Urinary catheterization in patients with acute ischemic stroke
Benefits and consequences. A prospective, observation study

Introduction: n order to facilitate nursing and prevent pressure sores, urinary catheterization is commonly used in stroke patients. Nevertheless, it is perceived to increase the risk of urinary track infections and fever, parameters that have been associated with an unfavourable stroke outcome.

Aim: The aim of our study was to evaluate the proportion of patients receiving urinary catheterization, the demographic and clinical characteristics of such patients and the association between urinary catheterization and the occurrence of medical complications in Greek patients with acute ischemic stroke.

Methods: Patients admitted with acute ischemic brain attack were included. Diagnosis was based on clinical picture and confirmed by CT or MRI brain scan in all cases. Each patient's attending physician was responsible for the decision whether a urinary catheter should be inserted or not. Patients were assessed on admission, day 5 and upon exit from hospital. Patient records were examined to determine whether urinary catheters were inserted and whether any of the following occurred: urinary track infections (diagnosed clinically or by urine culture), fever (T>37.5°C), the use of antibiotics and pressure sores.

Results: 111 patients with an acute ischemic stroke were admitted during a three-month period, 46 of them were male and 65 female. Mean age of patients was 71.9 years (SD=11.02, minimum age 42 years, maximum age 92 years). In total, 52 patients (46.9%) were catheterized (6 patients had been catheterized previously). Older patients and patients with higher NIH stroke scale score were more likely to be catheterized (OR 1.12, p<0.01 and OR 1.16, p<0.01 respectively). During hospital stay elevated body temperature was measured in 32.4% of patients and antibiotics were administered to all of them. Urinary catheterization was found to significantly increase the risk of urinary track infections (p<0.01), use of antibiotics (p<0.01) and fever (p<0.01). The risk of pressure sores was not influenced. After adjusting for case mix (including age, gender and stroke severity), urinary catheterization was found to significantly increase the risk of urinary track infections (p<0.01) use of antibiotics (p<0.01) and fever (p<0.01). The risk of pressure sores was not influenced (p=0.46).

Conclusions: Although urinary catheterization is perceived to be associated with medical complications in stroke patients, it is still commonly used in Greece. Preview studies have shown that the development of fever in ischemic stroke patients was associated with prior use of an invasive technique and, more specifically, with urinary catheterization. Also, the fact that body temperature is a strong predictor of good functional outcome has been demonstrated. The effectiveness of organized inpatient (stroke unit) care has been demonstrated in systematic reviews of clinical trials. Among the components of effective stroke unit care is avoidance of urinary catheterization. Our study demonstrated that urinary catheterization appears to increase the risk of urinary track infections, use of antibiotics and fever without decreasing the risk of developing pressure sores in patients with acute ischemic stroke. A randomized controlled trial is needed in order to establish the balance of risks and advantages of this commonly used practice.

Key words: Ischemic stroke, urinary catheterization, urinary track infection, fever, pressure sores.