Discussion paper| Volume 22, ISSUE 3, P136-143, September 2017

Download started.


Meatal cleaning with antiseptics for the prevention of catheter-associated urinary tract infections: A discussion paper

  • Oyebola Fasugba
    Corresponding author. Nursing Research Institute, Australian Catholic University and St Vincent's Health Australia (Sydney), Australian Capital Territory, Australia.
    Nursing Research Institute, Australian Catholic University and St Vincent's Health Australia (Sydney), Australian Capital Territory, Australia

    Lifestyle Research Centre, Avondale College of Higher Education, Cooranbong, New South Wales, Australia
    Search for articles by this author
  • Jane Koerner
    Nursing Research Institute, Australian Catholic University and St Vincent's Health Australia (Sydney), Australian Capital Territory, Australia
    Search for articles by this author
  • Brett G. Mitchell
    Faculty of Arts, Nursing and Theology, Avondale College, Wahroonga, New South Wales, Australia

    School of Nursing and Midwifery, Griffith University, Brisbane, Queensland, Australia
    Search for articles by this author
  • Anne Gardner
    School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Canberra, Australian Capital Territory, Australia
    Search for articles by this author


      • Evidence regarding effectiveness of meatal cleaning is inconclusive.
      • Antiseptic meatal cleaning may be an effective strategy to reduce or prevent CAUTI.
      • Effectiveness of meatal cleaning should be tested using a well-designed RCT.
      • Cost effectiveness of any potential antiseptic intervention should be considered.


      Urinary tract infections related to indwelling urinary catheters, known as catheter-associated urinary tract infections (CAUTI), are largely preventable healthcare-associated infections (HAI). Healthcare-associated infections including CAUTI are associated with prolonged hospital stay, increased resistance of microorganisms to antimicrobials, increased morbidity and mortality as well as additional financial burden on health care systems, patients and their families. While the optimal aim for patients and the health care system is to prevent CAUTI using measures such as reducing unnecessary placement and early removal of urinary catheters, there is evidence that cleaning of the meatal or peri-urethral area with antiseptic prior to catheter insertion and care of this area while the catheter is insitu has the potential to reduce CAUTI. Evidence suggests that meatal cleaning with antiseptics while the catheter is insitu is non-beneficial in reducing CAUTI but current international and Australian guidelines for infection control professionals identifies that the benefit of antiseptic solution versus non-antiseptic solution for meatal or peri-urethral cleaning before urinary catheter insertion remains unresolved. This discussion paper therefore focuses primarily on antiseptic meatal cleaning prior to urinary catheter insertion in preventing CAUTI. Using evidence from a recently published systematic review and meta-analysis of the literature, this paper discusses the scope of the problem and limitations in the evidence regarding the effectiveness of antiseptics for preventing CAUTI and finally, proposes a way forward through the undertaking of a rigorously conducted randomised controlled trial aimed at evaluating the effectiveness and cost-effectiveness of antiseptic meatal cleaning for prevention of CAUTI.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Infection, Disease & Health
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Hooton T.M.
        • Bradley S.F.
        • Cardenas D.D.
        • Colgan R.
        • Geerlings S.E.
        • Rice J.C.
        • et al.
        Diagnosis, prevention, and treatment of catheter-associated urinary tract infection in adults: 2009 international clinical practice guidelines from the infectious diseases society of America.
        Clin Infect Dis. 2010; 50: 625-663
        • World Health Organization
        Report on the burden of endemic health care-associated infection worldwide: a systematic review of the literature.
        2011 (Geneva)
        • Mitchell B.
        • Fasugba O.
        • Beckingham W.
        • Bennett N.
        • Gardner A.
        A point prevalence study of healthcare associated urinary tract infections in Australian acute and aged care facilities.
        Infect Dis Health. 2016; 21: 26-31
        • Magill S.S.
        • Edwards J.R.
        • Bamberg W.
        • Beldavs Z.G.
        • Dumyati G.
        • Kainer M.A.
        • et al.
        Multistate point-prevalence survey of health care–associated infections.
        N. Engl J Med. 2014; 370: 1198-1208
        • Nicolle L.E.
        Catheter associated urinary tract infections.
        Antimicrob Resist Infect Control. 2014; 3: 1-8
        • Gardner A.
        • Mitchell B.
        • Beckingham W.
        • Fasugba O.
        A point prevalence cross-sectional study of healthcare-associated urinary tract infections in six Australian hospitals.
        BMJ Open. 2014; 4: e005099
        • Saint S.
        Clinical and economic consequences of nosocomial catheter-related bacteriuria.
        Am J Infect Control. 2000; 28: 68-75
        • Conway L.J.
        • Carter E.J.
        • Larson E.L.
        Risk factors for nosocomial bacteremia secondary to urinary catheter-associated bacteriuria: a systematic review.
        Urol Nurs. 2015; 35: 191
        • Mitchell B.
        • Ferguson J.
        • Anderson M.
        • Sear J.
        • Barnett A.
        Length of stay and mortality associated with healthcare-associated urinary tract infections: a multi-state model.
        J Hosp Infect. 2016; 93: 92-99
        • Fasugba O.
        • Mitchell B.G.
        • Mnatzaganian G.
        • Das A.
        • Collignon P.
        • Gardner A.
        Five-year antimicrobial resistance Patterns of urinary Escherichia coli at an Australian Tertiary hospital: time series analyses of prevalence data.
        PloS one. 2016; 11: e0164306
        • Sundvall P.-D.
        • Elm M.
        • Gunnarsson R.
        • Mölstad S.
        • Rodhe N.
        • Jonsson L.
        • et al.
        Antimicrobial resistance in urinary pathogens among Swedish nursing home residents remains low: a cross-sectional study comparing antimicrobial resistance from 2003 to 2012.
        BMC Geriatr. 2014; 14: 30
        • World Health Organisation
        Antimicrobial resistance: global report on surveillance.
        • Umscheid C.
        • Mitchell M.
        • Doshi J.
        • Agarwal R.
        • Williams K.
        • Brennan P.J.
        Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs.
        Infect Control Hosp Epidemiol. 2011; 32: 101-114
        • Gould C.V.
        • Umscheid C.A.
        • Agarwal R.K.
        • Kuntz G.
        • Pegues D.A.
        Guideline for prevention of catheter-associated urinary tract infections 2009.
        Infect Control Hosp Epidemiol. 2010; 31: 319-326
        • Saint S.
        • Greene M.T.
        • Krein S.L.
        • Rogers M.A.
        • Ratz D.
        • Fowler K.E.
        • et al.
        A program to prevent catheter-associated urinary tract infection in acute care.
        N. Engl J Med. 2016; 374: 2111-2119
        • Zimlichman E.
        • Henderson D.
        • Tamir O.
        • Franz C.
        • Song P.
        • Yamin C.K.
        • et al.
        Health care–associated infections: a meta-analysis of costs and financial impact on the US health care system.
        JAMA Intern Med. 2013; 173: 2039-2046
        • Department of Health and Human Services
        HHS action plan to prevent healthcare-associated infections.
        2009 (Retrieved February 3, 2017)
        • Jackson T.
        • Nghiem H.S.
        • Rowell D.
        • Jorm C.
        • Wakefield J.
        Marginal costs of hospital-acquired conditions: information for priority-setting for patient safety programmes and research.
        J Health Serv Res Policy. 2011; 16: 141-146
        • Jacobsen S.M.
        • Stickler D.J.
        • Mobley H.L.T.
        • Shirtliff M.E.
        Complicated catheter-associated urinary tract infections due to Escherichia coli and Proteus mirabilis.
        Clin Microbiol Rev. 2008; 21: 26-59
        • Warren J.W.
        Catheter-associated urinary tract infections.
        Int J Antimicrob Agents. 2001; 17: 299-303
        • Subashchandrabose S.
        • Mobley H.L.T.
        Virulence and fitness determinants of uropathogenic Escherichia coli.
        Microbiol Spectr. 2015; 3 (1128/microbiolspec.UTI-0015-2012): 10
        • Ercole F.F.
        • Macieira T.G.R.
        • Wenceslau L.C.C.
        • Martins A.R.
        • Campos C.C.
        • Chianca T.C.M.
        Integrative review: evidences on the practice of intermittent/indwelling urinary catheterization.
        Rev Latino-Am Enfermagem. 2013; 21: 459-468
        • Mitchell B.
        • Ware C.
        • McGregor A.
        • Brown S.
        • Wells A.
        • Stuart R.L.
        • et al.
        ASID (HICSIG)/AICA position statement: preventing catheter-associated urinary tract infections in patients.
        Healthc Infect. 2011; 16: 45-52
        • Moola S.
        • Konno R.
        A systematic review of the management of short-term indwelling urethral catheters to prevent urinary tract infections.
        JBI Libr Syst Rev. 2010; 8: 695-729
        • Fink R.
        • Gilmartin H.
        • Richard A.
        • Capezuti E.
        • Boltz M.
        • Wald H.
        Indwelling urinary catheter management and catheter-associated urinary tract infection prevention practices in Nurses Improving Care for Healthsystem Elders hospitals.
        Am J Infect Control. 2012; 40: 715-720
        • Fasugba O.
        • Koerner J.
        • Mitchell B.
        • Gardner A.
        Systematic review and meta-analysis of the effectiveness of antiseptic agents for meatal cleaning in the prevention of catheter-associated urinary tract infections.
        J Hosp Infect. 2017; 95: 233-242
        • Loveday H.
        • Wilson J.
        • Pratt R.
        • Golsorkhi M.
        • Tingle A.
        • Bak A.
        • et al.
        epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England.
        J Hosp Infect. 2014; 86: S1-S70
        • National Health and Medical Research Council
        Australian guidelines for the prevention and control of infection in healthcare.
        Commonwealth of Australia, Canberra, ACT2010
        • Lo E.
        • Nicolle L.E.
        • Coffin S.E.
        • Gould C.
        • Maragakis L.L.
        • Meddings J.
        • et al.
        Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 update.
        Infect Control Hosp Epidemiol. 2014; 35: 464-479
        • Macias J.H.
        • Arreguin V.
        • Munoz J.M.
        • Alvarez J.A.
        • Mosqueda J.L.
        • Macias A.E.
        Chlorhexidine is a better antiseptic than povidone iodine and sodium hypochlorite because of its substantive effect.
        Am J Infect Control. 2013; 41: 634-637
        • McDonnell G.
        • Russell A.D.
        Antiseptics and disinfectants: activity, action, and resistance.
        Clin Microbiol Rev. 1999; 12: 147-179
        • Calogiuri G.
        • Di Leo E.
        • Trautmann A.
        • Nettis E.
        • Ferrannini A.
        • Vacca A.
        Chlorhexidine hypersensitivity: a critical and updated review.
        J Allergy Ther. 2013; 4
        • Krautheim A.
        • Jermann T.
        • Bircher A.
        Chlorhexidine anaphylaxis: case report and review of the literature.
        Contact Dermatitis. 2004; 50: 113-116
        • Parkes A.
        • Harper N.
        • Herwadkar A.
        • Pumphrey R.
        Anaphylaxis to the chlorhexidine component of Instillagel®: a case series.
        Br J Anaesth. 2009; 102: 65-68
        • Reichman D.E.
        • Greenberg J.A.
        Reducing surgical site infections: a review.
        Rev Obstet Gynecol. 2009; 2: 212
        • Mangram A.J.
        • Horan T.C.
        • Pearson M.L.
        • Silver L.C.
        • Jarvis W.R.
        • Committee H.I.C.P.A.
        Guideline for prevention of surgical site infection, 1999.
        Am J Infect Control. 1999; 27: 97-134
        • Edmiston C.E.
        • Bruden B.
        • Rucinski M.C.
        • Henen C.
        • Graham M.B.
        • Lewis B.L.
        Reducing the risk of surgical site infections: does chlorhexidine gluconate provide a risk reduction benefit?.
        Am J Infect Control. 2013; 41: S49-S55
        • Edmiston C.E.
        • Krepel C.J.
        • Seabrook G.R.
        • Lewis B.D.
        • Brown K.R.
        • Towne J.B.
        Preoperative shower revisited: can high topical antiseptic levels be achieved on the skin surface before surgical admission?.
        J Am Coll Surg. 2008; 207: 233-239
        • Eiselt D.
        Presurgical skin preparation with a novel 2% chlorhexidine gluconate cloth reduces rates of surgical site infection in orthopaedic surgical patients.
        Orthop Nurs. 2009; 28: 141-145
        • Chlebicki M.P.
        • Safdar N.
        • O'Horo J.C.
        • Maki D.G.
        Preoperative chlorhexidine shower or bath for prevention of surgical site infection: a meta-analysis.
        Am J Infect Control. 2013; 41: 167-173
        • Webster J.
        • Osborne S.
        Preoperative bathing or showering with skin antiseptics to prevent surgical site infection.
        Cochrane Database Syst Rev. 2015; 2: CD004985
        • Jakobsson J.
        • Perlkvist A.
        • Wann-Hansson C.
        Searching for evidence regarding using preoperative disinfection showers to prevent surgical site infections: a systematic review.
        Worldviews Evid Based Nursing. 2011; 8: 143-152
        • Edmiston C.E.
        • Krepel C.J.
        • Edmiston S.E.
        • Spencer M.
        • Lee C.
        • Brown K.R.
        • et al.
        Empowering the surgical patient: a randomized, prospective analysis of an innovative strategy for improving patient compliance with preadmission showering protocol.
        J Am Coll Surg. 2014; 219: 256-264
        • Carapeti E.
        • Andrews S.
        • Bentley P.
        Randomised study of sterile versus non-sterile urethral catheterisation.
        Ann R Coll Surg Engl. 1996; 78: 59
        • Duffy L.M.
        • Cleary J.
        • Ahern S.
        • Kuskowski M.A.
        • West M.
        • Wheeler L.
        • et al.
        Clean intermittent catheterization: safe, cost-effective bladder management for male residents of VA nursing homes.
        J Am Geriatr Soc. 1995; 43: 865-870
        • Dick A.W.
        • Perencevich E.N.
        • Pogorzelska-Maziarz M.
        • Zwanziger J.
        • Larson E.L.
        • Stone P.W.
        A decade of investment in infection prevention: a cost-effectiveness analysis.
        Am J Infect Control. 2015; 43: 4-9
        • Graves N.
        Economics and preventing hospital-acquired infection.
        Emerg Infect Dis. 2004; 10: 561-566
        • Tenke P.
        • Kovacs B.
        • Bjerklund J.T.E.
        • Matsumoto T.
        • Tambyah P.A.
        • Naber K.G.
        European and Asian guidelines on management and prevention of catheter-associated urinary tract infections.
        Int J Antimicrob Agents. 2008; 31: 68-78