Problem Statement

The urinary tract is usually sterile, however disturbance of the body’s natural defenses through surgical insertion of catheters introduces bacteria either intraluminally or extraluminally resulting to infection of the urinary tract. It is estimated that one out of four patients receiving hospitalized service has an indwelling urinary catheter for bladder drainage. Contraction of UTI is the most notable complication from these devices. For a long time, Urinary Tract Infections (UTI) has generated a lot of interest in medical practice and research. reported that UTIs are the leading cause of increased health expenditures and form basis for key policy issues.

The expenses are attributed to prolonged hospitalization and expenses due to lengthy diagnostic methods such as bacteria culturing. Among all hospital-acquired infections, UTI accounts for about 40% and increasing costs for health delivery by 25%. Catheter-associated UTIs accounts for over 40% or 1 million cases of all nosocomial infections in nursing homes and hospitals annually, the high incidence of this complication increases the overall cost of medication and untreated cases often leads to fatality. To reduce mortality and morbidity associated with urinary catheter infections, new approaches in prevention and treatment need to be designed. suggested that a more promising initiative is the anti-infective catheters.  A review of literature may help us to answer question of whether anti-infective catheters helps in prevention of UTIs.

Literature Review

Use of indwelling catheter for long term is restrictive. However, According to Linda (2008) indwelling catheters have been used in long-term patient management. asserted that over 100,000 facilities in United States use indwelling catheters for long-term, and in UK, 4% of homecare elders are managed by indwelling catheters. Despite its benefits such as convenience use of catheters for long term management is indicated as the last option due to complication such as recurrent UTI and chronic colonization of the devices bacteria in indwelling managed patients.  Urinary tract infection refers to inflammatory responses of the urinary tract epithelium to pathogenic (bacteria) invasion and colonization leading to bacteriuria and pyuria.

In the United States approximately $424 – $451million is spent annually on managing UTIs, this cost is anticipated to substantially, increase due to increased life expectancy. For example, aged population (> 65 years) represented 12.6% of the total US population in 2007. In the United Kingdom, the burden imposed to the National Health Service by because of catheter associated UTIs amounts to over £124 million annually. Recurrent and chronic cases of UTI and pyelonephritis have further complicates catheter-associated infection prognosis in patients.

Studies carried out a national survey to established efforts undertaken by hospitals in preventing catheter associated UTIs in USA. The authors targeted infection control coordinators from Veteran Affairs hospitals (n=119), and non-federal US hospitals having intensive care unit with capacity of over 50 beds (n=600). The participants were asked about initiatives undertaken at hospital level with aim of curbing spread of UTIs and other infections associated to medical devices. Specific questions requested respondents to rate on a scale of 1 to 5 how frequently certain catheter associated UTI practices were used on hospitalized adult patients. Participants were also asked about strategies employed in monitoring of urinary catheters and UTI at their facility. Additional questions related to whether the hospital had an epidemiologist or infection control coordinator. The study findings with response rate of 72% indicated that about 56% of hospitals had no monitoring systems for patients on urinary catheters, while about 74% never monitored duration of catheters in patients. Only 30% of the hospitals regularly reported use of potable bladder scanners and antimicrobial urinary catheters, those using condom catheters were 14%, and rest used catheter reminders (9%). Comparison of Veteran Affairs hospitals against non-Veteran Affairs hospitals show that the former used portable bladder scanners regularly (49% vs.29% p < .001), the ratio of using suprapubic catheters was (22% to 9% p < .001), while that of condom catheters was 46% to 12% (p < .001). on the other hand non-VA hospitals would use urinary catheters irrigated with antimicrobials regularly than VA hospitals (30% vs. 14% p < .002). They concluded that there was no long-term strategy widely applied in preventing spread of UTIs in hospitals, despite prevalence of UTI associated with urinary catheters. Less than one-third of the hospitals used practices such as antimicrobial catheters and bladder ultrasound, while urinary catheter despite its benefits was only used by less than 10% of hospitals in the US.

Study ranked United States is the major consumer of indwelling urinary catheters constituting 25% of total sales worldwide. According to this study, the most commonly used catheter is the Foley urethral catheter. Although Foley urethral catheter was meant to be used as short-term measure in draining patients’ bladder, the authors noticed cases of long-term usage. They also noted that indwelling catheters are unnecessarily used during hospitalization in 21 % to 50 % of cases thus exposing patients to greater risk complications associated with the devices. reviewed a number of studies on usage of catheters and their clinical implications. For example, in a study carried out on 1,540 nursing home patients, it was demonstrated that risk of hospitalization, duration of antibiotic therapy, and duration of hospitalization increased threefold in catheterized patients than noncatheterized patients. In another review, on clinical trials involving 482 patients using silver oxide-coated catheters, findings revealed decrease of UTI incidence only among women not using antimicrobial drugs (19% p = 0.004) compared to those using silicone coated catheter (1.36%). Due to the conflicting results from reviewed studies, the authors suggested that development of less expensive catheters with anti-infective surfaces is the remedy in successfully preventing infections .They also examined other measures such as identification and design of agents with ability of preventing attachment and formation of biofilm, and use of siderophores as inhibitors of bacterial virulence .

To reduce incidence of biofilm formation, catheters have been developed coated by biomaterials, incorporated with antimicrobials (minocycline, nitrofurazone, and rifampin) or antiseptics (silver oxide and silicone). investigated the clinical effectiveness of antibiotic- and silver alloy-coated catheters for patients placed on long-term supra pubic in comparison to non-coated catheters in decreasing blockages and UTIs. The methodology adopted and review of literature from key health technology evaluations such as PubMed, EuroScan, The Cochrane Library International HTA agencies, and Internet search. Reviewed 18 random or quasi random trials comparing various kinds indwelling urinary catheters used as short-term measure (up to 2 weeks) in hospitalized adults. Findings revealed that silver oxide catheters are not linked to statistically significant decrease in bacteriuria compared to non-coated catheters in short duration usage.

However, silicone coated catheters used as a short-term measure revealed a statistically significant decrease in bacteriuria for catheterization duration more than one week. These findings were similar to a systematic review which included 12 random and quasi-random trials for nitrofurazone-coated urinary catheterization for less than one month. It was  concluded that use of silicone-coated catheters for short-term significantly decreases the risk of catheter-associated UTI. The decrease in infection appeared to compensate for the increased costs of silicone catheters. The authors also concluded that antibiotics could decrease bacteria in catheterized hospitalized patients for duration of less than one week. These findings suggest that silver-coated and silicone-coated catheters saves costs compared to standard catheters .

Lippincott (2009) in a study that, described a Two-Phase Aqueous Micellar Systems to enhance the detection of UTIs. The significance of their study was seeking means to reverse expenditure on UTI patient care. The authors demonstrate experimentally how high costs and lengthy diagnosis process for bacterial infection, and inappropriate antibiotic medication without conclusive diagnosis may lead to pathogen resistance. They suggested a faster and sensitive method of detection to overcome such problems. Their experimental methodology involved generating of Triton X-114 phase diagram to determine surfactant concentrations in micelle-rich and micelle-poor phases within temperature range of 22-360C. Both theory and experiments were used in determination of the main driving forces in RNA partitioning of Triton X-114/PBS micellar systems.  Findings from the study show that concentration of bacterial RNA in patient’s urine samples before detection using UTI chip allows for earlier diagnosis shortening time before medical intervention. The study concluded that fragments of RNA could be concentrated in Triton X-114/PBS micellar systems in a predictable manner through reduction of volume ratios. The measured concentration factors would then form a single step in the diagnosis method using a UTI chip .

The reviewed data cost effectiveness and efficacy of using Bardex IC silver coated hydrogel Forey catheter from PubMed, NHS database, and www.highwire.org. The authors reviewed pathogenesis  and strategies for controlling catheter associated UTIs,and biofilm formation. They argued that use of bacteriuria as a determinant of infection is flawed arguing that for conclusions on efficacy of silver coated catheters to be drawn, there should be means of distinguishing asymptomatic bacteriuria from UTI. Although, most of the reviewed studies indicated reduction of UTIs following Bardex IC introduction, the studies were faced with limitations related to fewer samples of patients for clinical trials, absence of controls, and historical baseline data. For these reasons, no conclusion would be drawn on the cost and clinical significance of the findings .

Summary of Research Studies

  A B C D E
Authors and Date  Seymour Newman. Jackie & Josh, 2011

 

Linda, 2010

 

Lippincott, 2009

 

Sample Size 2 systematic reviews (18 random and quasi- random trials) Review of published clinical studies on silver alloy coated catheters. Randomized studies samples from 90 to 120 patients 1,540 / 432 Experimental VA=119 Non-VA= 600
Population Exploratory review of indwelling catheters in hospitalized adults Hospitalized adults Hospitalized adults Experimental review of diagnostic methods for UTI Infection control coordinators
Variables Clinical effectiveness of antibiotic-coated or silver coated catheters for patients with long-term supra pubic or urinary catheter in comparison to non-coated standard catheters Comparison of silicone coated catheter to control latex catheter. analysis of effectiveness through measurement of UTI incidence from urinalysis, blood culture, and hospital care Pathogenesis of CAUTIs

UTI prognosis

Formation of biofilm and invasiveness of UTIs

Comparison of coated Foley catheters in preventing bacterial colonization

Generation of Triton X-114 phase diagram to determine surfactant concentrations in micelle-rich and micelle-poor phases within temperature range of 22-360C. Both theory and experiments were used in determination of the main driving forces in RNA partitioning of Triton X-114/PBS micellar systems Comparing use of catheters among Veteran Affairs hospitals against non- Veteran Affairs hospitals
Results Three clinical trials revealed that silver oxide catheters have no statistical significant association with reduced bacteriuria compared to non-coated standard catheters used as short-term measure. Pooling results from 8 trials revealed a statistically significant correlation between silicone coated catheters and reduced bacteriuria within one week of catheterization, as well as reduction of risks of symptomatic UTI -47% decrease in symptomatic UTI

-44% decrease in bacteremia

– Silicone coated catheter effective in preventing UTIs.

Findings revealed decrease of UTI incidence only among women not using antimicrobial drugs (19% p = 0.004) compared to those using silicone coated catheter (1.36%) Concentration of bacterial RNA in patient’s urine samples before detection using UTI chip allows for earlier diagnosis shortening time before medical intervention Less than one-third of the hospitals used practices such as antimicrobial catheters and bladder ultrasound, while urinary catheter despite its benefits was only used by less than 10% of hospitals in the US.

Veteran Affairs hospitals versus non- Veteran Affairs hospitals show that they would use portable bladder scanners  more often (49%) than Non-VA (29%)

 

Research Questions

This review excluded questions on whether catheter insertion is indicate or not, and the duration before removing the catheter. Our review is about previous studies covering nursing initiatives aimed at decreasing urinary tract infection risks. To identify review articles on catheter associated urinary tract infections, we carried out a systematic search of literature from databases such as Cochrane, ACP, Jstor, and CDC databases using key words as “indwelling catheter,” “urinary tract infection,” “nursing guidelines and best practices in catheterization,” and “urinary catheterization.”

1. What formulated nursing initiatives aimed at reducing catheter associated UTIs have been promulgated in hospitals?

2. What technological modification in design of catheters (material, or size) decreases risks to urinary tract infections?

3. Does application of sterilization methods during catheter insertion reduce chances of contracting UTI?

4. What routine hospital care measures on reduces predisposition to catheter associated UTIs?

5. Does bladder and/or catheter irrigation decrease risks of urinary tract infections?

6. Does catheter securing decrease risks to urinary tract infections?

8. Does addition of antiseptic solution in urine drainage collector reduce risks of urinary tract infections?

9. Does frequent changes of catheter routinely affect risks to urinary tract infections?

10. Does separation of catheterized patients with catheter associated urinary tract infections decrease spread of UTI to other patients within the hospitals?

11. Does conducting staff training on Catheter associated UTIs and improvement of quality decrease chances of UTIs?

Recommendations and Implications of study

This study discovered that little initiatives are available in hospitals to prevent UTI occurrence. High variations were found regarding preventative practices in different hospitals for catheter associated UTIs. This could be attributed to more centralized healthcare delivery systems. Development of antiseptic coated catheters and new technologies for catheter surfaces would be the ultimate solution in prevention of catheter-associated UTIs. Incidence of symptomatic catheter associated UTIs is one of the major health concerns due to recurrence and complications of the infections. During our review, it was surprising how little data is available in literature specifically on UTI virulence given the higher numbers of patients developing this kind of infection.

As the risks to catheter associated UTIs increase among hospitalized patients worldwide, advances in clinical practice, academic, and research with goal of improving detection, prevention, and medication methods remains critical in reversing statistics on morbidity and mortality resulting from these infections. Therefore, future research should target elucidation of catheter associated UTI pathogenesis in order to develop new and advanced diagnosis, treatment, and prevention. Future research studies should also review mechanisms used by bacterial host cell components to attach to the catheter surface. This would help is irrigation measures on the catheter surface to prevent UTIs.

Summary

Catheter associated UTIs are common in catheterized hospitalized patients. However, catheterization is a common medical process despite the risks to UTIs with higher rates of complicated infections such as orchitis, prostatitis, epididymitis, urethral and vesicular abscesses among many other complications. These infections poses a major challenge in patient recovery and if left untreated results to death to prolonged hospitalization. Coupled with lengthy and time-consuming diagnostic procedures for bacteria, the infection increases healthcare costs in health delivery systems. Development of catheter with irrigated surfaces for preventing infection will circumvent such problems. Irrigation substances to prevent infection include hydrophilic substances, silver alloy, antiseptics, and antibiotics. This study reviewed literature on various approaches aimed at alleviating catheter associated UTI, one type of Silicone coated catheter (Foley catheter) was found to hold promising solution to CAUTIs by preventing colonization of catheter surfaces.

The Use of Specific   Catheters to can be seen as a first had defense in trying to reduce the threat of any infection. Although this works it’s not a permanent fix to the problem, more drastic measures must be applied is the infection persists. But it’s an easy and affordable method to all people in the world and it’s highly recommended.

 

References

.Jackie K, Josh B (2011). A Rehabilitation Hospital’s Experience with Ionic Silver Foley Catheters 28 (2) 97-99

Agency for health care research and quality .Prevention of catheter-associated urinary tract infectionshttp://www.guideline.gov/content.aspx?id=12923

Carol Pellowe, EdD, MA Ed, BA, RNT, RN, Nursing timeshttp://www.nursingtimes.net/reducing-the-risk-of-infection-with-indwelling-urethral-catheters/5005830.article

Linda M (2008).Preventing Infection in Elders with Long-term Indwelling Urinary Catheters 23 127–134

Lippincott W (2009). Nursing Interventions to Reduce the Risk of Catheters-Associated Urinary Tract Infection 36(1):23-34.

Diane K. Newman. (2007)J Wound Ostomy Continence Nurs The Indwelling Urinary Catheter Principles for Best Practice. Published by Lippincott Williams & Wilkins 34(6):655-661

Coral Seymour . (2006). British Journal of Nursing Audit of cadieter-assodated UTI using silver aUoy-coated Foley catheters . Vol 15. No II