Infection Risks Associated with Urinary Catheters - Literature review Example

Infection Risks Associated with Urinary Catheters Introduction This literature review is on the topic of the prevention of infections with urinary catheters. Whilst on several placement I found that Infection remains a cause for concern for the clinical staff. A literature review is an exploration undertaken in both research and evidence based practice. Aveyard (2007) suggests research based practice is a collection and analysis of data on the organisation, delivery, uses and outcomes of nursing care for the purpose of enhancing patient’s health. Hek and Moule (2006) also suggest that research can provide new insights into the phenomena or add to or reject what has gone on before. The Foundation of Nursing Studies (2001) recognised evidence based practice as the way forward in professional nursing. The use of evidence based practice is crucial to the development of nursing practice. Nurses use evidence base practice in order to continue to be up-to-date with their learning, and link theory to practice. Parahoo (2006) also recognises that the development and utilization of nursing knowledge is an integral element of improving patient care. Therefore, nurses are expected to implement evidence-based practice and draw on research findings to support them in the clinical work place. The Nursing Midwifery Council (NMC 2008) Code of Professional Conduct states that ; “You must deliver care based on the best available evidence or best practice.” P. 6. To define the differences between evidenced based practice (EBP) and research based practice (RBP).(EBP) is the combination of the best research evidence and professional expertise Sackett et al, (2000). Parahoo (2006) concurs with but states that patients’ views are included in the making of care decisions. Parahoo (2006) states that research can be defined as a systematic, planned and theory development of a specified problem with a predetermined result which may or may not include practice implications. Within the following literature review the choice of topic has developed from clinical placements it is based on the literature which has already been used to research preventing infections with urinary catheters. Aveyard (2007) mentions, that a literature review is a critical summary of previous literature, which is related to the research on a chosen topic. Search strategies Hek et al (2006) identified the importance of a planned search enabling a quality literature review. The search includes having the ability to retrieve and critically appraise all the findings on the chosen topic in the search for best evidence. In order to structure the literature review numerous text books regarding research was used and the use of resource guides (Hek, et al 2006, Parahoo, 2006, Aveyard, 2007, Sackett, 2000). The focus of this literature review is to interpret and evaluate existing published literature this provides current knowledge of a chosen topic (Parahoo, 2006). Developing a search strategy is essential to obtain as much information as possible (Aveyard, 2007). Having acknowledged the research topic for review, the relevant literature was search by using various recourses. To obtain as much information as possible the university library and the internet were fundamental in searching for literature. In order to access the library databases an Athens account was used. The databases searched were The Cochrane library, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Pubmed. And Assia databases were used. The search was made by using truncation and the Boolean logic, the databases were searched for literature with subject terms and major headings relevant to the chosen topic. Therefore the terms used were urinary catheter* and infection*. The year parameter was used for the last 5 years as this is recommended for current nursing practice. The search was limited to articles published in English language. Summary of database search. Database Number of hits narrowed down PUBMED 104210 328 CINAHL 364 89 The Cochrane Library 104 0 ASSIA 17 1 Total 104695 418 The database search generated a total of 418 hits but some articles appeared in more than one database. Exclusion criteria included articles with no reference list or included children and animals and non nursing content. The PubMed database was narrowed down by changing the year parameters as the hits were in too high to the last 3 years. CINAHL criteria used peer reviewed, main headings and research articles. The Cochrane Library hits showed to be not relevant for this literature review. ASSIA database had 17 hits but only 1 was used. . A Google scholar search for relevant journal was also conducted after entering the search words: “UTI prevention catheterisation” was entered. This showed the articles which was also in the databases. A search of the references of the relevant studies was also conducted and relevant articles were also considered for this paper. After gathering all the information a second look at the databases as run in order to search for any more updated material had been published which showed one update in CINAHL. Nineteen articles met the inclusion criteria after more search parameters were applied and were found to be of relevant to the topic. Also included are research books. What is urinary 4tilized4zation? In the 1920s, Frederic Foley introduced a catheter which was held in place with an intra-bladder balloon (Warren, 2005) which is made from latex and is now renowned as the Foley catheter. Today it is one of the most routinely 4tilized devices being used for the management of urinary incontinence (UI) bladder retention and many other conditions (Ahearn,2009) There are a wide range of urinary catheters which are now available therefore, careful assessment of the most appropriate one is essential (Pomfret, 2007)( see fig 1) Figure 1 catheters www.google.co.uk/images A catheter can be defined as a hollow tube, which is inserted into a body cavity or viscus’ for the purpose of removing or instilling fluids (Pomfret, 2007). Urinary catheterisation is the insertion of a specially designed hollow tube which is inserted into the bladder. It is a common nursing procedure in both acute and primary care. and can improve quality of life to patients but it does carry a risk of infections (Tew et al, 2005). There are millions of urinary catheters inserted every year, with an estimate of 25 per cent of these are patients who are in hospital (Ellen et al, 2005). Whenever catheterisation takes place the patient should be made aware of the procedure, the aftercare and possible risks and complications which can occur (Hart, 2008). Justification for urinary catheterisation The decision to catheterisation a patient should be made on the grounds if all other solutions have been tried (Pratt et al, 2009). There are a number of factors that need to be considered before catheterising a patient including patient’s needs, reasons as to why the patient needs it, the types of material, the balloon size and the length of the Catheter (RCN, 2008). (See Table 2) Table 2 reasons for urinary catheterisation Monitoring of urinary output Post-operative care, i.e. after a bladder or prostate operation Neurological bladder failure, i.e. multiple sclerosis, spinal injuries Relief of urinary obstruction Post-operative care following spinal anaesthesia Urodynamic or X-ray intervention Chemotherapy intervention As a comfort measure in palliative care To manage urinary incontinence when all other methods have failed (Nazarko, 2009) Preventing Urinary Tract Infections Urinary Tract Infection (UTI) is one of the most common and most preventable infections. It is caused by bacteria which enters the urethral opening and later, the bladder (Zieve, 2010). Sometimes it can infect the kidneys as well. The body normally gets rid of this bacterium however; some people are more susceptible to UTIs. For example women are more likely than men to get it because their urethra is shorter and closer to the anus which is a potential source of bacteria (Zieve, 2010). Other concerns like diabetes, older person, urinary retention, bowel incontinence, kidney stones, pregnancy, and surgery involving the urinary tract can increase a person’s chances of being afflicted with this disease (Zieve, 2010). UTIs can show with the following symptoms: cloudy or bloody urine, pain or burning while urinating, pressure or cramping of abdomen, and a strong need to urinate often (Zieve, 2010). If the bacteria has spread to the kidneys, symptoms include: chills and night sweats, fatigue and feeling ill, fever, flushed, warm, or reddened skin, confusion, nausea and vomiting, and severe abdominal pain (Zieve, 2010). Seymour (2006) conducted an audit of catheter-associated UTI using silver-alloy coated Foley catheters. The audit, covered a total of 117 newly catheterised patients who were then monitored for signs of symptoms of UTIs. The study revealed that CAUTI (catheter-associated urinary tract infections) was reduced significantly. The silver alloy-coated catheters proved to be effective in reducing the cost of care and in reducing the length of hospital stay of the patients. It also suggested the use of the silver alloy-coated catheter for short-term catheterisation and for acute patient admissions (Seymour, 2006). However, Ahearn, et.al (2005) examined the impact of hydrogel/silver coatings on in-vitro adhesion to catheter of bacteria associated with UTIs. The study, examined the adhesion qualities of Candida albicans microorganisms to catheters with and without hydrogel/silver-latex. The study was able to establish that adhesion to the hydrogel/silver catheters by Gram-positive and Gram-negative bacteria was significantly lower as compared to the adhesion in all-silicone catheters (Ahearn, et.al, 2005). This study was able to provide a link between the material used in catheters and the adhesion of bacteria to the material. This is relevant to this topic area because it provides a strong link between the type of catheter used and the potential infection that the catheterisation can bring to the patient. But a weakness of the paper was that patient participation was not however utilized. However, bacterial growth was reviewed in a controlled laboratory setting and not based on actual patient use. The results of this study needs to be incremented in the clinical setting. A later study by Parker, et.al., (2009) suggested that current evidence in relation to nursing interventions in the prevention of CAUTIs. In their review, they used different research databases and methods to gain evidence in relation to nursing interventions in the prevention of CAUTIs. It showed a strong support for the use of silver alloy-coated catheter in the prevention of CAUTIs for up to two weeks among adult patients in short-term catheterisation. The study revealed that the insertion of antibiotics in to the catheters also helps reduce the risk of CAUTI. This study strongly supports the use of silver alloy-coated catheters in the prevention of UTIs. However, most of these studies have focused on the use of for short-term catheterisation only. Occurrences’ to prevent infections for patients with long-term catheterisation have not shown adequate results. This study therefore, suggested that there are important aspects of research which need to be explored. Cope and Gentry (2005) also carried out an audit of 133 medical and surgical patients catheterised in an acute NHS hospital trust. As in other studies, Cope and Gentry (2005) establish lower infection rates and decreased clinical risks for patients. Moreover, lower costs for patients and for the NHS were established with the use of silver alloy hydrogel-coated catheters (Cope and Gentry, 2005). The study was able to establish the type of catheters which prevent infection among patients. This shows a clear link between the type of catheter used and the incidence of UTIs. It involved a large number of patients which made the results of this study viable. However, this study did not assess the impact of continuous catheterisation among patients with the use of silver alloy hydrogel-coated catheters. Therefore, the study is limited among acute care patients. Liedberg and Lundeberg (2008) researched into the effects of silver alloy on indwelling catheters and on the prevention of infection. They carried out their study in a randomized clinical setting with 120 patients. In their study, they coated a Foley catheter with silver alloy on both the inner and outer surfaces and used this catheter on 60 patients; 60 other patients received Teflonised latex Foley’s catheter. This showed a statistical significant difference in the 2 groups with 6 patients in the silver alloy group showing infection, and 22 patients in the Teflonised group developing a CAUTI. However, in order to gain better results there is a need to use a larger population and to be used for a longer period of time. By doing this it would increase the validity and reliability of the study results. Furthermore, Madeo,et al (2010), suggested whether or not the use of pre-connect urinary catheter system can reduce the occurrences of nosocomial UTIs. The study was carried out in order to establish the nosocomial UTI rates among patients using the pre-connected urinary catheter system in comparison to those using the traditional bag and catheter system. The study discovered that there were lower rates of CAUTI among those using the pre-connect catheters. This illustrates that the type of catheter used is an important consideration in the prevention of CAUTIs. The study however did not consider the insertion process of the catheter in relation to CAUTIs and infection control. The insertion process in both the intervention and the control group is an important variable which has to be considered before accurate and valid results are obtained. A study conducted by Johnson, et.al (2006) used the currently marketed catheters in terms of how well they prevent CAUTI. Their study used randomized and quasi-randomized trials of nitrofurazone-coated or silver alloy-coated antimicrobial urinary catheter use for less than 30 days. In their review, they showed that antimicrobial urinary catheters can prevent bacteriuria among patients with short-term catheterisation. This study was able to highlight that catheter use does not necessarily always mean UTIs, especially when the proper precautions in the form of antimicrobial coating is used by trained staff prior to catheterisation. This study was able to provide important guidelines in the prevention of CAUTIs, however it was limited in number and size. These limitations affect the generalisability of the study results therefore a larger study is needed. Hachem, et.al., (2009) conducted a study to measure in vitro the antiadherence activity of a novel antiseptic Gendine-coated urinary catheter against several multidrug-resistant bacteria. The Gendine-coated catheters were compared with silver hydrogel-coated Foley catheters and to uncoated catheters. The study showed that in vitro, Gendine-coated urinary catheters restricted the colony-forming unit of all microorganisms compared with uncoated and silver hydrogel-coated catheters. The results showed that the histopathologic evaluation revealed that Gendine-coated urinary catheters were more effective in preventing catheter-associated colonisation and UTIs than were the silver hydrogel-coated Foley catheters and the uncoated catheters. This study showed that there are alternatives in preventing infection through catheterisation this time with the use of Gendine-coated catheters. And also points out the importance of preventive methods for infection control during the catheterisation process. Although the results need to be reassessed on patients, these results still present a need for more research on the use of Gendine-coated catheters during the catheterization process. Estores, et.al., (2008) study was the use of silver-hydrogel in urinary catheters in order to prevent UTIs. They used patients in a prospective and randomized controlled study and also used silver-hydrogel catheter (SHC) for six months. This study revealed that the use of the indwelling SHC for six months successfully prevented the patient from developing UTI. This study showed the use of a long-term indwelling catheter and patient care used in order to prevent him/her from acquiring CAUTI. However the study is very limited because they only used one patient. There is a need to conduct further studies in order to establish support for the use of silver-coated hydrogels among long-term care patients. Reiche, et.al., (2008) conducted a study on the impact on UTIs among patients needing continuous indwelling catheterisation, which contains an antibacterial device which slowly releases silver ions into the inner surface of the system. The study was able to ascertain if there were fewer occurrences’ of UTI among those using the antibacterial device. The study highlighted the importance of using modifications to Foley catheters in order to prevent UTIs. This study is limited in terms of statistically significant results. Although the results indicate that there is less infection in the group using antibacterials; however, there is a need to carry out more studies in order to establish more reliable results. The importance of antimicrobial catheters in the prevention of CAUTI has also been emphasized in the study by Drekonja, et.al., (2008) where the authors set out to review studies on the use of antimicrobial catheters in the prevention of CAUTIs. The authors recognized the fact that CAUTIs have become common occurrences among patients needing catheterization. In some cases, symptoms represent with adverse consequences, like urosepsis and death for patients. The use of antimicrobial catheters has shown great benefits for different patients and various randomized and clinical trials have indicated that antimicrobial catheters potentially decrease the incidence of CAUTI. The review of the authors established variable evidence on antimicrobial-coated catheters preventing CAUTIs during short-term catheterization. This study gives strong support for the importance of using antimicrobial catheters in the catheterization process in order to eventually prevent UTI. The authors are however keen in pointing out that more randomized clinical trials have to be undertaken in order to cover clinically relevant issues, including studies which evaluate options in improving mechanisms for bladder drainage which reduce risks and discomforts. In support of the Reiche study (2008), the Regev-Shoshani, et.al., (2010) study on the impact of slow release of nitric oxide from charged catheters and its impact on biofilm formation by Escherichia coli. The study showed that the antiseptic charged catheters were able to prevent infection and biofilm formation on exterior surfaces. Moreover, they were able to observe that nitric-oxide impregnated catheters prevented the growth of Escherichia coli within the inner surfaces. This study provided support for the results shown in the Reiche study . It highlighted the use of nitric oxide in the prevention of UTI. Although the results showed that adequate support for the utilisation of charged catheters in the prevention of UTI, the study does not consider patients under chronic care. It is important to consider this group as they are the most vulnerable to get a UTIs. The importance of antimicrobial loaded catheters as used in a study by Stensballe, et.al., (2007) when they conducted a study in order to determine whether nitrofurazone-impregnated urinary catheters decreased the frequency of catheter-associated bacteriuria and funguria. In Their study they used a randomized, double-blind, controlled trial and used 212 adult trauma patients admitted between July 2003 and August 2005. They measured catheter-associated bacteriuria and funguria based on at least a 103 colony-forming units/mL. In their research it was establish that catheter-associated bacteriuria and funguria showed less in the nitrofurazone catheter-group in comparison to the silicone-catheter group. They suggested that nitrofurazone-impregnated urinary catheters reduced the prevalence of CAUTI among adult trauma patients, also reducing their need for antimicrobial therapy. This study shows viable results in the use of nitrofurazone catheters in the prevention of UTIs. Furthermore, they emphasise the need to implement measures in order to prevent UTIs and to lessen hospital stay of patients. This study needs more support for the decreased need for antibacterial therapy when nitrofurazone is used on patients. The use of bacterial interference has also been considered as a means for preventing urinary tract infection in patients under the intermittent catheterization program (ICP). In a study by Prasad, et.al. (2010), the authors set out to evaluate whether Escherichia coli 83972-coated urinary catheters in patients with spinal cord injury under intermittent catheterization program can gain bladder colonization with this benign organism and later decrease the rate of symptomatic UTI. This study was carried out as a non-randomized pilot trial in an outpatient SCI clinic in a Veterans Affairs hospital. This study was carried out based on the presumption that colonizing an area with one strain of bacteria can prevent infection by another strain. Eight subjects were successfully colonized for >3 days after catheter removal and in these 8 patients, the rate of UTI was 0.77 %, which is lower compared to the former rate of 2.27% per patient. The authors concluded that E.coli 83972-coated urinary catheters are effective means of gaining bladder colonization and of later preventing infection by other bacterial strains for patients with SCI undergoing ICP. This study presents a novel means of preventing UTI and offers a viable option in the catheterization process. More research however needs to be conducted in relation to this option in order to establish more support for the use of E-coli 83972 in the prevention of UTI. Recommendations Based on the studies which have been reviewed above, recommendation for further research needs to be considered in terms of options for the prevention of UTI among long-term catheterisation care in patients. Most of the studies were able to identify different treatments and options for reducing UTIs among short-term care patients. There is a need however to highlight the relevance of silver alloy or antibacterial filled catheters and to assess the efficacy of such interventions in the prevention of UTIs among these patients. The evidence has pointed out that medical staff should consider the use of silver alloy catheters when bacterium is a significant risk patients’. Long-term care patients are more likely to be vulnerable to CAUTI; therefore any interventions which can be applied in their favour in order to minimise UTIs this would be an advantage to them. Based on the literature reviewed, the medical staff needs to consider changes in the use of urinary catheters. Moreover, the medical staff need to think in terms of anticipating possible infections on the part of the patients with the use of urinary catheters and how if any infection can be prevented. It is suggested in the literature that the insertion of a urinary catheter should always be done aseptically when connecting and disconnecting the catheter, they are as important in the prevention of UTIs as the antibacterial therapies are. .The focus has to be on prevention and reducing the risks of infection. other catheter measures come in the form of antibacterial-filled urinary catheters, silver alloy-coated catheters, and even Gendine-coated catheters. Conclusion The studies above revealed that catheter-associated UTIs are one of the most common sources of hospital-related nosocomial infections. It has been shown that eighty per cent of UTIs are associated with urinary catheterisation. The most effective way of preventing a CAUTI is not to catheterise and if catheterisation is necessary, to remove the catheter as soon as possible.UTIs are also considered to be preventable infections with the proper use of aseptic techniques and with the use of antibacterial therapies. More than the use of aseptic techniques and antibiotics, however, the options on silver alloy-coated catheters, Gendine-coated catheters, nitrofurazone catheters, and antibacterial-filled catheters are important and effective choice for medical staff and nurses in the prevention of UTs. The studies above have pointed out the importance of preventing UTIs by considering the type and the use of protective coatings before these catheters can be used on the patient. Applying these preventive methods are important interventions in the care of patients because they help prevent lengthy hospitalisations which, in turn, can cause the patient more money, anxiety, and emotional trauma. Recommendations for studies on the prevention of UTIs among long-term care patients have been recognised within this research. These long-term care patients need as much care for their needs as do short-term care patients. Further recommendations for studies include a focus on actual use of preventive measures against catheter-associated UTIs. It is a gradual process, but a viable and highly-beneficial one. References Aveyard, H. (2007). Doing a literature review in health and social care. Maidenhead: Open University Press. Figure 1 catheters, available at: http://www.google.co.uk/images?hl=en&source=imghp&biw=1362&bih=578&q=urinary+catheter&gbv=2&aq=0&aqi=g7g-m3&aql=&oq=urinary+cathe&gs_rfai= ( accessed 12th December 2010) Figure 2. Parahoo, K. (2006). 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(2008) A prospective, controlled, randomized study of the effect of a slow-release silver device on the frequency of urinary tract infection in newly catheterized patients, BJU International, volume 85, Issue 1, pp. 54–59 Seymour, C. (2006) Audit of cadieter-assodated UTI using silver aUoy-coated Foley catheters, British Journal of Nursing, volume 15, number 2, pp. 598-603 Stensballe, J., Tvede, M., Looms, D., Lippert, F., Dahl, B., & Tonnesen, E. (2007) Infection Risk with Nitrofurazone-Impregnated Urinary Catheters in Trauma Patients: A Randomized Trial. Ann Intern Med., volume 147: pp. 285-293. Zieve, D., (2010) Urinary tract infection – adults, Medline Plus, viewed 10 December 2010 from http://www.nlm.nih.gov/medlineplus/ency/article/000521.htm Read More