More recent studies have evaluated the use of bedside bladder ultrasound in an attempt to determine when intermittent catheterization is needed and thereby limit its use compared with standard timed catheterization. Frederickson, et al., demonstrated that this intervention resulted in significantly fewer catheterizations in surgical patients, thus delaying or avoiding the need for catheterization in 81% of the cases.19 Given this drastic improvement, it is no surprise bladder ultrasound use reduced the rates of UTI.20
External condom catheters present another alternative to indwelling catheter use but the outcomes data is conflicting. While the risk of bacteriuria is approximately 12% per month, this rate becomes increasingly higher with frequent manipulation of the condom catheter. 21,22
Two parallel cohort studies in a VA nursing home showed the incidence of symptomatic UTI to be 2.5 times greater in men with an indwelling catheter than those with a condom catheter.23 On the other hand, a cross-sectional Danish study reported higher rates of UTI with external condom catheters than urethral catheters in hospitalized patients.24 Complications from condom catheters include phimosis and local skin maceration, necessitating meticulous care with the use of these devices. Although the data surrounding external catheterization is somewhat contradictory, this device warrants consideration in incontinent males without urinary tract obstruction.
There are several other alternatives to urethral catheterization (see Table 3, p. 31), many of which have excellent face validity even in the absence of rigorous evidence.
Antimicrobial catheters: The development of antimicrobial urinary catheters, including silver-alloy and nitrofurazone-coated catheters, has been greeted with much excitement, however, the jury is still out about their best use. A 2006 systematic literature review reported that in comparison to standard catheters, antimicrobial catheters can delay or even prevent the development of bacteriuria with short-term usage.25
However, not all antimicrobial catheters are equally effective; assorted studies lack data about clinically relevant endpoints such as prevention of symptomatic UTI, bloodstream infection or death.26, 27 In addition, there are no good trials comparing nitrofurazone to silver-alloy catheters. Therefore, the level of excitement surrounding antimicrobial catheters—particularly silver-alloy catheters—must be tempered by the additional costs incurred by their use.
To date, the cost-effectiveness of antimicrobial catheters has not been demonstrated. Although additional research in this topic is still needed, some experts currently recommend the consideration of silver-alloy catheters in patients at the highest risk for developing serious consequences from UTIs.
Efforts to reduce CAUTI: In response to significant public interest in hospital-acquired infections including CAUTI, the federal government and many state governments are beginning to demand change. In August 2007, the Centers for Medicare and Medicaid Services instituted a mandate making hospitals financially responsible for selected preventable hospital-acquired harms, including CAUTIs.28 In addition, beginning with Pennsylvania in 2006, several states have mandated public reporting of hospital-acquired infections.29
Given the available information about CAUTI prevalence, risks, and preventive techniques, it is surprising the majority of hospitals in the United States have not taken appropriate measures to limit indwelling catheter use. A recent study by Saint, et al., demonstrated the startling fact that only a minority of hospitals monitor the use of urethral catheters in their patients.30
Among study hospitals, there was no widely used technique to prevent CAUTI including evidence-based practices such as daily catheter reminders. The results of this investigation illustrate the urgent need for a national strategy to reduce CAUTI. Until that time, however, hospital-based physicians must take the lead to champion collaborative efforts, to promote evidence-based catheter use.
Back to the Case
As incontinence and fall risk are not medically appropriate indications for a urethral catheter, a Foley catheter should not have been utilized. Alternatives to indwelling catheterization in this patient would include a bedside commode with nursing assistance, a timed voiding program, intermittent catheterization with or without bladder ultrasound, incontinence pads, or a condom catheter.