Medical Hypotheses 137 (2020) 109561

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Medical Hypotheses
journal homepage: www.elsevier.com/locate/mehy

Prevention of catheter-related urinary tract infections: The octenidine T

hypothesis
⁎
Luka Grgar
School of Medicine, University of Zagreb, Šalata 3, 10000 Zagreb, Croatia

A B S T R A C T

Urinary bladder dysfunction and voiding disorders lead to the accumulation of residual urine. Left untreated, these conditions result in urinary tract infections. In
order to empty the urinary bladder properly, clean intermittent catheterization procedures are highly advocated as an effective measure. Clean intermittent ca-
theterization is a repetitive procedure, which includes inserting the urinary catheter into the urinary bladder. However, inserting the urinary catheter several times a
day into the urinary bladder further compromises patient’s safety since the procedure itself is a risk for acquiring catheter-related urinary tract infections. In order to
prevent catheter contamination and further infections, new catheter models or catheterization techniques need to be developed. In this paper, a possible method for
protection of catheter surface is hypothesized. Using octenidine as an effective antiseptic agent for creating an antimicrobial layer might prove effective against
bacterial adhesion and consequent catheter contamination. Additionally, using octenidine as catheter coating further facilitates the catheterization procedure. An
uncontaminated catheter throughout the whole catheterization process is the main goal of the procedure. Achieving it would prove beneficial to both patients and the
healthcare system due to the absence of infections, increase in patients’ quality of life and an overall cost reduction.

Introduction routes of contamination via urinary catheter whereas extraluminal

contamination is linked to intermittent catheterization procedure. Ex-
Urinary bladder dysfunction and voiding problems occur as a con- traluminal contamination is associated with direct inoculation of mi-
sequence of various neurological and trauma conditions [1]. In- croorganisms into the urinary bladder [8]. Bacteria can ascend to the
complete bladder emptying results in residual urine, thus leading to kidneys, giving rise to pyelonephritis [10]. As such, catheters provide
urinary tract infections. To prevent urinary tract infections due to urine the translocation mechanism for microorganisms during the urinary
retention, clean intermittent catheterization is used as recommended bladder catheterization procedure.
and effective procedure [2,3]. There is an increasing need for new technological advancements in
Clean intermittent catheterization is a well known procedure com- catheter forms that might prevent catheter-related urinary tract infec-
monly performed by inserting the urinary catheter through the urethra tions. Patients showed willingness to pay for innovative catheter solu-
into the urinary bladder and draining the bladder completely of urine. tions with possibility of urinary tract infections decrease [11]. There-
Procedure should be performed every few hours, or often enough to fore, possible method for preventing catheter contamination by
keep the residual volume below certain threshold [4]. Intermittent protecting the external catheter surface with antiseptic is further hy-
bladder catheterization improves quality of life in patients with bladder pothesized.
dysfunctions by reducing occurrence of infections and decreasing the
death rate [5–7]. Hypothesis
Although clean intermittent catheterization is considered effective
in complete bladder emptying, it also plays a role in developing ca- Hypothesized method states that treating intermittent urinary ca-
theter-related urinary tract infections [4]. In fact, catheter-related ur- theter with antiseptic agent octenidine dihydrochloride prior to ca-
inary tract infections are one of the most common consequences in theter insertion prevents catheter contamination and reduces the risk of
people who undergo clean intermittent catheterization [2,8]. Maki acquiring catheter-related urinary tract infections in people who un-
et al. [9] found that patients who are catheterized are at a high risk of dergo clean intermittent catheterization procedure.
developing urinary tract infections either by bacterial flora from peri-
neal and colon regions or by hand manipulation of healthcare personnel
performing the catheterization procedure. Authors describe multiple

⁎
Address: Grižanska 13, 10000 Zagreb, Croatia.
E-mail address: [email protected].

https://doi.org/10.1016/j.mehy.2020.109561
Received 26 November 2019; Received in revised form 27 December 2019; Accepted 8 January 2020
0306-9877/ © 2020 Elsevier Ltd. All rights reserved.
L. Grgar Medical Hypotheses 137 (2020) 109561

Evaluation of hypothesis the catheter surface must be complete and unobstructed, i.e. whole
catheter surface along the insertion site must be covered by octenidine
Early intermittent urinary catheter contamination is a precondition to be considered fully coated.
for introduction of microorganisms to urinary bladder. In order to
prevent bacterial adhesion on the catheter surface, certain barrier be- Conclusion
tween catheter surface and surroundings must exist. One possible way
of preventing bacterial adhesion is to create a protective antimicrobial Reducing the occurrence of catheter-related urinary tract infections
layer on the catheter surface prior to catheter application. Production of is the main goal of the hypothesized method, which can be accom-
such antimicrobial layer requires substance that has high antimicrobial plished provided that the octenidine layer contributes a substantial
potential. In addition, such substance should not possess any adverse level of antimicrobial protection to the catheter surface.
effects on mucosal tissue, i.e. urothelium. Provided that surface remains A decrease in catheter-related urinary tract infections results in
protected during the procedure, bacteria could not be translocated from prevention of some of the associated complications, such as pyelone-
perioperative area into the urinary bladder. phritis, chronic inflammation (e.g. chronic cystitis) and urosepsis.
This paper proposes octenidine dihydrochloride as proper anti- Likewise, kidney function would be preserved in the absence of such
microbial agent for treating hydrophilic urinary catheters prior to ca- negative effects. As a result, reducing catheter-related urinary tract
theter application. In addition, coating urinary catheters with octeni- infections would increase the quality of life in patients who undergo
dine is also considered under hypothesized method. Octenidine clean intermittent catheterization [11]. Moreover, costs associated with
dihydrochloride is a well known antiseptic widely used as an effective urinary tract infections treatment and prolonged hospital days should
broad-spectrum antimicrobial agent for a variety of both Gram-positive also reduce, thus having a positive net-effect on healthcare costs.
and Gram-negative bacteria. Octenidine compositions demonstrate no However, possible negative effects of octenidine in the hypothesized
teratogenic, mutagenic nor adverse atopic effects in mice. However, method also need to be assessed and determined. Although octenidine
bladder irrigation with octenidine solutions is not recommended due to has shown no short-term negative effects on mucosa or skin, long term
the lack of evidence on safety [12]. Moreover, using octenidine as a usage of this antiseptic agent remains unknown. Additionally, octeni-
single substance is suggested even though products are registered as a dine showed no adverse effects on pregnancy and reproduction phy-
combination of octenidine and phenoxyethanol [13]. In order to avoid siology in rats [12], yet further investigation regarding the long term
possible adverse effects, such as toxicity, using octenidine preparations effects in the given indication is recommended. Other, currently un-
without phenoxyethanol is recommended. known, side-effects might appear, which is why further research is re-
Octenidine coatings are used in various applications [14,15]. The commended.
effects of octenidine on human skin have been examined and suggested In conclusion, this hypothesis offers a new perspective on preven-
octenidine to be effective if applied on urethral meatus [16]. However, tion of catheter-related urinary tract infections. An octenidine layer
this only ensures limited perioperative area to be treated with anti- might play a major role in the prevention of bacterial adhesion on ca-
septic, while catheter surface in fact remains untreated and un- theter surface during intermittent catheterization procedure. If octeni-
protected. dine proves to be effective, patients and experts should consider ap-
It is hypothesized that if a person performing the urinary catheter- plying octenidine on intermittent catheters. Similarly, commercial
ization applies octenidine dihydrochloride in solution, gel or spray form medical products containing the combination of catheter and an octe-
on the catheter surface prior to the catheterization procedure, an an- nidine solution or octenidine coated catheters should also be considered
timicrobial layer on the catheter surface would be generated. This layer since it would provide a feasible and practical solution for patients who
would prevent extraluminal contamination and introduction of micro- undergo clean intermittent catheterization.
organisms into the urinary bladder. The antiseptic agent applied under
the hypothesized method may include forms, e.g. solution, gel spray as Declaration of Competing Interest
well as pre-lubrication of catheters with octenidine during manu-
facturing. Furthermore, manufacturing pre-lubricated catheters would Author is pending a patent for intermittent catheter combined with
enable an easier catheter manipulation, as well as reduce time needed octenidine solution under the patent application number P20161254A
for a catheter to be ready for application. Additionally, this creates a in Republic of Croatia Intellectual Property Office.
low friction surface that facilitates the insertion process and decreases No conflict of interest has been determined regarding funding or
the incidence of catheter-related urinary tract infections [17]. In the sponsorship of this paper.
case of pre-lubricated octenidine layer, sterile water activation would
be available as a method of activation. The antiseptic layer should have Acknowledgements
a substantial, yet limited, concentration in order to provide a protective
antimicrobial effect, while remaining within the concentration range of I would like to thank Professor Vedran Katavić, MD, PhD for his
safe application. A certain amount of antiseptic layer could succumb to suggestions during the manuscript preparation.
attrition from catheter surface due to mechanical forces and resistance No sources of support.
of urethral mucosa tissue during catheter insertion. The right catheter
size is essential to ensure preservation of quality of the octenidine layer, References
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