Catheter-associated urinary tract infection (CAUTI) is a common complication among patients performing clean intermittent catheterization (CIC) or with an indwelling catheter (IDC), and is often treated with antibiotics. With increasing rates of antibiotic resistance and increasing healthcare costs, it is necessary to explore alternatives for antibiotic treatment of CAUTIs which are cost-effective, well tolerated by patients and lead to less antibiotic resistance. 

This is the first study to prospectively evaluate the safety and effectiveness of bladder irrigation (BI) with tap water to reduce antibiotic use for the treatment of CAUTIs in patients with urinary catheters in the community setting. In addition, health-related quality of life (QoL) and treatment satisfaction were evaluated.

This single-center, prospective observational study included adult patients with urinary catheters (CIC or IDC) who started BI with tap water due to recurrent CAUTI symptoms between July 2022 and March 2024. Patients received a combination of self-developed and validated questionnaires at baseline (before BI) and after a 3-month follow-up. Health-related QoL was measured with the EQ-5D-5L and treatment satisfaction with the Treatment Satisfaction Questionnaire for Medication (TSQM-9). Both questionnaire assessments evaluated the number of self-reported antibiotic treatments for CAUTIs and the number of CAUTIs in the three months prior to questionnaire completion. 
A sample size of 58 was calculated based on a mean number of antibiotic use from a previous study (1) and an expected 30% antibiotic reduction after BI, to provide a study power of 80% with a 2.5% one-sided significance level. 

BI procedure 
BI with tap water was prescribed to patients with recurrent CAUTI symptoms and was used for the treatment of CAUTIs without systemic symptoms (e.g. fever, flank pain or delirium). CAUTI symptoms include cloudy or strong-smelling urine, hematuria, dysuria/pain during catheterization, urinary frequency, urinary urgency and suprapubic pain. Patients received BI instructions from our continence nurses at the outpatient clinic. For the BI procedure, a 50mL catheter-tip syringe was used, which was filled with tap water (at body temperature) from a clean, non-sterile container. The bladder was actively irrigated by flushing in and drawing back on the plunger to reduce the concentration of bacteria in the bladder. This procedure was repeated until the outgoing solution was clear, and thus without contamination. A tapering schedule was used for BI, which was resumed upon recurrent CAUTI symptoms. Patients were instructed to contact their physician and discontinue BI in the presence of systemic symptoms. Antibiotics were prescribed when BI was not feasible, did not sufficiently relieve CAUTI symptoms or in case of a CAUTI with systemic symptoms.

Sixty-one patients were included with a median age of 64.9 years (IQR 51.2-72.9), 67.2% were male, 83.6% were performing CIC, and 45.9% had neurogenic lower urinary tract dysfunction. Three months prior to the introduction of BI, 82% of patients had received ≥1 antibiotic treatments for  CAUTI(s), with an average number of 1.93 treatments per patient. At three-months follow-up, only 54% of patients received antibiotics for CAUTI(s), with an average number of 1.25 treatments per patient. Antibiotic use was decreased on average by 32% (IRR=0.64; p=0.027) and CAUTIs by 35.5% (IRR=0.64; p=0.009) (Table 1). No increase was observed in the incidence of CAUTIs with systemic symptoms. In addition, no differences were observed in the health-related QoL. The majority of patients were positive about the subjective effectiveness (81%), ease of use (86%) and overall satisfaction (85%) of the treatment (Figure 1). During the 3-month follow-up, 14 (23%) patients discontinued BI: 6 due to complete remission of recurrent CAUTIs, 2 for lack of improvement, 2 due to discomfort/pain during BI, 2 were unable to perform BI, and 4 received other new treatments during follow-up (e.g., IDC, oxybutynin BI, or intradetrusor OnabotulinumtoxinA).

The results of the present study reveal that the introduction of BI with tap water in patients with urinary catheters suffering from recurrent CAUTI symptoms resulted in 32% less antibiotic treatments for CAUTIs in combination with a 36% reduction in CAUTI incidence rates. The ease of use and treatment satisfaction of BI with tap water was notably high. We therefore recommend the use of BI with tap water (or bottled water depending on local conditions) in daily practice as therapeutic agent to minimize antibiotic use for CAUTIs and as a preventive agent to reduce the incidence of CAUTIs.

In the midst of the prevailing challenges posed by antibiotic resistance, this is the first study to prospectively investigate the safety and effectiveness of BI with tap water as an alternative treatment for CAUTIs. BI with tap water significantly reduces antibiotic use and CAUTI incidence in patients with recurrent CAUTIs. Implementing this safe and patient-friendly alternative not only reduces reliance on antibiotics, but also provides a pragmatic solution that can be easily integrated into clinical practice,  improving patient care and aligning with sustainable healthcare practices.

van Veen FEE, Den Hoedt S, Coolen RL, Boekhorst J, Scheepe JR, Blok BFM. Bladder irrigation with tap water to reduce antibiotic treatment for catheter-associated urinary tract infections: an evaluation of clinical practice. Front Urol. 2023;3.

Continence 12S (2024) 101586
DOI: 10.1016/j.cont.2024.101586