it. The role of

non-urease producing microorganisms in stone forming processes is not well

understood. Stones can now be successfully treated with a low morbidity index

by percutaneous stone surgery or extracorporeal shock wave lithotripsy (ESWL)

and recurrence of stone formation is then avoided by prolonged antibiotic

treatment and oral citrate. Catheter encrustations and damage caused by ammonia

released during urease activity can, however, be a serious problem in patients

with indwelling catheters and our remedies are unsatisfactory.

 

9. Catheter

encrustations 

Bacteria

colonize the lower urinary tract in patients with indwelling bladder catheters.

Escherichia coli is the first species present followed by other species

including urease-producing bacteria, frequently Proteus spp. and

staphylococci.

The bacteria produce a biofilm on the catheter and within this

protective film, urease precipitates ammonium magnesium phosphate and calcium

phosphate crystals [31].

The precipitated crystals undergo a mineralization process forming

encrustations that block the outflow of urine. This requires frequent washouts

or catheter changes to restore the flow.

The precipitation varies markedly between different individuals (blockers and

non-blockers).

It is negatively correlated to urine citrate and

positively correlated to urine calcium [13].

The catheter material is of less importance—the encrustations are less

pronounced on silicone and hydrogel coated catheters, but this has marginal

clinical implications.

Patients with a high tendency to catheter encrustations are complication-prone

and there is not much which can be done to improve the situation except

frequent washouts.

Consequently long term indwelling catheters should be avoided as far as

possible. Clean intermittent catheterization is a better alternative and should

be used whenever possible.

=======================================================

http://www.nature.com/sc/journal/vaop/ncurrent/full/sc201032a.html

 

Spinal

Cord , (6 April 2010) | doi:10.1038/sc.2010.32

The encrustation and

blockage of long-term indwelling bladder catheters: a way forward in prevention

and control

D J

Stickler and R C L Feneley

Abstract

Objectives:

To review the literature showing that understanding how Foley

catheters become encrusted and blocked by crystalline bacterial biofilms has

led to strategies for the control of this complication in the care of patients undergoing

long-term indwelling bladder catheterization.

Methods:

A comprehensive PubMed search of the literature published between

1980 and December 2009 was made for relevant articles using the Medical Subject

Heading terms ‘biofilms’, ‘urinary catheterization’, ‘catheter-associated

urinary tract infection’ and ‘urolithiasis’. Papers on catheter-associated

urinary tract infections and bacterial biofilms collected during 40 years of

working in the field were also reviewed.

Results:

There is strong experimental and epidemiological evidence that

infection by Proteus mirabilis is the main cause of the crystalline biofilms

that encrust and block Foley catheters. The ability of P. mirabilis to generate

alkaline urine and to colonize all available types of indwelling catheters

allows it to take up stable residence in the catheterized tract in bladder

stones and cause recurrent catheter blockage.

Conclusion:

The elimination of P. mirabilis by antibiotic therapy as soon as

it appears in the catheterized urinary tract could improve the quality of life

for many patients and reduce the current expenditure of resources when managing

the complications of catheter encrustation and blockage.

For patients who are already chronic blockers and stone formers,

antibiotic treatment is unlikely to be effective owing to the resistance of

cells in the crystalline biofilms.

Strategies such as increasing fluid intake with citrated drinks could control the problem until bladder

stone removal can be organized.

==========================================

 

http://content.karger.com/ProdukteDB/produkte.asp?Aktion=ShowFulltext & ArtikelNr=46015 & Ausgabe=227274 & ProduktNr=223854

Study on Concretions Developed around Urinary

Catheters and Mechanisms of Renal Calculi Development

Aims: To study the

structure and composition of encrustation and concretions developed on urinary

catheters to better understand their formation mechanism to be able to prevent

them.

Methods: The surface of

catheters was studied by direct and scanning electron microscopy observation.

In vitro formation of encrustations was performed in synthetic urine.

Results: The surface of

catheters was covered by a continuous layer of organic matter, on which a thin

scale consisting of crystals of calcium oxalate monohydrate (COM), uric acid

anhydrous or calcium phosphate developed. Encrustations observed on catheters

generally exhibited the same composition as the previously developed renal

calculi. In catheters collected from patients without previous episodes of

renal calculi or with previous episodes of infected renal calculi in which

infection was afterwards eradicated, on the first organic layer, in that case

plate-like COM crystals forming a columnar layer were observed. In vitro

experiments demonstrated that COM columnar structures were only formed when

normocalciuric urine containing organic matter was used, and the presence of

crystallization inhibitors, as phytate, notably delayed their formation.

Conclusion:

Calcium oxalate was the main crystalline phase developed on catheters inserted

in patients, specially in the absence of urinary infection or urinary pH values

<5.5 and high urinary uric acid levels.

Thus, prophylaxis of encrustations may consist of preventive measures usually

applied in cases of recurrent idiopathic calcium oxalate urolithiasis.

====================================

http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume82003/No3Sept2003/HirshArticle/CareofPatientswithLongTermIndwellingUrinaryCatheters.aspx

Encrustation

Catheter encrustation develops due to

urease producing bacteria, such as Proteus mirabilis species, that elevates the

urine pH. The lumen of the catheter becomes blocked by crystal formation from a

combination of an elevated urine pH, bacterial film, and calcium and magnesium

ions (

& Stickler, 1998; ,

Stickler, & Winters, 1997). Proteus species have been associated with

encrustation 24 hours after a glass bladder was inoculated (Stickler,

, Moreno, & Sabbuba, 1998). Acidification of the urine, without

removal of the source of the urease, did not prevent encrustation (Bibby

& Hukins, 1993).

In a laboratory model of the

catheterized bladder, pooled human urine was collected and Jack Bean urease

added to produce catheter encrustation (Getliffe,

, & Le, 2000).

A Suby G solution (3.2% citric acid, 0.38% light magnesium oxide,

0.7% sodium bicarbonate, and 0.01% disodium edetate) was used in one or two

sequential irrigations, using 100 ml or 50 ml of solution.

Two sequential irrigations of 50 ml of solution were more effective than one

irrigation with either 50 ml or 100 ml.

In a second study, Suby G or a 1% mandelic acid solution reduced encrustation

and improved mean patent luminal area of catheters more than 0.9% saline and no

irrigation treatment (Getliffe,

1994b).

The effectiveness of three bladder

irrigation treatments in preventing encrustation was explored in a group of

female, elderly, long-term care patients with indwelling catheters (Kennedy,

Brocklehurst, , & Faragher, 1992).

The bladder irrigation solutions Suby G, Sodium Chloride, and Solution R were

administered twice weekly for 3 weeks. Suby G contained 3.2% citric acid, 0.38%

light magnesium oxide, 0.7% sodium bicarbonate, and 0.01% disodium edetate. The

sodium chloride solution contained 0.9% sodium chloride. The Solution R

contained 6% citric acid, 0.6% gluconolactone, 2.8% light magnesium carbonate,

and 0.01% disodium edetate.

The amount of encrustation was lowest following Suby G irrigations.

Following the Suby G irrigations, there were more red bloods cells in the

washout fluid than after the other two irritation solutions, indicating

possible irritation to the bladder mucosa.

However, no baseline measures of RBCs in urine samples were taken before

irrigations.

The irrigation solutions were similar in their ability to remove

crystals at 10 days, but they had no effect on removal of bacteria or

urease-producing bacteria.

Encrustation was least common

in all-silicone catheters, compared to silicone-coated, latex, and

Teflon-coated catheters (Kunin,

Chin, & Chambers, 1987).

In a laboratory model of the catheterized bladder, all-silicone catheters took

longer to block than Teflon, silicon-coated, or hydrogel-coated catheters (

et al., 1997). However, the all-silicone catheter has a larger internal

diameter (2.8 mm) compared to the hydrogel catheter (1.8 mm), so the longer

time to blockage may be related to catheter diameter. One other study reported

that all-silicone and hydrogel-coated catheters of equivalent diameters were

equally resistant to encrustation (,

Hukins, & Sutton, 1988). Catheter blockage may pose a potential risk

for kidney damage. In a mouse model, catheter blockage of 3 hours duration was

associated with pyelonephritis and pyelitis (

, Lockatell, Zulty, & Warren, 1993). However, this has not been

studied in humans.

 

 

 

1 of 1 File(s)

Foley_Encrustation_1.pdf

[Guest guest]

I suppose swapping out the catheter weekly - which is what we are doing currently - is fine.There are cost and discomfort issues with frequent swapping.Would like to be able to just flush the catheter and have less frequent changes.

Thanks

 

Wouldn't it be simpler to change the catheter every month, or more often?Pedro Ballester, M.D.Warren, OH