Barsanti JA

Lees GE

Lund EM

Lusardi G

English

Holroyd, K

Humm, K R

RVC Research Online

  RVC OPEN ACCESS REPOSITORY – COPYRIGHT NOTICE  This is the Accepted Manuscript of the following article: Holroyd, K and Humm, KR (2015) Standards of care for feline urethral catheters in the United Kingdom. JOURNAL OF FELINE MEDICINE AND SURGERY. It has been published in The Journal of Feline Medicine and Surgery at http://jfm.sagepub.com/content/early/2015/03/17/1098612X15577845.  The full details of the published version of the article are as follows:  TITLE: Standards of care for feline urethral catheters in the United Kingdom AUTHORS: Holroyd, K and Humm, KR JOURNAL TITLE: The Journal of Feline Medicine and Surgery VOLUME/EDITION: 42/1 PUBLISHER: SAGE Publications PUBLICATION DATE: 17 March 2015 DOI: 10.1177/1098612X15577845  Standards of care for feline urethral catheters in the United Kingdom 1 Kate Holroyd BVetMed MRCVS 2 Karen Humm  3 The Lodge, Benington Lordship, Benington, Nr. Stevenage, Hertfordshire, SG2 7BS 4 Kholroyd@rvc.ac.uk 5 Khumm@rvc.ac.uk 6  7 Key Words: Feline urethral catheter, general practitioner, antibiotics, sterility, 8 asepsis, closed urinary collection system 9  10  11  12  13  14  15  16 Abstract 17 Objectives 18 This study aimed to determine the standards of care of urethral catheters (UCs) in 19 male cats with UCs placed due to urethral obstruction.  It also assessed whether 20 these standards were affected by year of graduation of the veterinary surgeon (VS).  21 Methods 22 One hundred veterinary practices were randomly selected and a telephone survey 23 was conducted with a VS in the practice.  Regarding the last urethral catheterisation 24 performed for a male cat with urethral obstruction the VS was asked about use of 25 antibiotics whilst the catheter was in situ, whether a closed urinary collection 26 system was used, whether aseptic skin preparation of the patient was performed 27 and whether aseptic hand preparation was performed.  An ANOVA with a post hoc 28 Tukey HSD was used to determine whether there were significant differences in 29 these percentages when considering year of graduation. 30 Results 31 Twenty seven percent of VSs did not use antibiotics whilst the urethral catheter was 32 in place, 44% used closed urinary collection systems, 41% performed aseptic skin 33 preparation of the patient and 60% aseptically prepared their hands and wore 34 sterile gloves.  VSs who graduated between 1975-1984 were significantly less likely 35 to wear sterile gloves and use closed urinary collection systems compared to VSs 36 who graduated between 2004-2013 (p<0.05).  They were also significantly more 37 likely to use antibiotics with the urinary catheter in situ (p<0.01).  38 Conclusions and relevance 39 Non-sterile urethral catheter placement with open urinary drainage and antibiotic 40 prophylaxis is still a widespread practice amongst VSs; however, more recent 41 graduates are more likely to perform the procedure aseptically with a closed urinary 42 collection system and withholding antibiotics. 43 There is a need for further education in postgraduate vets in the prevention of 44 catheter associated urinary tract infections in cats and further research to provide 45 evidence-based guidelines for feline urethral catheter care.  46  47 Introduction 48 Feline lower urinary tract disease (FLUTD) is a broad term including any disorder 49 affecting the urinary bladder or urethra of cats (e.g. uroliths, urethral plugs, 50 bacterial infection).1 Clinical signs include haematuria, stranguria, dysuria, 51 pollakiuria and periuria.1 FLUTD is a common presentation, reported to account for 52 3% of feline consultations in a 1995 survey of primary care veterinary hospitals in 53 the United States.2 The percentage of cats with FLUTD that present with urethral 54 obstruction (UO) has been found to range from 18% to 58%.3, 4,5 Treatment for feline 55 UO involves placement of a urethral catheter which is recommended to be left in situ 56 for a variable time period depending on individual factors but generally 24-48 57 hours.6   58  59 Guidelines exist for urethral catheterisation in humans,7 and general principles from 60 these have been adapted for feline urethral catheter management.  It is suggested 61 that feline urethral catheters are placed in an aseptic manner, that antibiotics are 62 not used prophylactically and that a closed urinary collection system is used to 63 reduce the incidence of catheter-associated urinary tract infection (CAUTI). 6-8 64  65 To the authors’ knowledge there is no research into the prevalence of the use of 66 aseptic technique, closed collection systems and antibiotics in cats undergoing 67 urethral catheterisation. The aim of this study was to determine the prevalence of 68 compliance with the advice on feline catheter management and a further aim was to 69 assess whether prevalence was affected by the year of graduation of the veterinary 70 surgeon performing the procedure.  71 Materials and Methods 72 A random number generatori was used to select veterinary practices from all those 73 listed on the Royal College of Veterinary Surgeons’ ‘Find a Vet’ database. Each 74 practice was contacted by telephone and the first available veterinary surgeon was 75 surveyed.  If no veterinary surgeon was available or if the veterinary surgeon 76 available had not placed a urethral catheter in a male cat with UO in the preceding 77 12 months no further data was collected.  One hundred surveys were completed. 78 The gender and year of graduation of the veterinary surgeons were determined.  79 They were then asked, when considering the last male cat that they had placed a 80 urethral catheter in for UO: 81 1. Did you aseptically prepare the perineum and prepuce of the cat? 82 2. Did you aseptically prepare your hands and use sterile gloves? 83 3. Did you use a closed urinary collection system?  84 4. Did you give antibiotics whilst the urethral catheter was in-situ? 85  86 Clarification and explanation of the questions was provided if requested or if 87 confusion was apparent.  The answers to the survey were analysed using statistical 88 software. ii  Percentages of veterinary surgeons answering yes and no to each 89 question were calculated. A chi squared test was used to determine whether there 90 were significant differences in these percentages when considering year of 91 graduation with p<0.05 being considered significant.  92   93 Results 94 Two hundred and forty-two veterinary practices were contacted to reach 100 95 veterinary surgeons eligible to be surveyed. Of these 57% (n=57) were female and 96 43% (n=43) were male. The year of graduation ranged from 1974 to 2013.  97 Veterinary surgeons were categorised into year groups. The results of the 98 questionnaire are summarised in Table 1. There was a significant difference in 99 antibiotic administration (p<0.01), use of closed urinary collection systems 100 (p<0.01) and aseptic hand preparation and gloving (p<0.01) between year groups.  101 There was no significant difference in aseptic preparation of the patients skin 102 between year groups (p=0.051). 103   104 Table 1: responses to questions regarding the most recent urethral catheter placement in a 105 male cat with urethral obstruction 106  107 The percentage of veterinary surgeons that both aseptically prepared their hands 108 and the cat’s skin was 6.3% for vets graduating in the 1975-1984 group and 109 increased to 50% for vets graduating in the 2005-2013 group.  The percentage of 110 veterinary surgeons that neither aseptically prepared their hands nor the cat’s skin 111 was 56.3% for vets graduating in the 1975-1984 group, which reduced to 12.5% for, 112 vets graduating in the 2005-2013 group. 113   114   Graduation Year Group       1975-  1985-  1995- 2005- P value Total population 1984 1994 2004 2013   N= 100 N= 16 N= 20 N= 24 N =40     Antibiotics given (%) 100.0 80.0 79.0 55.0 0.004 73 (n=16) (n=16) (n=19) (n=22)   (n=73) Open urine drainage (%) 100.0 85.0 58.0 47.5 0.000 56 (n=16) (n=17) (n=14) (n=19)   (n=66) No aseptic skin preparation (%) 75.0 70.0 67.0 42.5 0.051 59 (n=12) (n=14) (n=16) (n=17)   (n=59) No aseptic hand preparation and gloving (%) 75.0 45.0 46.0 20.0 0.002 40 (n=12) (n=9) (n=11) (n=8)   (n=40) Discussion 115 This paper reports a survey of the standard of care provided by veterinary surgeons 116 in the United Kingdom performing urethral catheterisation in male cats with UO. 117 The study aimed to establish the prevalence of aseptic placement technique, 118 antibiotic usage and closed urinary collection system usage.  119  120 This study found that the 1975-1984 graduates reported using antibiotics 100% of 121 the time when placing urethral catheters in obstructed cats, compared to 55% of 122 2005-2013 graduates. Antibiotic usage whilst urethral catheters are in situ is 123 associated with multi-drug resistant bacterial urinary tract infections in dogs and 124 cats,8 and in feline guidelines published in 2011 it was recommended that 125 symptomatic CAUTI, (>1000 colony forming units (CFU)/ml of bacteria grown from 126 a quantitative culture of urine collected by cystocentesis)9 should be treated with 127 antibiotics but preferably after removal of the catheter, although it was recognised 128 that this may not be possible in all patients.9 A recent study of healthy female dogs 129 with asymptomatic bacteriuria found that no dogs with subclinical bacteriuria 130 developed clinical signs requiring antimicrobial treatment during the 3-month 131 observation period. It is therefore suggested that asymptomatic bacteriuria should 132 not be considered as an indication for antibiotics10. Although, human, canine and 133 feline evidence suggests that antibiotics should not be routinely used in patients 134 with indwelling urethral catheters, the present study did not question the reason for 135 antibiotic administration in these cases. A small percentage of cases where 136 antibiotics were used may have been appropriate, due to pre-existing urinary tract 137 infection, pyrexia or systemic infection, for example. However, the use of 138 antimicrobial drugs in 55-100% of cats (dependent on year of graduation) in the 139 present study is likely to be unwarranted in the majority of cases as the incidence of 140 bacterial urinary tract infection (UTI) in cats presenting for symptoms of FLUTD has 141 been found to be low. In one study 37% of cats with FLUTD presented with urethral 142 obstruction and of these 10% had significant bacteriuria (>104 CFU/ml) in 143 combination with crystals and/or uroliths, and only 2% had bacteriuria alone.3 144 Another study had similar results in which 55% of cats with FLUTD were obstructed 145 and none of these cats had a significant bacteriuria.4 In a recent Cochrane review in 146 human medicine, bacteriuria was found to be reduced with antibiotic usage during 147 urethral catheterisation, however, it selected for antibiotic resistant bacteria.11 An 148 alternative approach suggested in human medicine to limit prophylactic antibiotic 149 usage, is to only use antibiotics in patients who are at high risk from complications of a 150 UTI, for example, those with implants, immunosuppression or diabetes.11 Previous use 151 of antibiotics in cats with UTI’s has also been found to be associated with multi-drug 152 resistant Escherichia coli12. 153  154 One hundred percent of graduates from the group 1975-1984 reported using open 155 urine drainage compared to 47.5% of vets from the 2005-2013 group. Closed 156 urinary collection systems are used in human medicine due to evidence suggesting 157 that they result in reduced bacteriuria13  Although small animal studies directly 158 comparing the use of open urine drainage with closed urinary collection systems are 159 lacking, a 1981 study found the incidence of bacteriuria in cats with indwelling 160 urethral catheters was 56% in cats maintained with an open indwelling catheter14 161 and a more recent study using closed collection systems found that the probability 162 of CAUTI after 24 hours of catheterisation was 16.7% and this increased to 33.3% 163 after 48 hours.15   Closed urinary collection systems have the additional benefit that 164 urine is diverted away from the body and contained, thereby preventing discomfort, 165 urine scald and potential distress.  166  167 In humans, most microorganisms causing CAUTI derive from the patient’s own 168 colonic and perineal flora or from the hands of health-care personnel during 169 catheter insertion or manipulation of the collection system.16 Expert opinion in 170 human medicine, clinical guidance and principles of best practice indicate that 171 aseptic technique is important in preventing CAUTI and consequently reducing 172 antibiotic usage.16 Currently veterinary surgeons were found to be poor at utilising 173 the aseptic technique recommended. Of the 100 vets sampled only 31 reported 174 performing both aseptic hand and patient skin preparation. The remaining 69% of 175 vets were either only performing one of these techniques or neither.  176  177 This study details the techniques reported by veterinary surgeons when placing 178 urethral catheters in feline patients with urethral obstruction.  It relied on self-179 report of an event happening up to 12 months prior to the questionnaire, potentially 180 leading to either intentional or unintentional misinformation being provided due to 181 poor recall or desire to provide the perceived ‘correct’ response respectively; 182 although it is felt that the latter is unlikely given the anonymised nature of the study.  183 The number of veterinary surgeons recruited was fair and allowed identification of 184 significant differences between graduating year groups.  The data gathered was 185 limited to encourage full survey response, meaning that the reasons for the 186 decisions made were not analysed, which was probably particularly relevant 187 regarding antibiotic use.  For example, if symptomatic bacteriuria was identified on 188 initial urinalysis when the urethral catheter was placed this could lead to 189 appropriate antibiotic use.    190   191 Conclusions 192 The study shows significant differences in techniques regarding performance and 193 management of feline urethral catherisation reported by vets who graduated prior 194 to 1985. These differences likely reflect changes in teaching and the move towards 195 evidence based medicine over this time period. This study suggests that recent 196 graduates are more aware of the evidence-based techniques now recommended and 197 are maintaining a more responsible approach to antibiotic usage. By following the 198 aseptic guidelines and by using closed drainage systems the likelihood of a CAUTI 199 reduces and consequently so does the potential need for antibiotics. However, 200 further research is still required into the advantages of closed urinary collection 201 systems in cats.  202  203 This research received no grant from any funding agency in the public, commercial 204 or not-for-profit sectors. 205 Conflict of interest 206 The authors do not have any potential conflicts of interest to declare.  207  208  209 References 210 1 Dru Forrester S and Roudebush P. Evidence-based management of feline 211 lower urinary tract disease. Vet Clin North Am Small Anim Pract. 2007; 37: 533-212 58. 213 2 Lund EM, Armstrong PJ, Kirk CA, et al. Health status and population 214 characteristics of dogs and cats examined at private veterinary practices in 215 the United States. J Am Vet Med Assoc. 1999; 214: 1336-41. 216 3 Eggertsdottir AV, Lund HS, Krontveit R, et al. Bacteriuria in cats with 217 feline lower urinary tract disease: a clinical study of 134 cases in Norway. J 218 Feline Med Surg. 2007; 9: 458-65. 219 4 Gerber B, Boretti FS, Kley S, et al. Evaluation of clinical signs and causes 220 of lower urinary tract disease in European cats. J Small Anim Pract. 2005; 46: 221 571-7. 222 5 Lekcharoensuk C, Osborne CA and Lulich JP. Epidemiologic study of risk 223 factors for lower urinary tract diseases in cats. J Am Vet Med Assoc. 2001; 218: 224 1429-35. 225 6 Balakrishnan A and Drobatz KJ. Management of urinary tract 226 emergencies in small animals. Vet Clin North Am Small Anim Pract. 2013; 43: 227 843-67. 228 7 Geng V, Cobussen-Boekhorst H and Farrell J. Catheterisation: indwelling 229 catheters in adults: urethral and suprapubic. European Asociation of Urology 230 Nurses http://wwwuroweborg/nurses/nursing-guidelines/:  (2012, accessed May 231 15, 2014). 232 8 Barsanti JA, Blue J and Edmunds J. Urinary tract infection due to 233 indwelling bladder catheters in dogs and cats. J Am Vet Med Assoc. 1985; 187: 234 384-8. 235 9 Weese JS, Blondeau JM, Boothe D, et al. Antimicrobial use guidelines for 236 treatment of urinary tract disease in dogs and cats: antimicrobial guidelines 237 working group of the international society for companion animal infectious 238 diseases. Vet Med Int. 2011; 2011: 263768. 239 10 Wan SY, Hartmann FA, Jooss MK, et al. Prevalence and clinical outcome of 240 subclinical bacteriuria in female dogs. J Am Vet Med Assoc. 2014; 245: 106-12. 241 11 Lusardi G, Lipp A and Shaw C. Antibiotic prophylaxis for short-term 242 catheter bladder drainage in adults. Cochrane Database Syst Rev. 2013; 7: 243 Cd005428. 244 12 Hernandez J, Bota D, Farbos M, et al. Risk factors for urinary tract 245 infection with multiple drug-resistant Escherichia coli in cats. J Feline Med 246 Surg 2014; 16: 75-81. 247 13 Gould CV, Umscheid CA, Agarwal RK, et al. Guideline for prevention of 248 catheter-associated urinary tract infections 2009. Infect Control Hosp 249 Epidemiol. 2010; 31: 319-26. 250 14 Lees GE, Osborne CA, Stevens JB, et al. Adverse effects of open indwelling 251 urethral catheterization in clinically normal male cats. Am J Vet Res. 1981; 42: 252 825-33. 253 15 Hugonnard M, Chalvet-Monfray K, Dernis J, et al. Occurrence of 254 bacteriuria in 18 catheterised cats with obstructive lower urinary tract 255 disease: a pilot study. J Feline Med Surg. 2013; 15: 843-8. 256 16 Maki D and Tambyah P. Engineering out the risk for infection with 257 urinary catheters. Emerg Infect Dis. 2001; 2. 258  Footnotes 259 i Microsoft Excel 2010 v14.0. ii IBM SPSS Statistics 21                                                           

Standards of care for feline urethral catheters in the United Kingdom

Standards of care for feline urethral catheters in the UK

Objectives This study aimed to determine the standards of care for urethral catheters (UCs) placed in male cats for treatment of urethral obstruction (UO). It also assessed whether these standards were influenced by year of graduation of the veterinary surgeon (VS). Methods One hundred veterinary practices were randomly selected, and a telephone survey was conducted with a VS in the practice. Regarding the last urethral catheterisation performed for a male cat with UO, the VS was asked about the use of antibiotics while the catheter was in situ, whether a closed urinary collection system was used, whether aseptic skin preparation of the patient was performed and whether aseptic hand preparation was performed. A χ2 test was used to determine whether there were significant differences in these percentages when considering year of graduation. Results Twenty-seven percent of VSs did not use antibiotics while the urethral catheter was in place, 44% used closed urinary collection systems, 41% performed aseptic skin preparation of the patient and 60% aseptically prepared their hands and wore sterile gloves. There was a statistically significant ( P &lt;0.01) difference in antibiotic usage, closed collection system usage and aseptic hand preparation across graduation year groups. Conclusions and relevance Non-sterile urethral catheter placement with open urinary drainage and antibiotic prophylaxis is still a widespread practice among VSs; however, more recent graduates are more likely to perform the procedure aseptically with a closed urinary collection system and withholding of antibiotics. There is a need for further education for postgraduate veterinarians in the prevention of catheter-associated urinary tract infections in cats and further research to provide evidence-based guidelines for feline urethral catheter care. </jats:sec

Standards of care for feline urethral catheters in the United Kingdom

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