Reducing Catheter Acquired Urinary Tract Infections: Mini Report of the State of the Evidence for Indwelling Versus External Urinary Devices

Introduction

or has been catheterized within the previous 48 hours [2]. Several measures have been proposed to reduce the incidence of CAUTI such as limiting the use of indwelling catheters in females and elderly patients due to high morbidity and mortality rates in these populations [3]. Catheter associated urinary tract infection in hospitalized patients can lead to longer lengths of stay, additional treatment for the infection that can result in medication interactions and other side effects, and increased patient discomfort during the stay [4]. Sex differences have been reported in CAUTI with females having higher rates [5].

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However, there is a lack of research to suggest causative factors associated with higher CAUTI rates in females, speculated to be related to the external genitalia harboring more organisms. With the introduction of new external urinary devices for females, there may be differences in the incidence of CAUTI in hospitalized females [5]. Several guidelines suggest indwelling catheters should be used for brief periods during hospitalization, and should be removed quickly to prevent complications [1, 6]. However, there are patients who need to have catheters in place for longer periods of time. New types of external devices, such as the vacuum assisted for females (e.g., Purewick) or external pouches for men (e.g., Liberty) may reduce this risk. The purpose of this mini review was to examine the literature on the effects of external urinary collection devices on CAUTI in hospitalized patients. The search question was: Do external urinary containment devices compared to indwelling containment devices reduce the incidence of catheter associated urinary tract infections (CAUTI) in hospitalized patients?

The literature was searched in PubMed, CINAHL, Virginia Henderson, Google Scholar, and Scopus for the use of urinary containment devices in hospitalized patients, from years 2012 to present. Inclusion criteria included adults, CAUTI, all published in English. Search terms were indwelling catheters, urinary incontinence, external, vacuum, mechanical devices, urinary management systems, catheter associated urinary tract infections, condom catheters, and urinary diversions. Exclusion criteria were pediatric urinary infections, urinary infections not associated with catheter insertion, and treatment for CAUTI. With the assistance of a medical librarian, the search yielded 52 papers, including systematic reviews, clinical trials, clinical guidelines, clinical papers in medicine and nursing, and reviews of the literature. Abstracts were then retrieved and after review for relevance to CAUTI in the hospital setting, 21 articles were retrieved, of which 4 were studies, and 1 was a systematic review, which are included in this paper. An older classic study from 2006 is included as one of the 4 studies as it remains a frequently cited paper (Table 1).

Authors Purpose Design/ Method

Sample/

Setting

All randomized

Independent

variable: Management of

or quasi- randomized adult female controlled trials. Total

urinary incontinence determined by symptom, sign, or urodynamic Trials identified from Determine usefulness reviewed were 3 studies from The Cochrane the Cochrane of mechanical Register of Controlled Trials, and hand searching of journals and Lipp A, Shaw diagnosis. Dependent variables: Self C, Glavind K devices in Central Register of Controlled (2014) female urinary incontinen reported symptoms, Trials (CENTRAL), conference proceedings.

ce.

objective MEDLINE, MEDLINE in

clinical measures, tolerability of device and side- process, ClinicalTrials.

gov, WHO

effects ICTRP

To compare

308 patients from 5 medicine and the microbiolo Grigoryan L,

Dependent variable: type of

5 extended- care wards of Abers MS, Kizilbash QR,

gy profile (number of Cross-sectional

organisms Independent variable: type of

a VA care facility with

study Petersen NJ, Trautner BW

organisms recovered) external catheters (n =

(2014) catheter from urine cultures in

135) and indwelling catheters (n =

patients with

Search Strategies

Major Variables Study Finding Study Strengths &

Significance for

Weaknesses

Practice

Strengths: Self reported symptoms are included as well as tolerability, two factors that have not been previously reported in the Compiles data from many studies There is insufficient evidence from controlled literature. Limitations: Study searched too wide of a spectrum of variables for into list form including many trials to determine whether mechanical different mechanical urinary devices should be a preferred treatment over the data. Should have focused more specifically devices and their effective statistical other methods such as on certain aspects that mechanical devices either indwelling catheters.

values in patients.

improve, worsen, or remain the same for females using catheters.

Both groups had Gram positive organisms, but there were no statistically Strengths: Standardized laboratory approaches to External catheters, once thought to have less risk of infection present analyze data so that all specimens were treated identically Large sample significant differences between groups for Staphylococci (p = 0.88), Enterococci (p = 0.83) or Corynebacterium/Lactob similar rates of infection and have more organisms as size based on a power analysis Limitations: There was no standardized urinary collection process noted on cultures.

acillus (p = 0.41) or for Patients with external devices Gram negative Enterobacteriaceae (p = from an external catheter so contamination could have been a problem. The require just as vigilant of care as

0.57). Statistically

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external

173) with positive urine and indwelling cultures during period catheters of October 2010-June

2011.

Dependent

75 hospitalized men aged 40 variable: incidence of To compare adverse outcomes (bacteriuria, symptomatic urinary tract [UTI] infection, and older receiving an condom Saint S, Kaufman SR, Prospective, randomized, and indwelling indwelling catheter (n = Rogers MA, urinary catheters in terms of unblinded, controlled trial

41) and condom catheter (n =

Baker PD, Ossenkop, K,

death) and patient device- conducted over a 4-year

Lipsky A

infection

34) in an academically related satisfaction Independent

(2006) period risk and patient satisfactio affiliated Veterans

variables: condom versus n Affairs Medical

indwelling Center

urinary catheters Dependent

To determine

variable: incidence of UTI

if three antimicrob at any time up to 6 weeks Independent

6394 hospitalized participants randomized ial catheters reduce the variables: nitrofurazone Pickard R, rate of symptomat Lam T, MacLannanG, impregnated silicone catheter Pragmatic multicenter randomized to receive one of three ic urinary Starr K, Kilonzo M, McPherson G, compared with standard PTFE- tract infection catheters between 1 and 14 days of their care after elective trial coated latex catheter; and (UTI) during short-term et al. (2012) silver alloy- coated hydrogel surgery hospital use and is latex catheter compared with standard PTFE- their use cost- effective.

coated latex catheter.

significant differences researchers were unaware those with indwelling were noted for Non- Enterobacteriaceae (p = 0.004) and Candida (p = 0.002) for the indwelling of the specific types of external catheters used, how they were applied and catheters.

if patients wore them catheters. There were more organisms noted continuously or intermittently There were no females in the study so overall for external catheters (p < 0.0001) with 2.3 versus 1.7 for results may not apply to them.

indwelling catheters.

Use of condom catheter is less Strengths: Good study likely to be associated with design to randomize patients to the type of catheter Asking patients bacteruria and The risk of bacteriuria, symptomatic urinary tract infection, or death.

symptomatic UTI, or death was twice as high in about their comfort important to improve acceptance of the catheter patients with an indwelling catheter but these findings were not There was higher Limitations: Relatively small sample of patients satisfaction with the condom catheter. Based on statistically significant. For bacteriuria (p = 0.11), were eligible over the study period due to these findings, condom catheter for UTI (p = 0.07) and for patients refusing participation and many already had an infection at the time of enrollment. The death (p = 0.09) Patients use should be considered over reported condom catheters were more comfortable (p = 0.02) and less painful (p = 0.02) than indwelling catheters.

indwelling catheters, but study was conducted at one site thus findings may more recent findings contradict not be appropriate for other people with these the risk for infection, as noted types of catheters.

in the Grigoryan

study.

While the nitrofurazone group had lower rates of infection The rate of symptomatic Strengths: Very large sample size in each group UTI within 6 weeks of catheter use was 10.6% in to determine differences among the three different catheters The methods for and those catheters were cheaper to use, they were more the nitrofurazone group (n = 2153); 12.5% in the silver alloy group (n = 2097); and 12.6% in the using the catheters were the same (the insertion of the catheters was done by study personnel using the likely to cause discomfort. This is PTFE group (n = 2144). The effect size {odds ratio a problem to determine whether (OR) [97.5% confidence same techniques) Limitations: Latex catheters are no longer in interval (CI)]} was 0.82 (97.5% CI 0.66 to 1.01) lower infection rates are more important than a for nitrofurazone (p = 0.037) and 0.99 (97.5% CI use in the U.S. but these catheters had higher infection rates and were the most expensive. The protocols at all of the 20+ institutions included in the catheter that is more conformable for patients. Newer

0.81 to 1.22) for silver alloy (p = 0.92) catheters.

The nitrofurazone catheters were more likely to cause discomfort catheters are now on the market but study were not clearly stated so it was difficult to there are no clinical trials to determine whether during use and on removal. Costs:

determine if there was a standard protocol followed nitrofurazone impregnated catheters would be, on average, the they are better and if not, infection could than those currently in use in have been attributed to least costly and most procedural factors.

terms of infection effective option.

and patient satisfaction.

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Results

Data from multiple sources (Table 1) including a large literature review of mechanical devices for the management of urinary incontinence in females [5], findings from a randomized study of indwelling versus external urinary catheters on the incidence CAUTI [7], and results from laboratory studies of both indwelling versus external catheters on the types of organisms present in the urine [8], suggest the best approach to the management of urinary incontinence and prevention of CAUTI remains elusive. There is no recommendation for the use of one type of catheter over the other in preventing infection in patients requiring catheters during hospitalization. Similar organisms are present in both indwelling and external devices, and there is conflicting data on whether external catheters are associated with fewer infections. An older study conducted by Saint, et al. in 2006 reported fewer catheter associated infections; however, a more recent paper by Grigorva, et al. (2015) demonstrated no differences. Indwelling catheters have been associated with discomfort but there are limited data on which ones are more comfortable and tolerable. There were no studies on a newer vacuum assisted device for females or pouches for males that could be located. Thus it is unclear whether these types of devices are associated with fewer infections and are more acceptable to patients.

Discussion

It is well established that the main causative organisms for infections are those from the perineal flora that invade the urinary system. Researchers have studied the types of materials used in indwelling catheters and found that silicone catheters containing ntirofurazone compared to latex catheters resulted in lower rates of CAUTI, however the nitrofurazone-containing catheters were reported to cause more discomfort [9]. Discomfort is not well studied in relation to the use of indwelling or external catheters, however in one study by Saint, et al. [7], male patients preferred condom catheters (external devices) over indwelling catheters. A downfall of this study is it is older, with more recent studies unable to be located to corroborate this finding. A limitation of the study by Saint was that it was conducted only in male patients. In fact, most of the studies of external devices were conducted in males as few external options exist for females. While new types of external devices are being used in females, there is a lack of research to determine if these devices are better than indwelling catheters on comfort and preventing CAUTI. Finally, some studies suggest that having had a previous CAUTI places one at higher risk of developing a recurrent CAUTI. However, findings from a study by Medina-Polo, et al. (2015) [10] suggest that a lower number of individuals had recurrent infections with catheter use, suggesting a previous infection was not predictive of another CAUTI. Current evidence, while limited, is conflicting regarding whether indwelling catheters place individuals at higher risk for CAUTI. The evidence is in support of short term use of both types of catheters, thus there is no one type considered better than the other. This is particularly so for females; for males, external catheter use may be preferred but there is weak evidence in support of external catheters as a means to reduce CAUTI.

Implications for Practice

Care of hospitalized patients requires vigilant assessment for infection, particularly CAUTI. Based on the Nursing & Healthcare International Journal

evidence presented in this mini review, short term use of catheters in patients in the hospital setting remains a strong recommendation to prevent CAUTI. In the hospital setting, similar organisms are common in both indwelling catheters and external containment devices, urinary tract infections increase with longer use with both types of catheters, and external devices may be more comfortable for males, but this has not been studied in females. Keeping the perineal area clean remains a critical nursing consideration as the organisms that lead to infection are mostly from the perianal area. Assessing patients for pain or discomfort and offering a choice, if possible, of the type of catheter are additional recommendations. Regular inspection of the urinary meatus and routine cleansing of the meatus during bathing or showering without the use of antiseptics remains two of the most crucial nursing considerations [11]. Unfortunately, there is limited information about new external urinary collection devices for females to suggest efficacy over indwelling catheters for short term use to prevent CAUTI. Until then, caution should be used when utilizing these devices for both females and males as there are very limited trials to suggest if they are better than indwelling catheters.