The Effectiveness of Sterile versus Non-Sterile Urinary Catheter Insertion at Reducing the Incidence of Catheter Associated Urinary Tract Infection A Systematic Review Fiona Bezzina RN BSc (Hons) Dr. Josette Bettany-Saltikov RCN Research Conference, The Sage, Gateshead - 12 th May 2010
37
Embed
The Effectiveness of Sterile versus Non-Sterile Urinary ...
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
The Effectiveness of Sterile versus
Non-Sterile Urinary Catheter Insertion at
Reducing the Incidence of Catheter
Associated Urinary Tract Infection
A Systematic Review
Fiona Bezzina RN BSc (Hons)
Dr. Josette Bettany-Saltikov
RCN Research Conference, The Sage, Gateshead - 12th May 2010
Background
• Around 26% of hospital patients undergo urinary catheterisation:
» To accurately monitor urine output
» To treat urinary retention or incontinence
» For investigation purposes
(Glynn, A., Ward, V. and Wilson, J. (1997) Socio-economic burden of
Healthcare associated infection. London:PHLS)
• Patients at a significant risk of acquiring a urinary tract infection;
by conducting a further search using urethral, bladder, and urinary
as search term combination.
Results of the search
THE ELECTRONIC DATABASE SEARCH
Total Results - 2687 limits were applied – 2628
Hit count reduced to - 1515
Only 27 of these studies and 4 other relevant studies yielded by
Hand searches were included in the first selection process
Methods of the Review
Three phases :
1. Study Selection process
2. Assessment of the methodological qualities of the selected
studies
3. Data extraction process
All three phases were carried out by one of the authors due to
restrictions of time and work constraints
2 Stages:
First Stage: Title and abstract 13 Studies
Second Stage: Reading the full text 8 Studies
Standardised forms used in both stages
Methods of the Review
1. Study Selection process
List of Included
Studies
Study No CITATION
1
Carapeti, E.A., Andrews, S.M. and Bentley, P.G. (1994) Randomized study of sterile versus non-sterile urethral catheterisation. Ann R Coll Surg Eng: 76, pg59-60.
2
Cheung, K., Leung, P., Wong, Y., To, Oi-king., Yeung, Y., Chan, M., Yip, Y., and Kwok, C. (2008) Water versus antiseptic periurethral cleansing before catheterisation among home care patients: A randomized controlled trial. Journal of Infection Control, 36, pg 375-380.
3
Webster, J., Hood, R.H., Burridge, C.A., Doidge, M.L., Philips, K.M. and George, N. (2001) Water or Antiseptic for Periurethral Cleaning before urinary Catheterization: A Randomized Controlled Trial. Journal of Infection control, 29, pg 389 – 394.
4
Moore, K.N., Burt, J. and Voaklander, D., C. (2006) Intermittent catheterization in the rehabilitation setting: a comparison of Clean and Sterile Technique. Clinical Rehabilitation, 20, pg 461 – 468.
5
Pickard, W.G. and Grundy, D.J. (1996) A Comparison of two methods of Sterile urethral catheterisation in spinal injured adults, Paraplegia, International Medical Society of Paraplegia, 34, pg 30-33.
6
Schiøtz, H. A. (1995) Antiseptic catheter gel and urinary tract infection after short-term postoperative catheterisation in women. Arch Gynecology Obstetrics 258, pg 97-100.
7
Cohen, A. (1985) A microbiological comparison of a Povidone-iodine lubricating gel and a control as catheter lubricants. Journal of Hospital Infection, 6 (supplement), pg 155-161.
8Harrison, L. H. (1980) Comparison of a Microbicidal Povidone-iodine gel and a placebo gel as catheter lubricants. The Journal of Urology, 124, pg 347-349.
2. Assessment of the methodological qualities of the selected studies
Methods of the Review
Assessement Tool:
Adapted version of critical review form designed by Law et al at
the McMaster University (Critical Review Form – Quantitative Studies Law, M., Stewart, D., Pollock, N., Letts,
L. Bosch, J., & Westmorland, M. McMaster University)
Reasons:
1. Applied in analysis of all types of Quantitative study designs
2. Set of very detailed guidelines which makes it easier to use
and increases its inter- and intra-rater reliability
Outcome measure was reliable and valid in 7 Studies
Detailed description 7 studies
Contamination Avoided 6 studies
Co'intervention Avoided 1 study
Statistical significance & Drop Outs 8 studies
Analysis method 7 studies
Clinical Importance 6 studies
Appropriate Conclusions in 5 Studies
Data Extraction Form
156
20
436
36 46
519
2850
0
100
200
300
400
500
600
Study 1 Study 2 Study 3 Study 4 Study 5 Study 6 Study 7 Study 8
No
of
Part
icip
an
ts
Study sample Size
Study Participants
Study Participants
Subjects’ Gender
Mixed5
Females2
Males1
Theatre2
Obstetric Unit
1Spinal
Rehab Unit2
Not Specified
2
Nursing Home
1
Hospital7
Nursing Home
1
Study Setting
Study Participants
Criteria used to define CAUTI
CAUTI CRITERIA
Study BacteruriaBacteriuria
>105
Bacteriuria
>106
Urethral
Bacterial
colony
Leukocyte
Count
≥10/HPF
Symptoms Antibiotics
1 x
2 x x
3 x
4 x x
5 x x x
6 x x
7 x x
8 x
CFU/mlCFU/ml
STU
DY
CATHETERISATION
TYPE
REASONSIndwelling Intermittent
Short
Term
Long
Term
(Not self-
catheterisation)
No clear
indication
Peri-
operative
Urinary
Obstruction
Neurogenic
BladderExperimental
1 X X
2 X X
3 X X
4 X X
5 X X
6 X X
7 X X
8 X X X X
Catheterisation Type and Reason
Intervention
5 studies investigated an element or a combination of elements of
the catheter insertion technique
Carapeti et al,1994
Cheung et al, 2008
Webster et al, 2001
Moore et al, 2006
Pickard et al, 1996
3 studies examined the effect of antiseptic in the lubricating gel,
used in catheter insertion, at reducing CAUTI.
Schiotz, H. A. (1995)
Harrison, L. H. (1980)
Cohen, A. (1985)
Hand washing was investigated in two studies;
soap and water / a full surgical scrub.
Sterile gowns were worn in the intervention groups
Aprons (non-sterile) were worn in both the intervention and control
groups in the study by Cheung et al (2008) and were worn in only the
control group in the study by Pickard et al (1996)
Masks were used in both the intervention and the control in one study
only (Cheung, 2008).
Gloves: Two of the studies investigated their use by contrasting sterile
gloves in the intervention versus non-sterile gloves in the control group
(Carapeti et al 1994; Moore et al , 2006).
Intervention
Sterile Packs were used in both intervention and control in two
studies and in three studies they were used only in the intervention.
Sterile drapes: clearly indicated in only two studies; in one study
used in both intervention and control whereas in the other study were
only used in the intervention.
Meatal cleansing agent:
• Sterile water used in both intervention and control in 2 studies
• Chlorhexidine was used;
in the intervention only, in 3 studies; (in the control, tap
water or sterile water was used)
in both intervention and control in 2 studies.
Intervention
Non-touch technique (handling the catheter with forceps or by leaving it
partially sheathed in its sterile plastic container) in both interventions and
controls was clearly indicated in all the studies except one. (Schiøtz, 1995)
Lubricating gel:
• Sterile, antiseptic-free gel used in both intervention and control in
3 studies (Cheung et al, 2008; Moore et al, 2006; Pickard et al,1996).
• Sterile, antiseptic-free gel used in the intervention versus
non- sterile, antiseptic-free gel in the control in 1 study (Carapeti
et al,1994).
• Sterile gel containing Chlorhexidine used in the intervention
in contrast to no gel in the control in 1 study (Schiøtz,1995)
• Povidone-iodine-containing gel used in the intervention against
sterile antiseptic-free gel used in the control in 2 studies.
(Cohen,1985; Harisson,1980)
Intervention
The results of 5 of the studies suggest that there is no difference in
the incidence of CAUTI when non-sterile or sterile catheterisation
techniques are used(Carapeti et al, 1994; Cheung et al, 2008; Webster et al, 2001; Moore et al ,
2006, and Pickard et al, 1996).
1 study found that there was no advantage in using antiseptic-
containing lubricating gel at catheter insertion (Schiøtz, 1995)
The results of 2 studies supported the hypothesis that antiseptic-
containing gel reduces the incidence of urinary contamination(Cohen, 1985; Harrison, 1980)
Results
Our Appraisal of these studies has revealed:
• major flaws in their study design and execution
• the quality has been judged to range from poor to moderate.
Therefore great caution is to be exercised on translating the findings
of these studies into clinical practice.
Implications to Practice
Small number of studies identified for inclusion (despite the search
for studies being as comprehensive as possible)
Most of the studies have been shown to be of poor to moderate
quality and therefore one should be extremely cautious at applying
their findings
Selection bias is another probable limitation (all publications which
were not in English were excluded from the search)
Single rater was involved in this review project
Publication Bias is another possible limitation
Limitations of the Review
1. Study design of RCT with strict adherence to random
allocation, including stratification and blinding
2. Multicentre studies; improve recruitment and ensure samples
of adequate size (which should be determined by a power
analysis)
3. Training of those involved in the study with regards to
techniques involved and outcome measures.
Suggestions for Future Research
4. Consensus on a clear definition of what CAUTI is as an
outcome and how to measure it reliably; probably definitions
relying on symptoms should be avoided given the
subjectiveness involved in their identification.
5. A number of different variables should be studied such as
effect of different antiseptics and the effect of gender;
however, it is essential that not too many variables are
investigated simultaneously.
Suggestions for Future Research
REFERENCES
• Mullings, A. and McCoubrey, J. (2004) Scottish Surveillance of Healthcare Associated Infection Programme (SSHAIP): Catheter Associated Urinary Tract Infection (CAUTI) Surveillance [online] http://www.hps.scot.nhs.uk/haiic/sshaip/cautisurveillance.aspx (Accessed on 18th June 2008).
• Bryan, C., S. and Reynolds, K., L. (1984) Hospital-acquired bacteraemic urinary infection: epidemiology and outcome. Journal of Urology, 132, pg 494-498.
• Turck, A. and Stamm, W. (1981). Nosocomial infection of the urinary tract. American Journal Medicine, 70, pg 651-654.
• The Royal Collage of Nursing (2008) Catheter Care, RCN guidelines for nurses.
• Published by the Royal Collage of Nurses: London [RCN online] www.rcn.org.uk/direct (accessed on 19thJune2008).