Abstract
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 <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.
Introduction
Feline lower urinary tract disease (FLUTD) is a broad term referring to any disorder affecting the urinary bladder or urethra of cats (eg, uroliths, urethral plugs, bacterial infection). 1 Clinical signs include haematuria, stranguria, dysuria, pollakiuria and periuria. 1 FLUTD is a common presentation, reported to account for 3% of feline consultations in a 1995 survey of primary care veterinary hospitals in the USA. 2 The percentage of cats with FLUTD that present with urethral obstruction (UO) has been found to range from 18–58%.3–5 Treatment for feline UO involves placement of a urethral catheter, which is recommended to be left in situ for a variable time period depending on individual factors, but generally 24–48 h. 6
Guidelines exist for urethral catheterisation in humans, 7 and general principles from these have been adapted for feline urethral catheter management. It is suggested that feline urethral catheters are placed in an aseptic manner, that antibiotics are not used prophylactically and that a closed urinary collection system is used to reduce the incidence of catheter-associated urinary tract infection (CAUTI).6–8
To our knowledge there is no published research into the prevalence of the use of aseptic technique, closed collection systems and antibiotics in cats undergoing urethral catheterisation. The aim of this study was to determine the prevalence of compliance with the advice on feline catheter management; a further aim was to assess whether prevalence was affected by the year of graduation of the veterinary surgeon (VS) performing the procedure.
Materials and methods
A random number generator (Excel; Microsoft) was used to select veterinary practices from all those listed on the Royal College of Veterinary Surgeons’ ‘Find a Vet’ database. Each practice was contacted by telephone and the first available VS was surveyed. If no VS was available or if the VS available had not placed a urethral catheter in a male cat with UO in the preceding 12 months no further data was collected. One hundred surveys were completed.
The sex and year of graduation of the VSs were determined. They were then asked, in relation to the last male cat that they had placed a urethral catheter in for UO:
Did you aseptically prepare the perineum and prepuce of the cat?
Did you aseptically prepare your hands and use sterile gloves?
Did you use a closed urinary collection system?
Did you give antibiotics while the urethral catheter was in situ?
Clarification and explanation of the questions was provided if requested or if confusion was apparent. The answers to the survey were analysed using statistical software (SPSS Statistics 21; IBM). Percentages of VSs answering yes and no to each question were calculated. A χ2test was used to determine whether there were significant differences in these percentages when considering year of graduation, with P <0.05 being considered significant.
Results
Two hundred and forty-two veterinary practices were contacted to reach 100 VSs eligible to be surveyed. Of these, 57% (n = 57) were women and 43% (n = 43) were men. Year of graduation ranged from 1974 to 2013. VSs were categorised into year groups. The results of the questionnaire are summarised in Table 1. There was a significant difference in antibiotic administration (P <0.01), use of closed urinary collection systems (P <0.01), and aseptic hand preparation and gloving (P <0.01) between year groups. There was no significant difference in aseptic preparation of the patient’s skin between year groups (P = 0.051).
Responses to questions regarding the most recent urethral catheter placement in a male cat with urethral obstruction
Values are given as n (%)
The percentage of VSs who both aseptically prepared their hands and the cat’s skin was 6.3% for vets graduating in the 1975–84 group, and increased to 50% for vets graduating in the 2005–13 group. The percentage of VSs that neither aseptically prepared their hands nor the cat’s skin was 56.3% for vets graduating in the 1975–84 group, which decreased to 12.5% for vets graduating in the 2005–13 group.
Discussion
This paper reports a survey of the standard of care provided by VSs in the UK performing urethral catheterisation in male cats with UO. The study aimed to establish the prevalence of aseptic placement technique, antibiotic usage and closed urinary collection system usage.
This study found that the 1975–84 graduates reported using antibiotics 100% of the time when placing urethral catheters in obstructed cats, compared with 55% of 2005–13 graduates. Antibiotic usage while urethral catheters are in situ is associated with multidrug-resistant bacterial urinary tract infections (UTIs) in dogs and cats, 8 and in feline guidelines published in 2011 it was recommended that symptomatic CAUTI (>1000 colony forming units [CFU]/ml of bacteria grown from a quantitative culture of urine collected by cystocentesis) 9 should be treated with antibiotics but preferably after removal of the catheter, although it was recognised that this may not be possible in all patients. 9 A recent study of healthy female dogs with asymptomatic bacteriuria found that no dogs with subclinical bacteriuria developed clinical signs requiring antimicrobial treatment during the 3 month observation period. It is therefore suggested that asymptomatic bacteriuria should not be considered an indication for antibiotics. 10
Although human, canine and feline evidence suggests that antibiotics should not be routinely used in patients with indwelling urethral catheters, the present study did not question the reason for antibiotic administration in these cases. A small percentage of cases where antibiotics were used may have been appropriate, owing to pre-existing UTI, pyrexia or systemic infection, for example. However, the use of antimicrobial drugs in 55–100% of cats (dependent on year of graduation) in the present study is likely to be unwarranted in the majority of cases as the incidence of bacterial UTI in cats presenting for clinical signs of FLUTD has been found to be low. In one study, 37% of cats with FLUTD presented with UO; of these, 10% had significant bacteriuria (>104 CFU/ml) in combination with crystals and/or uroliths, and only 2% had bacteriuria alone. 3 Another study had similar results, in which 55% of cats with FLUTD were obstructed and none of these cats had a significant bacteriuria. 4 In a recent Cochrane review in human medicine, bacteriuria was found to be reduced with antibiotic usage during urethral catheterisation; however, it selected for antibiotic-resistant bacteria. 11 An alternative approach suggested in human medicine to limit prophylactic antibiotic usage is to only use antibiotics in patients who are at high risk from complications of a UTI; for example those with implants, immunosuppression or diabetes. 11 Previous use of antibiotics in cats with UTIs has also been found to be associated with multidrug resistant Escherichia coli. 12
One hundred percent of graduates from the group 1975–84 reported using open urine drainage compared with 48% of vets from the 2005–13 group. Closed urinary collection systems are used in human medicine owing to evidence suggesting that they result in reduced bacteriuria. 13 Although small animal studies directly comparing the use of open urine drainage with closed urinary collection systems are lacking, a 1981 study found that the incidence of bacteriuria in cats with indwelling urethral catheters was 56% in cats maintained with an open indwelling catheter, 14 and a more recent study using closed collection systems found that the probability of CAUTI after 24 h of catheterisation was 16.7% and increased to 33.3% after 48 h. 15 Closed urinary collection systems have the additional benefit that urine is diverted away from the body and contained, thereby preventing discomfort, urine scald and potential distress.
In humans, most microorganisms causing CAUTI derive from the patient’s own colonic and perineal flora, or from the hands of healthcare personnel during catheter insertion or manipulation of the collection system. 16 Expert opinion in human medicine, clinical guidance and principles of best practice indicate that aseptic technique is important in preventing CAUTI and consequently reducing antibiotic usage. 16 Currently, VSs were found to be poor at utilising the aseptic technique recommended. Of the 100 vets sampled, only 31 reported performing both aseptic hand and patient skin preparation. The remaining 69% of vets were either only performing one of these techniques or neither.
This study details the techniques reported by VSs when placing urethral catheters in feline patients with UO. It relied on self-report of an event happening up to 12 months prior to the questionnaire, potentially leading to either unintentional or intentional misinformation being provided owing to poor recall or a desire to provide the perceived ‘correct’ response, respectively, although it is felt that the latter is unlikely given the anonymised nature of the study. The number of VSs recruited was fair and allowed identification of significant differences between graduating year groups. The data gathered were limited to encourage full survey response, meaning that the reasons for the decisions made were not analysed, which was probably particularly relevant regarding antibiotic use. For example, if symptomatic bacteriuria was identified on initial urinalysis when the urethral catheter was placed it could lead to appropriate antibiotic use.
Conclusions
The study shows significant differences in techniques regarding performance and management of feline urethral catheterisation reported by vets who graduated earlier (pre-1985) compared with those graduating in 2005 or later. These differences likely reflect changes in teaching and the move towards evidence-based medicine over time. This study suggests that recent graduates are more aware of the evidence-based techniques now recommended and are maintaining a more responsible approach to antibiotic usage. By following the aseptic guidelines and by using closed drainage systems the likelihood of a CAUTI reduces and, consequently, so does the potential need for antibiotics. However, further research is still required into the advantages of closed urinary collection systems in cats.
Footnotes
Acknowledgements
We gratefully acknowledge Stefano Cortellini for his kind help with the statistics of this paper.
Conflict of interest
The authors do not have any potential conflicts of interest to declare.
Funding
This research received no grant from any funding agency in the public, commercial or not-for-profit sectors.