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Review
. 2014 Sep 23;2014(9):CD004013.
doi: 10.1002/14651858.CD004013.pub4.

Types of indwelling urethral catheters for short-term catheterisation in hospitalised adults

Thomas B L Lam  1 , Muhammad Imran Omar, Euan Fisher, Katie Gillies, Sara MacLennan
Affiliations
Review

Types of indwelling urethral catheters for short-term catheterisation in hospitalised adults

Thomas B L Lam et al. Cochrane Database Syst Rev. .

Abstract

Background: Urinary tract infection (UTI) is the most common hospital-acquired infection. The major associated cause is indwelling urethral catheters. Several measures have been introduced to reduce catheter-associated urinary tract infections (CAUTIs). One of these measures is the introduction of specialised urethral catheters that have been designed to reduce the risk of infection. These include antiseptic-coated and antimicrobial-impregnated catheters.

Objectives: The primary objective of this review was to compare the effectiveness of different types of indwelling urethral catheters in reducing the risk of UTI and to assess their impact on other outcomes in adults who require short-term urethral catheterisation in hospitals.

Search methods: We searched the Cochrane Incontinence Group's Specialised Trials Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE in process, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 9 September 2014). We also examined the bibliographies of relevant articles and contacted catheter manufacturer representatives for trials.

Selection criteria: We included all randomised controlled trials (RCTs) and quasi-RCTs comparing types of indwelling urethral catheters for short-term catheterisation in hospitalised adults. 'Short-term' is defined as a duration of catheterisation which is intended to be less than or equal to 14 days.

Data collection and analysis: At least two review authors independently screened abstracts, extracted data and assessed risk of bias of the included trials. Any disagreement was resolved by discussion or consultation with a third party. We processed data as described in the Cochrane Handbook for Systematic Reviews of Interventions. We assessed the quality of evidence using the GRADE approach.

Main results: Twenty-six trials met the inclusion criteria involving 12,422 hospitalised adults in 25 parallel group trials, and 27,878 adults in one large cluster-randomised cross-over trial. No trials compared one antiseptic catheter versus another, nor an antimicrobial catheter versus another. Antiseptic-coated indwelling urethral catheters versus standard indwelling urethral cathetersThe primary outcome, symptomatic CAUTI was reported in one large trial with a low risk of bias, comparing silver alloy hydrogel-coated latex catheter (antiseptic-coated) against a standard polytetrafluoroethylene (PTFE)-coated latex catheter (control). The trial used a pragmatic, US Centers for Disease Control and Prevention (CDC)-based definition for symptomatic CAUTI. For the comparison between silver alloy-coated catheter versus standard catheter, there was no significant difference in symptomatic CAUTI incidence (RR 0.99, 95% CI 0.85 to 1.16).For secondary outcomes, the included trials reported on two types of antiseptic catheters (coated with either silver oxide or silver alloy). For the outcome of bacteriuria, silver oxide catheters were not associated with any statistically significant reduction (RR 0.90, 95% CI 0.72 to 1.13). These catheters are no longer manufactured. Silver alloy catheters achieved a slight but statistically significant reduction in bacteriuria (RR 0.82, 95% CI 0.73 to 0.92). However, the one large trial with a low risk of bias did not support this finding (RR 0.99, 95% CI 0.85 to 1.16). The randomised 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 showed less bacteriuria in the silver alloy catheter group.For the outcome of discomfort whilst the catheter was in-situ, fewer patients with silver alloy catheters complained of discomfort compared with standard catheters (RR 0.84, 95% CI 0.74 to 0.96). Antimicrobial-impregnated indwelling urethral catheters versus standard indwelling urethral cathetersThe primary outcome measure, symptomatic CAUTI was reported in one large trial with a low risk of bias, comparing nitrofurazone-impregnated silicone catheter (antimicrobial-impregnated) against a standard PTFE-coated latex catheter (control). The nitrofurazone catheter achieved a reduction in symptomatic CAUTI incidence which was of borderline statistical significance (RR 0.84, 95% CI 0.71 to 0.99).For secondary outcomes, the included trials reported on two types of antimicrobial catheters (impregnated with either nitrofurazone or minocycline/rifampicin). Antimicrobial-impregnated catheters, compared with standard catheters, were found to lower the rate of bacteriuria in the antimicrobial group for both minocycline and rifampicin (RR 0.36, 95% CI 0.18 to 0.73), and nitrofurazone (RR 0.73, 95% CI 0.64 to 0.85). The minocycline and rifampicin catheter is no longer manufactured.For the outcome of discomfort whilst the catheter was in-situ, more patients with nitrofurazone catheters complained of pain whilst the catheter was in-situ compared with standard catheters (RR 1.26, 95% CI 1.12 to 1.41). For the period after catheter removal, more patients with nitrofurazone catheters complained of pain than standard catheters (RR 1.43, 95% CI 1.30 to 1.57). Antimicrobial-impregnated indwelling urethral catheters versus antiseptic-coated indwelling urethral cathetersOne large trial compared antimicrobial-impregnated (nitrofurazone) catheters versus silver alloy-coated (antiseptic-coated) catheters. The results showed people were less likely to have a symptomatic CAUTI with nitrofurazone-impregnated catheters (228/2153, 10.6%) compared with silver alloy-coated catheters (263/2097, 12.5%), but this was of borderline statistical significance (RR 0.84, 95% CI 0.71 to 1.00). They did, however, have significantly less bacteriuria (RR 0.78, 95% CI 0.67 to 0.91),While the catheter was in-situ (RR 1.50, 95% CI 1.32 to 1.70), and on removal (RR 1.32, 95% CI 1.20 to 1.45), nitrofurazone catheters were associated with more discomfort compared with silver-coated catheters. One type of standard indwelling urethral catheter versus another type of standard indwelling urethral catheterNone of the trials comparing standard catheters versus other types of standard catheters measured symptomatic CAUTI. In terms of reducing bacteriuria, individual trials were too small to show whether one type of standard catheter was superior to another type. For the outcome of urethral reactions, fully siliconised catheters appeared to be superior to latex-based catheters. However, the trials involved small numbers of participants. There were no statistically significant differences between the different catheters for all other outcomes.

Authors' conclusions: Silver alloy-coated catheters were not associated with a statistically significant reduction in symptomatic CAUTI, and are considerably more expensive. Nitrofurazone-impregnated catheters reduced the risk of symptomatic CAUTI and bacteriuria, although the magnitude of reduction was low and hence may not be clinically important. However, they are more expensive than standard catheters. They are also more likely to cause discomfort than standard catheters.

PubMed Disclaimer

Conflict of interest statement

Thomas BL Lam was involved in the Catheter Trial, funded by the NIHR HTA Programme in the UK (Pickard 2012)

Muhammad Imran Omar: None known

Euan Fisher: None known

Katie Gillies was involved in the Catheter Trial, funded by the NIHR HTA Programme in the UK (Pickard 2012)

Sara MacLennan: None known

Figures

1
1
PRISMA study flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 Antiseptic‐coated catheter versus standard catheter, Outcome 1 Symptomatic CAUTI: using non‐microbiological‐based definition.
1.2
1.2. Analysis
Comparison 1 Antiseptic‐coated catheter versus standard catheter, Outcome 2 Symptomatic CAUTI: using microbiological‐based definition.
1.3
1.3. Analysis
Comparison 1 Antiseptic‐coated catheter versus standard catheter, Outcome 3 Number with bacteriuria.
1.4
1.4. Analysis
Comparison 1 Antiseptic‐coated catheter versus standard catheter, Outcome 4 Number with bacteruria (< 1 week).
1.5
1.5. Analysis
Comparison 1 Antiseptic‐coated catheter versus standard catheter, Outcome 5 Number with bacteriuria (>1 week).
1.7
1.7. Analysis
Comparison 1 Antiseptic‐coated catheter versus standard catheter, Outcome 7 Patient discomfort whilst catheter is in situ.
1.8
1.8. Analysis
Comparison 1 Antiseptic‐coated catheter versus standard catheter, Outcome 8 Number with pain on catheter removal.
1.9
1.9. Analysis
Comparison 1 Antiseptic‐coated catheter versus standard catheter, Outcome 9 Number with urethral secretions.
1.10
1.10. Analysis
Comparison 1 Antiseptic‐coated catheter versus standard catheter, Outcome 10 Number with pain with catheter in place.
1.11
1.11. Analysis
Comparison 1 Antiseptic‐coated catheter versus standard catheter, Outcome 11 Number with urinary symptoms (7 ‐ 10 days post‐catheterisation).
1.12
1.12. Analysis
Comparison 1 Antiseptic‐coated catheter versus standard catheter, Outcome 12 Number with bacteriuria ‐ subgroup analysis for silver oxide catheters.
2.1
2.1. Analysis
Comparison 2 Antimicrobial‐impregnated catheter versus standard catheter, Outcome 1 Symptomatic CAUTI: using non‐microbiological‐based definition.
2.2
2.2. Analysis
Comparison 2 Antimicrobial‐impregnated catheter versus standard catheter, Outcome 2 Symptomatic CAUTI: using microbiological‐based definition.
2.3
2.3. Analysis
Comparison 2 Antimicrobial‐impregnated catheter versus standard catheter, Outcome 3 Number with bacteriuria (< 1 week).
2.4
2.4. Analysis
Comparison 2 Antimicrobial‐impregnated catheter versus standard catheter, Outcome 4 Number with bacteriuria (> 1 week).
2.5
2.5. Analysis
Comparison 2 Antimicrobial‐impregnated catheter versus standard catheter, Outcome 5 Number with pain with catheter in place.
2.6
2.6. Analysis
Comparison 2 Antimicrobial‐impregnated catheter versus standard catheter, Outcome 6 Number with pain on catheter removal.
3.1
3.1. Analysis
Comparison 3 Antimicrobial‐coated catheter versus antiseptic‐coated catheter, Outcome 1 Symptomatic CAUTI: using non‐microbiological‐based definition.
3.2
3.2. Analysis
Comparison 3 Antimicrobial‐coated catheter versus antiseptic‐coated catheter, Outcome 2 Symptomatic CAUTI: using microbiological‐based definition.
3.3
3.3. Analysis
Comparison 3 Antimicrobial‐coated catheter versus antiseptic‐coated catheter, Outcome 3 Number with bacteriuria.
3.4
3.4. Analysis
Comparison 3 Antimicrobial‐coated catheter versus antiseptic‐coated catheter, Outcome 4 Number with pain with catheter in place.
3.5
3.5. Analysis
Comparison 3 Antimicrobial‐coated catheter versus antiseptic‐coated catheter, Outcome 5 Number with pain on catheter removal.
4.1
4.1. Analysis
Comparison 4 One type of standard catheter versus another standard catheter, Outcome 1 Number with bacteruria.
4.2
4.2. Analysis
Comparison 4 One type of standard catheter versus another standard catheter, Outcome 2 Urethral reaction.
4.3
4.3. Analysis
Comparison 4 One type of standard catheter versus another standard catheter, Outcome 3 Number with burning sensation in urethra.
4.4
4.4. Analysis
Comparison 4 One type of standard catheter versus another standard catheter, Outcome 4 Number with urethritis.
4.5
4.5. Analysis
Comparison 4 One type of standard catheter versus another standard catheter, Outcome 5 Number with meatal stricture.
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References to ongoing studies

NCT00482547 2007 {published data only}
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NCT01681511 2012 {published data only}
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NCT02198833 2014 {published data only}
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