Running head: UTILIZATION OF ANTIMICROBIAL COATED URINARY
CATHETERS
Utilization of Antimicrobial Coated Urinary Catheters
Kimberly Baylen
University of South Florida
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UTILIZATION OF ANTIMICROBIAL COATED URINARY CATHETERS
Abstract
Clinical Problem: Hospitalized patients are in a vulnerable condition. By being in the
hospital, patients are automatically at risk for acquiring a nosocomial infection such as a
urinary tract infection (UTI). Those who require urinary catheterization are at risk of
obtaining a catheter associated urinary tract infection (CAUTI), which is increases
patients morbidity and mortality as well as resulting in an increased costs to healthcare
(Lederer et al., 2014).
Objective: To determine if the use of an antimicrobial-coated urinary catheter will
decrease the incidence of catheter associated urinary tract infection (CAUTI) in
hospitalized adult patients.
Search Engines: CINAHL and PubMed were the search engines used to retrieve study
trials and guidelines.
Key Words Used: When conducting a search in these search engines, key words included
catheter associated urinary tract infection, CAUTI, antimicrobial, urinary catheter,
nosocomial infections, and prevention.
Results: Lederer and colleagues (2014) showed that the use of a silver-alloy catheter
significantly reduced symptomatic CAUTI occurrences (p<0.0001). Stensballe and
collaborators (2007) demonstrated that nitrofurazone-impregnanted catheters
significantly reduced the incidence of catheter associated bateriuria and funguria
(p=0.005). Stenzelius and colleagues (2011) showed that there was a significant
decreased incidence of bacteriuria by using a noble metal alloy-coated catheter(p=0.027).
Conclusion: Using antimicrobial-coated urinary catheters instead of using standard
urinary catheters decreases the incidence of CAUTI in hospitalized patients.
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UTILIZATION OF ANTIMICROBIAL COATED URINARY CATHETERS
Utilization of Antimicrobial Coated Urinary Catheters
The risk for acquiring a urinary tract infection (UTI) presents great concern for
hospitalized adult patients. Patients who need a urinary catheter are at increased risk for
obtaining a urinary tract infection known as a catheter associated urinary tract infection
(CAUTI). Patients with CAUTI have increased morbidity and mortality and an increase
in unnecessary healthcare costs. A previous study showed that patient’s with catheter
associated urinary tract infections obtained excess health care costs of $3,803 (Lederer et
al., 2014). Decreasing the incidence of CAUTIs should be a primary goal in order to
improve patient outcomes and decrease healthcare costs. Several evidence-based
practices (EBPs) have effectively demonstrated practices and interventions to decrease
the incidence of CAUTIs. This paper will address the how antimicrobial-coated catheter
use can decrease the incidence of CAUTIs. Three randomized controlled trials (RCTs)
and a guideline were evaluated in order to assess the effectiveness of this intervention.
PICOT Question
In adult patients, how does the use of antimicrobial-coated urinary catheters
compared to the use of standard urinary catheters affect the rate of catheter associated
urinary tract infections within 6 months?
Infrastructure to Support Practice Change
Tampa General Hospital (2015) is committed to providing care with a patientcentered approach by delivering their services in an exceptional matter to optimize
clinical outcomes, care process, cost-effectiveness, and patient experience. Tampa
General Hospital partners with academic and other healthcare in order to support medical
education and research. The hospital has great pride in delivering care most up to date
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UTILIZATION OF ANTIMICROBIAL COATED URINARY CATHETERS
with the current evidence based research. Tampa General Hospital’s commitment to
improving patient outcomes by implementation of evidence-based practice is apparent
through their vision and mission statements. The hospital encourages the use of evidencebased practice in order to optimize patient care. The cooperation of physicians,
practitioners, and nurses helps put an evidence based practice change into action and
helps encourage other staff members to support a practice change.
Literature Search
The Cumulative Index of Nursing and Allied Health Literature (CINAHL),
PubMed, and the National Guideline Clearinghouse (NGC) were used to search for
research trials and a guideline for evidence related to the PICOT question. Key terms
used during a search include: catheter associated urinary tract infection, CAUTI,
antimicrobial, urinary catheter, nosocomial infections, and prevention.
Literature Review
Three randomized controlled trials and a guideline of diagnosis, prevention, and
treatment of CAUTI were used to evaluate the effectiveness of using an antimicrobialcoated urinary catheter rather than a standard urinary catheter to decrease the incidence of
UTIs (See Table 1).
Lederer’s (2014) study compared the rate of catheter associated urinary tract
infections (CAUTI) when using a standard urinary catheter verses a silver-alloy hydrogel
catheter. The multicenter before-after non-randomized cohort study included seven acute
care hospitals ranging in size and included adult patients who underwent Foley
catheterization and had a positive urine culture two days after admission. Surveillance
was conducted at these seven hospitals for at least three months. From the seven
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UTILIZATION OF ANTIMICROBIAL COATED URINARY CATHETERS
hospitals, a sample of 2,778 acute care beds participated in the study with six of the
hospitals ranging in size from 124 to 607 beds and the seventh hospital with 921 beds. Of
those patients, 1,580 qualified for the study. Standard catheters were used for the first
three months and then an additional three months with the use of the silver-alloy hydrogel
catheter. Each candidate’s medical records were reviewed to determine inclusion in the
study. Results showed that there was a 47% reduction rate in CAUTI when using the
silver-alloy hydrogel catheter compared to the standard catheter (p<.0001).
A strength of Lederer’s study is the use of a clearly defined definition of CAUTI
making it easily measured. A weakness of the study was the use of a before-after cohort
study, where a randomized controlled trial may have yielded more robust evidence. The
study supports that the use of an antimicrobial-coated catheter compared to a standard
catheter decreases the rates of urinary tract infection in patients in patients and therefore
provides evidence to support the proposed PICOT question.
Stensballe’s (2007) study aimed to determine whether nitrofurazone-impregnated
urinary catheters reduce the incidence of catheter-associated bacteruria and funguria
(CABF). In the randomized, double-blind, controlled trial, 212 adult trauma patients were
randomly assigned to either the standard silicone catheter group or the nitrofurazone
catheter group. A urine sample for culture was taken from the participants immediately
after insertion and then daily until the catheter was removed in order to determine the
presence of catheter-associated bacteriuria and funguria. Catheter-associated bacteruria
and funguria occurred in 9.1% of patients in the nitrofurazone catheter group and in
24.7% of patients in the silicone catheter group (p=0.005).
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UTILIZATION OF ANTIMICROBIAL COATED URINARY CATHETERS
In Stensballe’s (2007) study, the strength was the use of randomized assignments
of groups and the use of a double-blind study preventing any influence on the participant
or testers. A weakness to the study is there was no analysis of symptoms of UTIs to
patients. The results of the study showed that an antimicrobial-coated catheter decreased
the incidence of bacteria and funguria related to the use of catheters and thus provides
data to support the PICOT question.
In Stenzelius’s (2011) study, the use of a noble metal (silver, gold, palladium)
alloy-coated latex and silicone Foley catheter (standard catheter) were compared in the
incidence of catheter-associated bacteriuria in a randomized controlled study. The study
included 439 adult patients needing short-term catheterization due to an elective
orthopedic surgery. These patients were randomly assigned a type of urinary catheter that
was only known by the nurse with 217 assigned to receive a silicone catheter and 222
patients assigned with a coated latex catheter. This study was a partially blind study; the
patient and microbiologist in charge of the urine cultures were not aware of the
allocations. Urine cultures were taken before catheter insertion and before removal.
Results showed that the incidence of bacteruria was 1.5% with the coated latex catheter
and 5.5% with the silicone catheter (p=0.027) with a mean period of two days
catheterization time.
The study’s strength includes the use of participants who were randomly assigned
to the experimental and control groups. A weakness to this study includes the inability to
keep the nurses blind to the study due to the appearance of the different catheters. This
study provides a randomized study to show that noble metal alloy-coated catheters reduce
the occurrence of CAUTI and therefore provides support for the PICOT question.
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UTILIZATION OF ANTIMICROBIAL COATED URINARY CATHETERS
The guideline published by the Infectious Diseases Society of America by Hooten
and colleagues (2010) provided evidence based recommendation related to the diagnosis,
prevention, and management of patients presenting with a catheter associated urinary
tract infection. The Infectious Diseases Society of America recommends the use of an
antimicrobial-coated urinary catheter to reduce and delay the onset of catheter-associated
bacteriuria. According to the guideline, there is insufficient evidence to make a
recommendation for the use of antimicrobial-coated catheters to reduce catheter
associated urinary tract infection in patients.
Synthesis
Exploration of the use of antimicrobial-coated urinary catheters to decrease the
incidence of catheter associated urinary tract infection has demonstrated the positive
effect this use has for patients.
Lederer’s (2014) study showed a 47% reduction in CAUTI rates with the use of a
silver-alloy hydrogel catheter compared to the use of a standard catheter (p<0.0001).
Stensballe (2007) demonstrated how the use of nitrofurazone-impregnated urinary
catheters significantly decreased the incidence of catheter associated bacteriuria and
funguria (p=0.005), which is related to the cause of urinary tract infections. Stenzelius’s
(2011) study showed that a noble metal alloy-coated urinary catheter had a 1.5%
incidence of bacteriuria and the standard catheter had a 5.5% incidence (p=0.027).
Hooten’s (2010) recommended the use of an antimicrobial coated urinary catheter to
reduce and delay the onset of catheter associated bacteriuria.
Research has shown that antimicrobial-coated (noble metal alloy, nitrofurazone,
silver alloy) urinary catheters have significantly reduced the incidence of catheter
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UTILIZATION OF ANTIMICROBIAL COATED URINARY CATHETERS
associated urinary tract infections. However, the use of these antimicrobial-coated
catheters has not positively impacted morbidity and mortality rates. Further research may
be needed to determine if the use of an antimicrobial-coated urinary catheter instead of
the standard urinary catheter will decrease these complications. The research reviewed
studied the use of short-term urinary catheterization. Further research is necessary to
determine if the effects of an antimicrobial urinary catheter will still be effective with
long-term use.
Proposed Practice Change
Using antimicrobial-coated urinary catheters for patients requiring urinary
catheterization is a relatively low risk intervention for decreasing the incidence of CAUTI
in adults. Instead of the using a standard catheter, an antimicrobial-coated catheter such
as a nitrofurazone urinary catheter, silver-alloy hydrogel coated urinary catheter, or a
noble metal alloy-coated urinary catheter should be used. Urinary catheter insertion
should follow the insertion guidelines using sterile technique.
Change Strategy
Promoting Engagement
Every staff and team member including nurses and physicians should be
encouraged to participate in the process. The evidence and reasoning should be presented
to the team in order to increase compliance and involvement. If individuals present with
concerns or doubts about the proposed practice change, they should be allowed to express
their feelings openly in order to create a unified team by addressing any issues that.
Addressing concerns of the team can help create strategies to focus on the issues brought
about.
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UTILIZATION OF ANTIMICROBIAL COATED URINARY CATHETERS
Evidence-Based Practice Model for Change
A leadership team must be establish and staff, nurses, and physicians must
acknowledge the problem that catheter associated urinary tract infections are serious
conditions that can be amenable with an evidence based solution. Tampa General
Hospital currently uses the Iowa Model in order to guide their evidence-based practice
studies. According to Melnyk and Fineout-Overholt (2015), The Iowa Model of EBP
helps nurses and physicians by ating as a guide to aid them in deciding whether clinical
and administrative practices will affect patient outcomes in a positive way. The model
utilizes problem solving steps based upon the scientific process and implements a
multiphase change process with feedback loops in order to make its use applicable.
Roll Out Plan
Steps
Step 1: Identify Problem
Focused Triggers or a
Knowledge Focused
Trigger
Definition
Problem Focused Trigger
 Identify the clinical
problem
 Process
improvement data
Knowledge Focused
Triggers
 Knowledge from
new research
 Agencies or
organizational
standards of care
If it is decided that the
Step 2: Identify the
priority of the problem for problem is of priority to the
organization then a
the organization
leadership team should be
established, find research
and literature relevant to the
problem, critique and
synthesize research for use
in practice. (Continue to
next step)
Timeframe for Rollout
Completion by Aril 2015
Completion by April 2015
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UTILIZATION OF ANTIMICROBIAL COATED URINARY CATHETERS
Step 3: Establish a
sufficient base
Step 4: Analyze
appropriateness of the
adoption change in
practice
Step 5: Monitor and
Analyze Structure,
Process, and Outcome
Data
If the topic is not a priority
then go back to step one to
identify another problem
If a sufficient base can be
established:
 Pilot the change in
the facility and
continue onto step
four
If a sufficient base cannot
be established
 Is there other
evidence to base
practice on?
 Or conduct research
If adoption is appropriate
 Institute the change
into practice.
Continue to next
step
If adoption is not
appropriate
 Reevaluate quality
of care and any
further knowledge
 Return to step one
Prior to the implementation
of the practice change,
continue to evaluate effects
on the environment, staff
members, patient, family,
and costs.
Distribute results
Implement by May 2015
Evaluate change November
2015
Completion by December
2015
January 2015
Project Evaluation
Once the change is identified as having a sufficient base for change, according to
the research provided in this paper, then the change to use antimicrobial-coated urinary
catheters will be implemented into practice. Rather than receiving the standard urinary
catheter, patients who need urinary catheterization will be catheterized using an
antimicrobial-coated urinary catheter. The incidence of CAUTI in patients while using
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UTILIZATION OF ANTIMICROBIAL COATED URINARY CATHETERS
antimicrobial coated urinary catheters will be analyzed from the data collected. Data
before the implementation of the practice change will be compared to data after the
change. The rates will be followed monthly for a six-month period to evaluate the impact
on catheter associated urinary tract infections and the incidence of the infection. A
decrease in the incidence of CAUTI with the antimicrobial coated catheters then the
practice change is a success.
Dissemination of EBP
The practice change described is of great importance in reducing risks to patients
and optimizing their quality of care. The change should be disseminated locally and
regionally. In order to disseminate the change, the study and change should be published
for other organizations to analyze and consider for implementation into their own
facilities. To raise awareness in the facility guideline changes can be made and educated
to the entire staff.
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UTILIZATION OF ANTIMICROBIAL COATED URINARY CATHETERS
References
Hooton, T.M., Bradley, S.F., Cardenas, D.D., Colgan, R., Geerlings, S.E., Rice, J.C., . . .
Nicolle, L.E. (2010). Diagnosis, prevention, and treatment of catheter-associated
urinary tract infection in adults. Clinical Infectious Diseases, 50(5), 625-623.
Lederer, J. W., Jarvis, W. R., Thomas, L., & Ritter, J. (2014). Multicenter cohort study to
assess the impact of a silver-alloy and hydrogel-coated urinary catheter on
symptomatic catheter-associated urinary tract infections. Journal of Wound,
Ostomy, and Continence Nursing, 41(5), 473-480. doi:
10.1097/WON.00000000000
Melnyk, B.M., & Fineout-Overholt, E. (2015). Evidence-Based Practice in Nursing &
Healthcare. Philadelphia, PA: Wolters Kluwer.
Stensballe, J., Tvede, M., Looms, D., Lippert, F. K., Dahl, B., Tonnesen, E., &
Rasmussen, L. S. (2007). Infection risk with nitrofurazone-impregnated urinary
catheters in trauma patients: A randomized trial. Annals of Internal Medicine,
147(5), 285-293. doi: 10.7326/0003-4819-147-5-200709040-00002
Stenzelius, K., Perssons, S., Olsson, U., & Stjarnedblad, M. (2011). Noble metal alloycoated latex versus silicone foley catheter in short-term catheterization: a
randomized controlled study. Scandinavian Journal of Urology and Nephrology,
45, 258-264. doi: 10.3109/00365599.2011.5600007
Tampa General Hospital (2015) Mission & Vision. Retrieved from: https://www.tgh.org
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13
Table 1
Literature Review
Reference
Aims
Lederer, J. W., Jarvis,
W. R., Thomas, L., &
Ritter, J. (2014).
Multicenter cohort study
to assess the impact of a
silver-alloy and
hydrogel-coated urinary
catheter on symptomatic
catheter-associated
urinary tract infections.
Journal of Wound,
Ostomy, and Continence
Nursing, 41(5), 473-480.
doi:
10.1097/WON.0000000
0000
To measurethe
effects of a
silver-alloy
coated urinary
catheter on
CAUTIs in
comparison to a
standard, nonsilver coated
urinary
catheter.
Stensballe, J., Tvede,
M., Looms, D., Lippert,
F. K., Dahl, B.,
Tonnesen, E., &
Rasmussen, L. S.
(2007). Infection risk
with nitrofurazoneimpregnated urinary
catheters in trauma
patients: A randomized
trial. Annals of Internal
Medicine, 147(5), 285293. doi: 10.7326/00034819-147-5-20070904000002
To determine
the effects of a
nitrofurazoneimpregnated
urinary catheter
t on the
incidence of
bacteriuria and
funguria related
to catheter use.
Design and
Measures
Retrospective,
multicenter,
before-after
study
conducted at
seven acute
care hospitals.
Sample
Outcomes/
Statistics
From the seven The use of the
hospitals, 1,580 coated catheter
patients
reduced the
participated in
incidence of
the study. A
catheter
total of 853
associated
patients
urinary tract
qualified for the infection by a
CAUTI was
study.
47% relative
measured using
reduction
the definition as
(p<0.0001)
defined by the
CDC NHSN of
symptomatic
urinary tract
infection and
clinical catheter
associated
urinary tract
infection.
Randomized,
double-blind,
controlled trial
during a 24month period.
A total of 212
adult trauma
patients were
included in the
study; 1,190
urine cultures
were collected.
Measures: A
positive urine
culture
contained at
least 103
colony-forming
units/mL
Nitrofurazoneimpregnated
catheters
significantly
decreased the
incidence of
catheterassociated
bacteriuria and
funguria.
(p=0.005)
UTILIZATION OF ANTIMICROBIAL COATED URINARY CATHETERS
Stenzelius, K., Perssons,
S., Olsson, U., &
Stjarnedblad, M. (2011).
Noble metal alloycoated latex versus
silicone foley catheter in
short-term
catheterization: a
randomized controlled
study. Scandinavian
Journal of Urology and
Nephrology, 45, 258264. doi:
10.3109/00365599.2011
.5600007
To compare the
incidence of
catheterassociated
bacteriruia with
the use of a
noble metal
alloy-coated
urinary catheter
to a standard
catheter.
A randomized
controlled trial
was conducted.
Measures:
A positive
bacteriuria
urine sample
was defined as
the growth of
≥100,000
cfu/ml.
A total of 439
patients were
randomized;
217 patients
were put into
the standard
catheter group
and 222
patients were
put into the
noble metal
coated catheter
group.
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The use of
urinary
catheters with a
noble metal
alloy coating
significantly
reduced the
incidence of
catheter
associated
bacteriuria.
(p=0.027)