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					Jpn. J. Infect. Dis., 63, 277­279, 2010



Short Communication

                       Microbial Contamination of Disinfectants Used for
                                Intermittent Self­Catheterization
                   Harumasa Hakuno*, Mitutaka Yamamoto1, Shigeharu Oie2, and Akira Kamiya3
                             Department of Pharmacy, and 1Department of Urology,
                                Yamaguchi Grand Medical Center, Hofu 747­8511;
                   2Department of Pharmacy, Yamaguchi University Hospital, Ube 755­8505; and
                                  3Ube Frontier University, Ube 755­0805, Japan


                                (Received November 25, 2009. Accepted April 19, 2010)

       SUMMARY: We investigated the microbial contamination of 0.02z benzalkonium chloride solution
       used in catheter kits for intermittent self­catheterization. Of 20 samples examined, 12 (60.0z) were con­
       taminated with 8.8 ~ 102–3.1 ~ 106 colony­forming units (cfu)/mL. The contaminants were Pseudo­
       monas fluorescens, Burkholderia cepacia, and Aeromonas spp. These results showed that 0.02z ben­
       zalkonium chloride solution used for the lubrication/disinfection of catheters for self­catheterization is
       susceptible to contamination. Therefore, the lubricant/disinfectant for catheters for self­catheterization
       was changed from 0.02z benzalkonium chloride solution to 84–87z glycerin containing 0.02z ben­
       zalkonium chloride, and microbial contamination of the latter in catheter kits for self­catheterization
       was reinvestigated. Of 42 samples, 5 (11.9z) were contaminated with 20–2.0 ~ 104 cfu/mL. However,
       the rate of contamination of 84–87z glycerin containing 0.02z benzalkonium chloride was significant­
       ly lower than that of 0.02z benzalkonium chloride solution (P º 0.0001). The contaminant of 84–87z
       glycerin containing 0.02z benzalkonium chloride was Bacillus spp. in all contaminated samples. In this
       survey, neither contaminants of 0.02z benzalkonium chloride solution nor the contaminant of 84–87z
       glycerin containing 0.02z benzalkonium chloride were the causative microbial species of urinary tract
       infection.

   Intermittent self­catheterization is widely used as a          containing 0.02z benzalkonium chloride prepared in
urination method in patients with urination disorders             the hospital) was recovered, and microbial contamina­
such as neurogenic bladder (1–4). Nondisposable                   tion was evaluated. In addition, bacterial cultures of
catheters used in this method are stored in catheter kits         patients' urine samples were evaluated. Residual solu­
containing lubricants/disinfectants, and can be repeat­           tions of 0.02z benzalkonium chloride solution and
edly used for about 1 month. This method is straightfor­          84–87z glycerin containing 0.02z benzalkonium chlo­
ward and economical. However, due to the repeated use             ride in catheter kits for self­catheterization were used as
of catheters in the bladder, the management of disin­             samples. For the quantification of contaminants, each
fectants in catheter kits is important. We investigated           sample was diluted 1:101, 102, 103, 104, 105, 106, and 107
the microbial contamination of 0.02z benzalkonium                 with sterile distilled water containing 0.5z Twin 80,
chloride solution and 84–87z glycerin containing                  0.5z Lubrol W, and 0.25z Soya lecithin as inactiva­
0.02z benzalkonium chloride in catheter kits used dur­            tors of disinfectants (5), and 0.2 mL of the undiluted
ing intermittent self­catheterization, and evaluated              sample or 0.2 mL of each dilution was used to inoculate
preventive measures against microbial contamination               a medium. After culture, colonies were counted. As the
and the association between contamination and infec­              medium, trypticase soy agar was used for bacteria and
tion.                                                             Sabouraud's glucose agar for fungi. The culture temper­
   We investigated microbial contamination after                                             C
                                                                  ature and time were 309 and 24–72 h for bacteria and
recovering 0.02z benzalkonium chloride solution                       C
                                                                  259 and 48 h–7 days for fungi. Contaminants were
(0.02z Pribc} solution; Otsuka Pharmaceutical Facto­              identified by Gram staining, morphological evaluation,
ry, Tokushima, Japan) in catheter kits used by patients           the OF test, cytochrome­oxidase test, and Api 20NE.
performing intermittent self­catheterization in the out­          Bacterial culture of urine was performed in the labora­
patient clinic of Yamaguchi Grand Medical Center be­              tory of the hospital. Statistical differences were ana­
tween October 2001 and April 2002, and evaluated the              lyzed using Mann­Whitney U test.
results. Between July 2002 and September 2005, a disin­              Of 20 samples of 0.02z benzalkonium chloride solu­
fectant containing a lubricant (84.0–87.0z glycerin               tion in catheter kits for self­catheterization, 12 (60.0z)
                                                                  were contaminated with 8.8 ~ 102–3.1 ~ 106 colony­
                                                                  forming units (cfu)/mL. The contaminants were Pseu­
  *Corresponding author: Mailing address: Department of           domonas fluorescens, Burkholderia cepacia, and Aero­
   Pharmacy, Yamaguchi Grand Medical Center, 77 Osaki,            monas spp. as Gram­negative rods (Table 1). Of 42
   Hofu 747­8511, Japan. Tel: {81­835­22­5343, Fax: {81­          samples of 84–87z glycerin containing 0.02z ben­
   835­38­1761, E­mail: hakuno.harumasa—white.megaegg.            zalkonium chloride as a disinfectant containing a
   ne.jp                                                          lubricant, 5 (11.9z) were contaminated with 20–2.0 ~

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                 Table 1. Microbial contamination of 0.02z benzalkonium chloride solution in the catheter kit used
                   by patients for intermittent self­catheterization (20 samples)

                                  0.02z Benzalkonium chloride solution                        Urine
                 Sample
                   no.          Colony count            Contaminant                Result             Contaminant
                                  cfu/mL

                    1            3.1 ~ 106         Burkholderia cepacia                        NT
                    2            1.2 ~ 106         Burkholderia cepacia                        NT
                                                   Aeromonas spp.
                    3            1.2 ~ 106         Pseudomonas fluorescens                     NT
                    4            5.5 ~ 105         Burkholderia cepacia                        NT
                    5            4.0 ~ 105         Burkholderia cepacia                        NT
                    6            3.0 ~ 105         Burkholderia cepacia                        NT
                    7            1.0 ~ 105         Pseudomonas fluorescens                     NT
                    8            8.3 ~ 104         Burkholderia cepacia                        NT
                    9            6.8 ~ 104         Pseudomonas fluorescens                     NT
                   10            2.4 ~ 104         Pseudomonas fluorescens                     NT
                   11            1.1 ~ 104         Burkholderia cepacia               {               Pseudomonas aeruginosa
                   12            8.8 ~ 102         Burkholderia cepacia                        NT
                   13                 5            Burkholderia cepacia                        NT
                   14               º5                        |                       {               Pseudomonas aeruginosa
                   15
                   ¿                º5                        |                                NT
                   20

                 NT, not tested; {, positive culture (organisms in concentrations of †103 cfu/mL).


                        Table 2. Microbial contamination of 84–87z glycerin containing 0.02z benzalkonium
                          chloride in the catheter kit used by patients for intermittent self­catheterization (42
                          samples)

                                          Glycerin containing                         Urine
                        Sample        0.02z benzalkonium chloride
                          no.
                                     Colony count
                                       cfu/mL           Contaminant          Result           Contaminant

                            1          2.0 ~ 104         Bacillus   spp.               NT
                            2          1.6 ~ 104         Bacillus   spp.               NT
                            3          7.9 ~ 102         Bacillus   spp.               NT
                            4          4.3 ~ 102         Bacillus   spp.               NT
                            5          2.0 ~ 10          Bacillus   spp.               NT
                            6             º5                  |                {              Streptococcus agalactiae
                                                                                              MRSA
                                                                                              Citrobacter freundii
                           7              º5                  |                {              Klebsiella oxytoca
                           8              º5                  |                {              Citrobacter diversus
                           9
                          ¿               º5                  |                        NT
                          42

                        NT, not tested; {, positive culture (organisms in concentrations of †103 cfu/mL).



104 cfu/mL. The contaminant was Bacillus spp. in all                       other 8 uncontaminated samples, bacterial culture of
samples (Table 2). The microbial contamination rate                        urine had been performed, and P. aeruginosa had been
significantly decreased after the change from 0.02z                        detected (Table 1). In 5 cases yielding contaminated
benzalkonium chloride solution to 84–87z glycerin                          samples of 84–87z glycerin containing 0.02z ben­
containing 0.02z benzalkonium chloride (P º 0.0001)                        zalkonium chloride, no bacterial culture of urine had
(Fig. 1).                                                                  been performed. For 3 of the 37 uncontaminated sam­
   In 1 of the 12 contaminated samples of 0.02z ben­                       ples, the bacterial culture of urine had been carried out,
zalkonium chloride solution, bacterial examination of                      and Streptococcus agalactiae, methicillin­resistant
urine had been performed. B. cepacia was detected in                       Staphylococcus aureus (MRSA), Citrobacter freundii,
the sample of 0.02z benzalkonium chloride solution                         Klebsiella oxytoca, and Citrobacter diversus had been
whereas Pseudomonas aeruginosa was detected in the                         detected (Table 2).
urine culture. Thus, the bacterial species differed be­                       In this study, 0.02z benzalkonium chloride solution
tween the disinfectant and urine culture. For 1 of the                     in catheter kits used for intermittent self­catheterization

                                                                     278
                                                                       disinfectant containing a lubricant, the catheter could
                                                                       be inserted without the need for additional lubricants.
                                                                       This method could be more readily performed.
                                                                          The results of this study showed that contaminants of
                                                                       lubricants/disinfectants stored in catheter kits used for
                                                                       intermittent self­catheterization were not causative spe­
                                                                       cies of urinary tract infection. However, in terms of
                                                                       microbial contamination, the sensation on insertion,
                                                                       and method of use, 84–87z glycerin containing 0.02z
                                                                       benzalkonium chloride is more appropriate than 0.02z
                                                                       benzalkonium chloride solution (10).
                                                                          However, even 84–87z glycerin containing 0.02z
                                                                       benzalkonium chloride sometimes causes microbial con­
                                                                       tamination when used for a prolonged period. Its as­
                                                                       sociation with infection has been reported (11).
                                                                       Catheters after use should be thoroughly washed, dried,
 Fig. 1. Comparison of the contamination rate between 0.02z
   benzalkonium chloride solution and 84–87z glycerin contain­
                                                                       and stored in kits. Disinfectants containing lubricants
   ing 0.02z benzalkonium chloride in catheter kits for self­          should be regularly replaced every other day. Adequate
   catheterization.                                                    attention should be paid to the hygiene management of
                                                                       disinfectant containing lubricants in kits.

were contaminated with high levels of microorganisms.                                             REFERENCES
Thus, 0.02z benzalkonium chloride solution used for
the lubrication/disinfection of catheters for self­                     1. Lapides, J., Diokno, A.C., Silber, S.J., et al. (1972): Clean, inter­
                                                                           mittent self­catheterization in the treatment of urinary tract dis­
catheterization is susceptible to microbial contamina­                     ease. J. Urol., 107, 458–461.
tion. After a change from 0.02z benzalkonium chlo­                      2. Orisaka, S., Koyanagi, T., Motomura, M., et al. (1976): Ex­
ride solution to 84–87z glycerin containing 0.02z ben­                     perience with non­sterile intermittent self­catheterization. J.
zalkonium chloride, the microbial contamination rate                       Urol., 115, 141–142.
decreased. The contaminants of 0.02z benzalkonium                       3. Wyndaele, J.J. and Maes, D. (1990): Clean intermittent self­
                                                                           catheterization: a 12­year followup. J. Urol., 143, 906–908.
chloride solution were P. fluorescens, B. cepacia, and                  4. Moore, K.N., Kelm, M., Sinclair, O., et al. (1993): Bacteriurea in
Aeromonas spp. as glucose­nonfermentative Gram­                            intermittent catheterization users: the effect of sterile versus clean
negative rods, which can be causative species of urinary                   reused catheters. Rehabil. Nurs., 18, 306–309.
tract infection (6–9). The contaminant of 84–87z glyce­                 5. Russell, A.D., Ahonkhai, I. and Rogers, D.T. (1979): Microbio­
                                                                           logical applications of the inactivation of antibiotics and other
rin containing 0.02z benzalkonium chloride was Bacil­                      antimicrobial agents. J. Appl. Bacteriol., 46, 207–245.
lus spp. in all contaminated samples. There have been                   6. Bennet, C.J., Young, M.N. and Darrington, H. (1995): Differ­
no reports of urinary tract infection by Bacillus spp.,                    ences in urinary tract infections in male and female spinal cord in­
suggesting that this species is nonpathogenic. In terms                    jury patients on intermittent catheterization. Paraplegia, 33,
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                                                                        7. Prieto­Fingerhut, T., Banovac, K. and Lynne, M.C. (1997): A
zalkonium chloride solution or 84–87z glycerin con­                        study comparing sterile and nonsterile urethral catheterization in
taining 0.02z benzalkonium chloride was not the same                       patients with spinal cord injury. Rehabil. Nurs., 22, 299–302.
as that detected in urine culture. Thus, contaminants of                8. Schlager, T.A., Dilks, S., Trudell, J., et al. (1995): Bacteriurea in
the lubricant/disinfectant solution did not cause urinary                  children with nerogenic bladder treated with intermittent
                                                                           catheterization: natural history. J. Pediatr., 126, 490–496.
tract infection.                                                        9. Lu, D.C., Chang, S.C., Chen, Y.C., et al. (1997): Burkholderia
   Concerning the actual method of use, when 0.02z                         cepacia bacteremia: a retrospective analysis of 70 episodes. J.
benzalkonium chloride solution alone was employed,                         Formos. Med. Assoc., 12, 972–978.
catheters were stored in 0.02z benzalkonium chloride                   10. Oie, S. and Kamiya, A. (1998): Microbial contamination of ben­
solution in catheter kits. Since the solution was difficult                zalkonium chloride products. Am. J. Health­Syst. Pharm., 55,
                                                                           2534–2537.
to insert, Benoxil} (oxybuprocaine hydrochloride) jelly                11. Oie, S., Kamiya, A., Seto, T., et al. (2000): Microbial contamina­
containing a local anesthetic had been used as a                           tion of in­use lubricants for non­touch urethral catheters in inter­
lubricant before insertion. After the change to 84–87z                     mittent self­catheterization. Biol. Pharm. Bull., 23, 781–783.
glycerin containing 0.02z benzalkonium chloride as a




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