Infektionsprävention bei der Katheterdrainage der Harnblase

 

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Zusammenfassung

Harnweginfektionen (HWI) gehören in Krankenhäusern mit einem Anteil von 22,4% neben den postoperativen Wundinfektionen (24,7%), Pneumonien (21,5%), Clostridium difficile-Infektionen (6,6%) und der primären Sepsis (6%) zu den häufigsten nosokomialen Infektionen [1]. 80% aller nosokomialen HWI (nHWI) sind dabei mit einem Katheter assoziiert, wobei zwischen 12–16% aller Krankenhauspatienten und bis zu 81,8% aller Patienten auf Intensivstationen im Verlauf ihres stationären Aufenthaltes einen Blasenverweilkatheter erhalten [2] [3]. Fundierte Kenntnisse über die Grundlagen Harnwegkatheter-assoziierter Infektionen (HKI) und der korrekte Umgang mit Harnwegkathetern haben deshalb nicht nur eine große individuelle sondern auch sozio-ökonomische Bedeutung [4] [5]. Es wird davon ausgegangen, dass bis zu 70% aller HKI durch geeignete Präventionsmaßnahmen verhindert werden können [6] [7].

Die Autorinnen Conway u. Larson haben 2012 8 englischsprachige Empfehlungen zur Prävention von HKI verglichen und eine bemerkenswerte Konstanz der Empfehlungen über 30 Jahre feststellt [8]. Zu speziellen Fragestellungen gibt es nur wenige valide Studien mit zum Teil heterogenen Ergebnissen. So sind in der SHEA (Society of Hospital Epidemiologists of America) – Empfehlung aus dem Jahr 2008 nur 3 Empfehlungen und 4 Verbote enthalten, die auf mehr als einer randomisierten, kontrollierten Studie basieren [9] [10] [11].

Die gesicherten Empfehlungen zur Prävention von HKI stimmen in den folgenden Gemeinsamkeiten überein [12] [13] [14] [15] [16] [17]:

• Jede Anlage eines Harnwegkatheters bedarf einer gut begründeten ärztlichen Indikationsstellung.

• Medizinisch begründete Indikationen für einen Harnwegkatheter sind bspw. die akute Harnretention, die Anwendung bei mehrstündigen Operationen mit hohem Flüssigkeitsumsatz und bei urologischen Operationen, die Notwendigkeit der Bilanzierung bei schwer kranken Patienten, eine Verbesserung der Lebensqualität bei im Sterben liegenden Patienten oder die Förderung der Wundheilung im Bereich des äußeren Genitale bei Harninkontinenz. Beispiele für unnötige Anwendungen eines Katheters sind die Verordnung nur aufgrund einer Harninkontinenz und die Verlängerung der Katheterliegedauer, z. B. nach chirurgischen Eingriffen oder nach Abschluss der intensivmedizinischen Überwachung/Bilanzierung

• Regelmäßiges Training in der Technik beim Legen von Harnwegkathetern, bei der Katheterpflege und in der Erkennung von Katheter-assoziierten Komplikationen

• Die Katheterisierung hat unter aseptischen Kautelen zu erfolgen.

• Es sind nur sterile und geschlossene Harndrainagesysteme zu verwenden.

• Harnwegkatheter sollen so früh wie möglich wieder entfernt werden.

Abstract

With a share of 22.4%, nosocomial urinary tract infections (nUTIs) are among the most frequent infections acquired in hospitals, along with surgical site infections (24.7%), pneumonia (21.5%), clostridium difficile infections (6.6%) and primary sepsis (6%) [1]. 80% of all nUTIs are associated with indwelling urinary catheters, with 12–16% of all hospitalised patients and up to 81.8% of all intensive care patients receiving an indwelling urinary catheter during their hospital stay [2] [3]. Therefore, profound knowledge about the basics of catheter-associated nUTIs and the correct management of urinary catheters are of utmost individual and socio-economic importance [4] [5]. It is estimated that up to 70% of all nUTIs occurring in Germany may be avoided by using appropriate preventative measures [6] [7].

In 2012, the authors Conway and Larson compared 8 recommendations in English language for the prevention of UTIs and noticed that they have been largely consistent over a period of 30 years [8]. Special issues have rarely been addressed in valid studies, and study results are rather heterogeneous. For example, the 2008 SHEA (Society of Hospital Epidemiologists of America) guideline contains only 3 recommendations and 4 prohibitions which are based on more than one randomised controlled clinical study [9] [10] [11].

The confirmed recommendations on the prevention of UTIs are consistent in the following aspects [12] [13] [14] [15] [16] [17]:

• Every insertion of a urinary catheter must be based on a well-founded medical indication.

• Well-founded medical indications include acute urinary retention, interventions lasting several hours with a high fluid turnover, surgery involving the urinary tract, the necessity to record fluid turnover especially in critically ill patients, comfort for the dying, facilitating wound healing in the external genitals in the presence of urinary incontinence. Examples of unnecessary use of urinary catheters include prescriptions based on urinary incontinence alone and prolongation of use, e. g. after surgical procedures or after intensive care monitoring/recording has been completed.

• The insertion technique as well as catheter care and the detection of catheter-associated complications must be trained continuously.

• Catheterisation must be performed under sterile precautions.

• Only sterile and closed urinary drainage systems may be used.

• Catheters must be removed as early as possible.

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