K Schumm1, T B L Lam. 1. Academic Urology Unit/CHaRT, University of Aberdeen, Aberdeen, UK. k.schumm@abdn.ac.uk
Abstract
BACKGROUND: Urinary tract infection (UTI) is the most common hospital acquired infection. The major associated cause is indwelling urinary catheters. Currently there are many types of catheters available. A variety of specialized urethral catheters have been designed to reduce the risk of infection. These include antiseptic impregnated catheters and antibiotic impregnated catheters. Other issues that should be considered when choosing a catheter are ease of use, comfort and cost. OBJECTIVES: The primary objective of this review was to determine the effect of type of indwelling urethral catheter on the risk of urinary tract infection in adults who undergo short-term urinary catheterization. METHODS: We searched the Specialized Trials Register of the Cochrane Incontinence Group (searched September 11, 2007). We also examined the bibliographies of relevant articles and contacted catheter manufacturer representatives for trials. All randomized and quasi-randomized trials comparing types of indwelling urinary catheters for short-term catheterization in hospitalized adults. Short-term catheterization was defined as up to and including 14 days, or other temporary short-term use as defined by the trialists (for example <21 days with data time points at 7-day intervals). Data were extracted by one reviewer and independently verified by a second reviewer for both the original review and for the update. Disagreements were resolved by discussion. Data were processed as described in the Cochrane Handbook. Where data in trials were not fully reported, clarification was sought directly from the trialists (secondary sources were used to confirm results of one trial). RESULTS: Twenty-three trials met the inclusion criteria involving 5,236 hospitalized adults in 22 parallel group trials and 27,878 adults in one large cluster-randomized cross-over trial. The antiseptic catheters were either impregnated with silver oxide or silver alloy. Silver oxide catheters were not associated with a statistically significant reduction in bacteriuria in short-term catheterized hospitalized adults but the confidence intervals were wide (RR 0.89, 95% CI 0.68-1.15) and these catheters are no longer available. Silver alloy catheters were found to significantly reduce the incidence of asymptomatic bacteriuria (RR 0.54, 95% CI 0.43-0.67) in hospitalized adults catheterized for <1 week. At >1 week of catheterization the risk of asymptomatic bacteriuria was still reduced with the use of silver alloy catheters (RR 0.64, 95% CI 0.51-0.80). The randomized cross-over trial of silver alloy catheters versus standard catheters was excluded from the pooled results because data were not available prior to crossover. The results of this trial indicated benefit from the silver alloy catheters and included an economic analysis that indicated cost savings of between 3.3% and 35.5%. Antibiotic impregnated catheters were compared to standard catheters and found to lower the rate of asymptomatic bacteriuria in the antibiotic group at <1 week of catheterization for both minocycline and rifampicin combined (RR 0.36, 95% CI 0.18-0.73), and nitrofurazone (RR 0.52, 95% CI 0.34-0.78). However, at >1 week the results were not statistically significant. One of 56 men in the antibiotic impregnated group had a symptomatic UTI compared with 6 of 68 who had standard catheters (RR 0.20, 95% CI 0.03-1.63). Three trials compared two different types of standard catheters (defined as catheters that are not impregnated with antiseptics or antibiotics) to investigate infection. Individual trials were too small to show whether or not one type of standard catheter reduced the risk of catheter related urinary tract infection compared to another type of standard catheter. CONCLUSIONS: The results suggest that the use of silver alloy indwelling catheters for catheterizing hospitalized adults short-term reduces the risk of catheter acquired urinary tract infection. Further economic evaluation is required to confirm that the reduction of infection compensates for the increased cost of silver alloy catheters. Catheters impregnated with antibiotics are also beneficial in reducing bacteriuria in hospitalized adults catheterized for <1 week but the data were too few to draw conclusions about those catheterized for longer. There was not enough evidence to suggest whether or not any standard catheter was better than another in terms of reducing the risk of urinary tract infection in hospitalized adults catheterized short-term. Siliconized catheters may be less likely to cause urethral side effects in men; however, this result should be interpreted with some caution as the trials were small and the outcome definitions and specific catheters compared varied. (c) 2008 Wiley-Liss, Inc.
BACKGROUND:Urinary tract infection (UTI) is the most common hospital acquired infection. The major associated cause is indwelling urinary catheters. Currently there are many types of catheters available. A variety of specialized urethral catheters have been designed to reduce the risk of infection. These include antiseptic impregnated catheters and antibiotic impregnated catheters. Other issues that should be considered when choosing a catheter are ease of use, comfort and cost. OBJECTIVES: The primary objective of this review was to determine the effect of type of indwelling urethral catheter on the risk of urinary tract infection in adults who undergo short-term urinary catheterization. METHODS: We searched the Specialized Trials Register of the Cochrane Incontinence Group (searched September 11, 2007). We also examined the bibliographies of relevant articles and contacted catheter manufacturer representatives for trials. All randomized and quasi-randomized trials comparing types of indwelling urinary catheters for short-term catheterization in hospitalized adults. Short-term catheterization was defined as up to and including 14 days, or other temporary short-term use as defined by the trialists (for example <21 days with data time points at 7-day intervals). Data were extracted by one reviewer and independently verified by a second reviewer for both the original review and for the update. Disagreements were resolved by discussion. Data were processed as described in the Cochrane Handbook. Where data in trials were not fully reported, clarification was sought directly from the trialists (secondary sources were used to confirm results of one trial). RESULTS: Twenty-three trials met the inclusion criteria involving 5,236 hospitalized adults in 22 parallel group trials and 27,878 adults in one large cluster-randomized cross-over trial. The antiseptic catheters were either impregnated with silver oxide or silver alloy. Silver oxide catheters were not associated with a statistically significant reduction in bacteriuria in short-term catheterized hospitalized adults but the confidence intervals were wide (RR 0.89, 95% CI 0.68-1.15) and these catheters are no longer available. Silver alloy catheters were found to significantly reduce the incidence of asymptomatic bacteriuria (RR 0.54, 95% CI 0.43-0.67) in hospitalized adults catheterized for <1 week. At >1 week of catheterization the risk of asymptomatic bacteriuria was still reduced with the use of silver alloy catheters (RR 0.64, 95% CI 0.51-0.80). The randomized cross-over trial of silver alloy catheters versus standard catheters was excluded from the pooled results because data were not available prior to crossover. The results of this trial indicated benefit from the silver alloy catheters and included an economic analysis that indicated cost savings of between 3.3% and 35.5%. Antibiotic impregnated catheters were compared to standard catheters and found to lower the rate of asymptomatic bacteriuria in the antibiotic group at <1 week of catheterization for both minocycline and rifampicin combined (RR 0.36, 95% CI 0.18-0.73), and nitrofurazone (RR 0.52, 95% CI 0.34-0.78). However, at >1 week the results were not statistically significant. One of 56 men in the antibiotic impregnated group had a symptomatic UTI compared with 6 of 68 who had standard catheters (RR 0.20, 95% CI 0.03-1.63). Three trials compared two different types of standard catheters (defined as catheters that are not impregnated with antiseptics or antibiotics) to investigate infection. Individual trials were too small to show whether or not one type of standard catheter reduced the risk of catheter related urinary tract infection compared to another type of standard catheter. CONCLUSIONS: The results suggest that the use of silver alloy indwelling catheters for catheterizing hospitalized adults short-term reduces the risk of catheter acquired urinary tract infection. Further economic evaluation is required to confirm that the reduction of infection compensates for the increased cost of silver alloy catheters. Catheters impregnated with antibiotics are also beneficial in reducing bacteriuria in hospitalized adults catheterized for <1 week but the data were too few to draw conclusions about those catheterized for longer. There was not enough evidence to suggest whether or not any standard catheter was better than another in terms of reducing the risk of urinary tract infection in hospitalized adults catheterized short-term. Siliconized catheters may be less likely to cause urethral side effects in men; however, this result should be interpreted with some caution as the trials were small and the outcome definitions and specific catheters compared varied. (c) 2008 Wiley-Liss, Inc.