Preventing Catheter Related Urinary Infections: A Literature Review

This literature review explores the knowledge and efficacy of nursing professionals in preventing catheter related urinary tract infections (CAUTI) among patients. It sheds light on the attributes that make nurses accountable for preventing CAUTI and the importance of preventing such infections to reduce patient suffering and manage healthcare resources effectively.

Running head: LITERATURE REVIEW
LITERATURE REVIEW
Name of the student:
Name of the university:
Author note:

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LITERATURE REVIEW
Part One
Introduction:
Catheterization refers to the procedure where a urinary catheter is placed inside the
bladder of a patient, through the urethra. The process facilitates free drainage of the patient’s
urine from the bladder for collection. The procedure is often performed under circumstances
when patients suffer from urinary incontinence, urinary retention, surgery in the genitals, or
under medical illnesses such as, spinal cord injury and dementia. Although use of catheterization
has irrefutable benefits in medical situation, their prolonged usage is allied with increased
healthcare costs, greater discomfort and morbidity amid the patients (Parientiet al.
2015).Indwelling catheter can be described as the tube that is inserted into the urethra. This tube
helps in draining urine from the bladder into a particular collection bag. Such catheters are
mainly inserted into a patient when they had already undergone a surgery or when the person
does not have control over the bladder function. Catheter related urinary tract infection (CAUTI)
often occurs due to inoculation of organisms by the urethral catheters to bladder, and subsequent
colonization that results in mucosal irritation. CAUTI has been found to be one of the most
common infections that a patient can contract from the healthcare centers. Hence, presence of
urinary catheters are considered as a crucial risk factor that increases the susceptibility of
bacteriuria. Several reasons that result in the onset of CAUTI are namely, (i) contamination of
catheter upon insertion, (ii) failure to empty the drainage bag, (iii) bacteria entry in catheter due
to bowel movement, (iv) backward flow of urine in catheter bag, and (v) unclean catheter. Owing
to the fact that appropriate catheter insertion and removal procedures help in lowering the risks
of CAUTI, and keeping them inserted for long increases the infection risk, nursing professionals
should have adequate knowledge on its usage (Vincitorioet al. 2014). This assignment would

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LITERATURE REVIEW
mainly be focusing on reviews of different literature that shed light on efficiency and expertise of
the nurses in prevention of the CAUTI and provision of safe and quality healthcare that prevent
sufferings and increase satisfaction of patients.Conduction of this literature review would help in
changing the existing behavior among the nursing staff on CAUTI and its prevention. The
collected evidences will also be disseminated, with the aim of increasing awareness among the
staff and hospitalized patients, thereby reducing rates of infection among patients.
Background:
Patients suffering from CAUTI show symptoms like cloudy urine, presence of blood in
the urine, strong odor present in the urine, urine leakage around the catheter. The patients are
also seen to suffer from pressure, pain as well as discomfort in the lower back of the stomach.
They may experience chills, fever, unexplained fatigue as well as vomiting. Therefore, CAUTI
results in preventable sufferings among the patients that affect their quality of life. Such
infection can disrupt the main treatment intervention plans for the patient with the main disorder
that had made them admitted to the healthcare centers (Rea et al., 2018). CAUTI results in
increasing the suffering of the patient in addition to the various disorder symptoms with which
the patient is already suffering from. This has many negative effects. Studies have stated that
preventable infections like CAUTI increases the length of hospital staysas well as readmission
rates along with sufferings of the patient. The patients seem to lose trust over the capabilities of
caring by the healthcare professionals and this creates a rift between the patients and family
memberwith that of the professionals of the hospitals.
It is very important for the nursing professionals to have proper knowledge about the
different ways by which CAUTI can occur among the patients. These would help them to

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LITERATURE REVIEW
develop detailed knowledge about the specific initiatives that they need to undertake during
insertion of catheters for prevention of the occurrence of the infection. Firstly, the catheter might
become infected upon insertion and secondly, the drainage bag might not be emptied often
enough that may become the source of infection (Pickard et al., 2012). Third, bacteria from the
bowel movement might also enter the catheter. Fourth, urine that remains present in the catheter
bag might flow backward into the bladder. Fifth, the catheter might not also be regularly cleaned
for prevention of infection. These factors might result in development of CAUTI among the
patients.
However, the prevalence of CAUTI in the nation of UK is quite high.. urinary tract
infection is one of the most important cause of morbidity as well as mortality in the healthcare
settings and even accounts for about 19% of all the nosocomial infections. Out of them, data
suggests that about 43 to 56% of the cases are cases of CAUTI. When inadequately treated,
CAUTI situations in patients might progress to cases of bacteraemia and even consequent
urosepsis syndromes. This contributes to the multiplication of the risks of the extended hospital
stays and even mortality (Peter et al., 2018). Due to the high-level prevalence of CAUTI,
economical analysis of different collected data shows that the economic implications of CAUTI
are quite high costing an estimated of about £1968 per patient episode as well as that of about
£99 million annually to the NHS (Barry et al., 2017). Therefore, it is highly significant to learn
how effective are the nurses in preventing such infections and accordingly develop strategies and
interventions to help nurses develop skills by which such infection can be prevented. This would
not only prevent occurrence of CAUTI among patients and reduce their suffering, but would also
help in managing the healthcare resources on more crucial treatment modalities.
Literature review question:

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LITERATURE REVIEW
The literature review question would be “How effective are nurses in preventing catheter
related urinary infections?”
Aim of the research:
 To explore the knowledge and efficacy of nursing professionals in preventing catheter
related urinary tract infections among patients.
Objectives of the research:
 To determine the idea harbored by nurses regarding CAUTI
 To understand the perception of the nurses about prevention of CAUTI among patients
 To assess the presence or absences of skills and knowledge that need to be harbored by
nurses for preventing CAUTI
 To explore the hygiene levels maintained by nurses
 To determine the attributes that make nurses accountable for preventing CAUTI
Methodology:
The study was based on secondary research that involved a comprehensive collation,
summary and synthesis of already existing scientific evidences. This methodology was in clear
contrast with primary research approach in that the latter involves data generation, while the
former takes into account primary scholarly articles for data analysis. The steps involved in the
methodology are given below:
 Formulation of the research question
 Searching for relevant scientific literature
 Screening articles for inclusion

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LITERATURE REVIEW
 Assessing the quality of the extracted primary studies
 Extraction of data
 Analysis of data
The research question was formulated with the use of the PEO framework that is a
commonly used criteria for framing and defining the clinical question of qualitative nature.
This framework comprises of three components namely, (i) population and their problems
(P), (ii) exposure (E), and (iii) outcomes or themes (O). The framework used for this
literature search is provided below:
P Nursing staff
E Knowledge, awareness, efficacy
O Catheter related urinary tract infection (CAUTI)
prevention
Table 1- PEO components
Search strategy:
The structure of this literature review was based on elaboration of the research question,
outlining the eligibility criteria for selection of prospective scholarly literature, extracting
articles, and detailed analysis. Four electronic databases namely, PUBMED, CINAHL, BRITISH
NURSING DATABASE, MEDLINE were used for extracting the articles.The search terms and
key phrases that were fed into the databases were namely, “effectiveness of nurses to prevent
CAUTI”, “prevention of CAUTI”, “skills of nurses and CAUTI”, “ways or prevention for
CAUTI”, “efficiency of nurses and CAUTI”, “perception or awareness and CAUTI”. Use of
boolean operators helped in combining the search terms in certain ways, thereby broadening or

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LITERATURE REVIEW
narrowing down the extracted hits. The using of the Boolean operators of “AND” helped in
narrowing down our researches and the using of the “OR” broadened the search by combining
different synonyms for covering the research question that was being explored. Determination of
the inclusion and exclusion criteriabeforehand facilitated selection of appropriate articles that
aligned with the phenomenon under investigation.
Inclusion criteria Exclusion criteria
Articles that are published in the English language Articles that are containing non-English language
Articles that had been published on or after 2008 Articles that are published before 2008
Articles that mainly emphasize on nurse’s
perception about skills and knowledge required to
prevent CAUTI or contain measurement of their
skills or expertise
Articles that focus on other healthcare associated
infections should be avoied
Primary research articles would only be chosen Secondary research articles
Articles that are published in the peer-reviewed
journals only needs to be chosen
Manuscripts as well as clinical guidelines should
be avoided
Table 1- Inclusion and exclusion criteria
Finally, the most reliable, per reviewed articles that aligned with the inclusion criteria and
helped in solving the literature review question were selected for the assignment.
Part Two
Literature review:
The article provided bySingha, Locklin & Handa (2017) had put focus on an interesting
aspect of the cause of the CAUTI among different hospitals. The authors are of the opinion that

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LITERATURE REVIEW
the major cause for the development of CAUTI is the bacteria travelling up to the bladders and
thereby causing infections. One of the main reasons for the occurrence of this event can be
attributed to the utilization of the different non-ideal material in the fabrication of the urinary
catheters. It has been found by them that such types of materials allow for the colonization of the
microorganisms that lead to bacteriuria and even the infection depending on the severity of the
symptoms (Royet al. 2018). They are of the opinion that the catheter should be made up of
materials that should be biocompatible, antifouling and antimicrobial.
Over many years, it has been found that many of the professionals have often argued
about the use of antimicrobial catheters in comparison to that of the standard polytetrafl
uoroethylene (PTFE) catheterization. Many of the nursing professionals had been seen to believe
that antimicrobial catheters are indeed helpful in obstructing the growth of microbes in the
catheters or prevent the chance of development of microbes at the entry site of the catheters into
the urethra (Saini, 2018). However, not much fruitful effect had been yet established that make
antimicrobial catheters the gold practice to prevent CAUTI. However, Pickard et al. (2012) have
conducted randomized controlled trail to test the efficiency of the antimicrobial catheters over
the normal use of the standard polytetrafl uoroethylene (PTFE) catheterization. The results of
this outcome had showed that although many experts support the use of anti-microbial catheters,
but its efficiency to prevent CAUTI is quite low (Krein et al. 2017). The interpretation of their
findings showed that levels of benefits obtained from using the antimicrobial catheters are so low
that bringing changes in practice would not bring out successful outcomes in prevention of
CAUTI. One of the best parts of the study was that the author did not only use one type of
antimicrobial catheter while comparing with the standard polytetrafl uoroethylene (PTFE)
catheterization. This is because only one type of antimicrobial agent failing to bring out positive

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LITERATURE REVIEW
results in prevention of CAUTI could not have represented same result by other antimicrobial
agents (Rhee et al. 2016). Therefore, the best part as the study was that they used two types of
antimicrobial catheters like that of the silver alloy catheter and that of the nitrofural-impregnated
catheters. It was found that the efficiency of silver-coated catheters was found to be not more
than that of the control showing that it does not have additional benefits in prevention of CAUTI.
It proved to be entirely failure in providing extra protection against bacteria. Another one is the
nitrofural-impregnated catheters which although showed a slight better efficiency than that of the
control but the number was not high enough to bring successful extraordinary outcomes when
implemented in practices.
The paper as written by McClurg et al. (2018) has given insights into the physical as well
as the psychological impacts on the health of persons who engages in habit of using clean
intermittent self-catheterization. This study showed that as habit of using this form of
catheterization normalized with the frequency of uses, many of people showed positive feelings
about their quality of life. However, many of the participants also stated that this habit often
seemed a burden on the life of people preventing them from participating in potential activities
of lives and hence seem as burden to them. They even try to reduce their water intake for getting
the chance if issuing this procedure less. Moreover, urinary tract infections are also found to be
quite common among the people using this mode of catheterization. Many of them have stated
that development of such infections due to use of catheters often acted as burden to lifestyle,
working as well as social life mainly within those who experienced them more than one month
(Purvis et al. 2017). This paper is therefore very useful to the nursing professionals to understand
about the feelings and perceptions about the patients suffering from long term bladder problems
and using clean intermittent self-catheterization. Another important aspect of this study was the

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LITERATURE REVIEW
positive perception of the people in using low dose antibiotics in management of their tract
infections. However, such low dose antibiotics were only taken after the recommendation of
healthcare professionals and decision were taken based on three factors. These were utility,
gravity of need and perceived efficacy.
Clayton (2017) had discussed some of the important information that the nursing
professional need to keep in mind for the effective prevention of CAUTI. Prevention of CAUTI
mainly begins with the avoiding of the nursing professionals in the unnecessary use of catheters.
Policies need to be developed for the insertion as well as the maintenance of the catheters along
with the proper election of the appropriate catheter, instituting surveillance of CAUTI and even
catheter use. The researchers are of the opinion that implementation of the facility wide CAUTI
protocol not only results in the reduction of the incidence of CAUTI (Teal et al. 2017). This
protocol can help in the improvement of the plan of care for the patients by ensuring that the care
can successfully meet different established criteria for the insertion of the catheters along with
adherence to standardized catheter guidelines along with prompt early removal of the catheters.
Protocols would also help the nursing professionals in improvement of the documentation of
dates of catheter insertion as well as removal, type of catheter, reason for insertion and even
justification of necessary. Every nursing professionals need to develop good knowledge about
every aspect of the CAUTI protocols successfully so that they can prevent the disorders
successfully.
Study conducted by Meddings et al. (2014) had supported the previous study and their
findings were much similar to that of the study conducted by Clayton. The study conducted by
them had provided various important interventions regarding reduction of the chances of the
occurrence of CAUTI. One of them is the proper use of the reminder system for removing the

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LITERATURE REVIEW
catheters at the right time (Mody et al. 2016). The other one is the unnecessary use of catheters
like in cases where it can be avoided thereby stopping such orders of insertion of catheters. Some
of the other CAUTI prevention strategies that can be well used for the reduction of the
prevalence is the aseptic insertion along with effective catheter maintenance. Many of the other
strategies are the use of the antimicrobial urinary catheters and even effective application of the
bladder bundle implementation.
Hutton et al. (2018) had published an important article that focused on the economic
evaluation of the implementation of CAUTI prevention programs in the nursing homes. This
paper is selected as it has a randomized control trial that provide level 2 evidence to readers
regarding the reliability as well as applicability of the information. The program that was
implemented was a 3 year targeted infection prevention multimodal program called the TIP
(Pashnik et al. 2017). The interventions that included in the program were mainly a structured
interactive educational program for the NH staff along with hand hygiene promotion, preemptive
barriers precautions for the CAUTI along with the infection preventionist supporting monthly
data feedback. The outcomes were then economically evaluated. The authors are of the opinion
that a 120 bed healthcare center would have around a program costs of $20279 in each year
(Richards et al. 2017). This would help in reducing the cost of the treatment of CAUTI by
$54,316 per year. This would result in a net cost savings of $34,037. The most of the savings as
found by the authors would come directly from the reduced number of hospitalization due to
CAUTI for about $39180 along with the savings of 15136 from CAUTI care within the
healthcare center. Even the authors had shown that this program would result in gaining of about
0.197 quality-adjusted life-years (QALYs). The best part of the study was that the authors were
the first to conduct an economic analysis and thereby developed a program that can be helpful

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LITERATURE REVIEW
for the trainers to train nurses and develop their knowledge and skills over the prevention of
CAUTI.
Another very interesting article depicting an innovative concept for the prevention of
CAUTI by the nurses had been found. Kathleen et al. (2018) had been innovative in a way, as
she had introduced technological perspective for the first time to help nurses become more
competent in their services towards patients and prevention of CAUTI. The initial stage of the
experiment included nurse champions to first evaluate evidence based catheter associated urinary
tract infection prevention practices with the help of the manual and paper-based feedback. This
process helped in the reduction of the rates of CAUTI in the hospitals over about 18 months.
However, the main issues with the program was that it was resource intensive (Mody et al.
2015). Following this, the cloud based software technology was also introduced for replacement
of the paper. After the new intervention was introduced, four important components were
selected which were satisfaction of the nurse champion, indwelling urinary catheter utilization,
catheter associated urinary tract infection and also prevention practices and then they were
compared with before and after the technology intervention (Brown, 2017). Nurse Champion’s
satisfaction rate was higher with the cloud-based technology and indwelling urinary catheter
utilization rate was lower for the later intervention. However, no considerable changes in the
rates of catheter-associated urinary tract infection rates were found. This is one of the best
articles as it had successfully applied the innovative concept of cloud-based technology
overcoming the traditional system of controlling CAUTI. It provided one of the most innovative
ways by which they can control the CAUTI in hospitals. Reduction in the utilization of the
catheters would help in reducing the prevalence of CAUTI successfully.

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LITERATURE REVIEW
Another important article authored by Saint et al. (2016) had focused on the different
technical and the socio-adaptive factors that the nurses need to consider for the prevention of the
catheter-associated urinary tract infection of CAUTI. Some of the technical factors that were
involved in the prevention program are the appropriate catheter utilization, proper asceptic
insertion as well as proper maintenance of the catheters (Mody et al. 2016). The other socio-
adaptive factors are the cultural as well as behavioral changes in the hospital units. The
researchers wanted to examine whether these factors can help nurses in developing their
efficiency in the prevention of the CAUTI. A positive outcome had resulted which showed that
these factors should be implemented. In both adjusted and non-adjusted cases, the rate of CAUTI
had decreased in the non-ICU departments along with the decrease of the catheter use in the
same departments. Therefore, such factors need to be implanted by the nursing managers or the
higher authorities of the hospital to help the nurses in developing their efficiency and thereby
reducing CAUTI rates (McCoy et al. 2017). However, the factors could not help in preventing
the rates of CAUTI in ICU departments and hence more researches need to be done on this
aspect to find out the gap that prevented successful results of the interventions in the ICU
departments.
One of the paper developed by Carter et al. (2015) had focused on the perception of the
emergency nurses about the issues rising due to CAUTI and the ways they believe to be effective
in managing the infection successfully. The authors had conducted interviews of about 102
participants and had coded the interview dialects to find out emerging themes. They were of the
opinion that they felt some form of ownership regarding urinary catheters, as they are individuals
who initiated most of the urinary catheters. They also believed themselves to be responsible for
the catheter placements and the care. It was also stated by the nurses that the they do have the

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LITERATURE REVIEW
opportunities for minimization of the catheter use along with ensuring of proper insertion
techniques and thereby maintain catheters post insertion. For minimization of the catheter
use, the nurses affixed different types of indications for urinary catheter to insertion kits,
questioned urinary catheter orders to recheck the appropriateness of the orders and thereby
champion the use of the alternatives like that of unisex urinals and many others (Kuriachan et al.
2017). For the improvement of the aseptic techniques during the placement of the catheter,
nurses have developed their own protocols for improvement of the perineal care. They also
promoted after implementing the two-person techniques of insertion in their practices. Here, the
helper provided technical assistance that allowed the different primary operators on focusing of
sterility. For effective maintenance of the catheters post insertion, nurses believed in
collaborating with different supply personnel for fastening urinary catheter hooks onto the
mobile equipments (Fletcher et al. 2016). This mainly helped in the prevention of the backflow
of the urine inside the urinary catheter drainage systems. Therefore, this paper was unique in the
way that it showed that CAUTI prevention efforts can be largely nurse-driven and the
interventions are mainly nurse –centric. Therefore, responsible nurses cannot blame the
authorities but can change their own working procedures and develop skills to become more
efficient (Daviset al. 2016).
Another important paper by Carter et al. (2016) had discussed about the contribution of
the nurse leaders and their actions facilitating the active involvement of the clinical nurses in the
emergency department during the CAUTI prevention program. This paper had shown that there
are certain important areas where nurse leaders play vital roles. Firstly, they can help the clinical
nurses by reframing urinary catheters as a source that might result in potential harms. Secondly,
they can also empower the clinical nurses in empowering the clinical nurses for proper

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identification as well as addressing of the CAUTI improvement opportunities. Thirdly, they can
also help in fostering a culture of teamwork that will facilitate interdisciplinary communication
based on the urinary catheter appropriateness and alternatives. Fourth, leaders should also hold
the clinical nurses accountable for the different CAUTI procedures as well as help in outcome
measures. The table given below summarizes the findings from the 10 articles incorporated in
the literature review:
# Studies included Country
of
publicatio
n
Study aims Design:
Sample:
Data collection:
Analysis
methods:
Key findings
1 Carter, E.J., Pallin, D.J.,
Mandel, L., Sinnette, C. and
Schuur, J.D., 2016.
Emergency department
catheter-associated urinary
tract infection prevention:
multisite qualitative study of
perceived risks and
implemented
strategies. infection control
& hospital
epidemiology, 37(2), pp.156-
162.
United
Kingdom
To
determine
the
perceived
risk and
motivations
for
acquisition
of CAUTI
and the
different
strategies
that are used
for
addressing
these risks
among
emergency
Design: The trial
was a qualitative
comparative
study
Sample: Early
adopting
emergency
department
those that were
using criteria for
placement of
urinary catheters
and track
catheter
frequency
placed in the
departments
Early
adopting
emergency
departments
were found to
redesign their
workflow to
reduce use of
catheter and
also in
accurate
insertion
technique.

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LITERATURE REVIEW
# Studies included Country
of
publicatio
n
Study aims Design:
Sample:
Data collection:
Analysis
methods:
Key findings
department
which have
had CAUTI
prevention
programs
were selected.
Data collection:
the qualitative
data collection
involved
conduction of 9
focus groups
and 52 semi-
structured
interviews amid
emergency
department and
hospital
participants
Data
analysis: respons
es from the
interviews and
focus groups
were
comprehensivel
y analysed in
order to identify
repeated patterns
of information
or themes from

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LITERATURE REVIEW
# Studies included Country
of
publicatio
n
Study aims Design:
Sample:
Data collection:
Analysis
methods:
Key findings
where
conclusions
could be drawn
2 Carter, E.J., Sinnette, C.,
Mandel, L. and Schuur, J.,
2015, December. Emergency
department catheter-
associated urinary tract
infection prevention: role of
the clinical nurse. In Open
Forum Infectious
Diseases (Vol. 2, No.
suppl_1). Oxford University
Press.
United
Kingdom
To describe
the role of
emergency
department
nurses in
prevention
of CAUTI
Design- it was a
qualitative study
conducted
nationwide
Sample-
following
screening of 400
emergency
departments
through national
publicity and
service, 6
emergency
departments
were selected
for the study
Data collection-
52 semi
structured
interviews and 9
focus groups
were conducted
Nurses
reported a
sense of
ownership
for placement
of urinary
catheters and
its
maintenance.
They
developed
protocols for
improving
perineal care
and also used
insertion
practice,
besides
collaborating
with the
supply
personnel for

17
LITERATURE REVIEW
# Studies included Country
of
publicatio
n
Study aims Design:
Sample:
Data collection:
Analysis
methods:
Key findings
among 102
doctors infection
control staff and
nurses
Data analysis-
the responses
were recorded
and transcribed
verbatim,
followed by use
of NVivo9
preventing
urine
backflow
3 Clayton, J.L., 2017.
Indwelling Urinary
Catheters: A Pathway to
Health Care‐Associated
Infections. AORN
journal, 105(5), pp.446-452.
United
Kingdom
To discuss
the causes
and
prevention
strategies for
CAUTI
Design-
Literature
review
Sample- 33
articles
Data collection-
assortment of
information
from 33 articles
in addition to a
case study
Data analysis-
categorising the
information into
Finding- the
prolong The
effects of
CAUTI are
costly, and
increase the
length of
hospitalizatio
n and result
in sepsis and
death.
Guidelines
established
by CDC must

18
LITERATURE REVIEW
# Studies included Country
of
publicatio
n
Study aims Design:
Sample:
Data collection:
Analysis
methods:
Key findings
different
headings and
subheadings like
placement
indications,
maintenance and
prevention
strategies
be followed
for
preventing
the infection
4 Hutton, D.W., Krein, S.L.,
Saint, S., Graves, N., Kolli,
A., Lynem, R. and Mody, L.,
2018. Economic Evaluation
of a Catheter‐Associated
Urinary Tract Infection
Prevention Program in
Nursing Homes. Journal of
the American Geriatrics
Society, 66(4), pp.742-747.
United
Kingdom
To
determine
the
economic
impact and
cost
effectiveness
of targeted
CAUTI
prevention
programs
and nursing
homes
Design-
randomised
clinical trial
Sample- 418
nursing home
residents with
indwelling
urinary catheter
Data collection-
staff education,
barrier
precautions and
active
surveillance
Data analysis-
measuring cost
of intervention,
The
prevention
program
provides
benefit to the
payers, by
lowering
costs and
enhancing
health
outcome.

19
LITERATURE REVIEW
# Studies included Country
of
publicatio
n
Study aims Design:
Sample:
Data collection:
Analysis
methods:
Key findings
disease, health
outcomes, and
cost-
effectiveness
ratio
5 McClurg, D., Walker, K.,
Pickard, R., Hilton, P.,
Ainsworth, H., Leonard, K.,
Suresh, S., Nilsson, A. and
Gillespie, N., 2018.
Participant experiences of
clean intermittent self-
catheterisation, urinary tract
infections and antibiotic use
on the ANTIC trial–A
qualitative
study. International journal
of nursing studies, 81, pp.1-
7.
United
Kingdom
To assess
experiences
and views of
adults using
clean self
catheterizati
on for
prolonged
bladder
disorder
Design-
qualitative
descriptive study
Sample- 26
individuals
recruited from
ANTIC trial
from Aug 2015-
Jan 2016
Data collection-
26 semi
structured
interview
Data analysis-
verbatim
transcription of
responses
followed by
thematic
analysis
Three
identified
themes were,
(i) attitudes
of patients
towards
antibiotics
for treatment,
(ii)
experiences
of using
prophylaxis
antibiotics,
and (iii)
experiences
of urinary
tract
infection.
Perceived
efficacy,

20
LITERATURE REVIEW
# Studies included Country
of
publicatio
n
Study aims Design:
Sample:
Data collection:
Analysis
methods:
Key findings
severity of
the
requirement
and utility,
controlled the
beliefs
pertaining to
the condition
6 Meddings, J., Rogers, M.A.,
Krein, S.L., Fakih, M.G.,
Olmsted, R.N. and Saint, S.,
2014. Reducing unnecessary
urinary catheter use and
other strategies to prevent
catheter-associated urinary
tract infection: an integrative
review. BMJ Qualsaf, 23(4),
pp.277-289.
United
Kingdom
To
summarise
the strategies
that help in
reducing use
of catheters
sent CAUTI
Design-
narrative review
Sample- 30
scholarly articles
Data collection-
information
updated from
previous
systematic
review
conducted in
2012
Data analysis-
meta analysis
Rate of
CAUTI was
found
reduced by
53% with the
use of stop
order or
reminder.
SMD in
duration of
catheterisatio
n was -1.06
overall. No
significant
damage
noted from
the removal
strategies.

21
LITERATURE REVIEW
# Studies included Country
of
publicatio
n
Study aims Design:
Sample:
Data collection:
Analysis
methods:
Key findings
7 OConnell, K., Neale, R.,
Oliver, L., Quirk, D.,
WIlcox, V., Donilon, D.,
Uustal, K., Bird, B. and
Insana, C., 2017. Our
Journey to Zero Catheter-
Associated Urinary Tract
Infections through a
Multidisciplinary
Approach. American
Journal of Infection
Control, 45(6), p.S107.
United
Kingdom
To assess
the hospital
wide
prevalence
of use of
urinary
catheters and
subsequent
rates of
CAUTI
Design-
experimental
study
Sample-
multidisciplinar
y task force
Data collection-
review of
literature and
guidelines
Data analysis-
monitoring
CAUTI rate,
adherence to
prevention
guidelines, and
catheter use
CAUTI rates
reduced from
2.8 to
1.2/1000
days.
Standard
infection
ratio
demonstrated
37%
reduction.
8 Pickard, R., Lam, T.,
MacLennan, G., Starr, K.,
Kilonzo, M., McPherson, G.,
Gillies, K., McDonald, A.,
Walton, K., Buckley, B. and
Glazener, C., 2012.
Antimicrobial catheters for
United
Kingdom
To
determine
the role of
short term
use of
antimicrobia
l catheters
Design-
multicenter
randomised
control trial
Sample- 6394
participants
Data collection-
Catheter
discomfort
was greater
in nitrofural
group. Silver
alloy coated
catheters

22
LITERATURE REVIEW
# Studies included Country
of
publicatio
n
Study aims Design:
Sample:
Data collection:
Analysis
methods:
Key findings
reduction of symptomatic
urinary tract infection in
adults requiring short-term
catheterisation in hospital: a
multicentrerandomised
controlled trial. The
lancet, 380(9857), pp.1927-
1935.
on lowering
CAUTI
risks, in
comparison
to PTFE
catheterizati
on
random
allocation in
1:1:1 basis,
followed by use
of patient
reported
questionnaires
Data analysis-
incidence of
CAUTI
were less
effective in
lowering
CAUTI
incidence
rate. In
comparison
to 271
(12·6%) of
2144
participants
allocated to
the control
group, 263
(12·5%) of
2097
participants
from the
silver alloy
catheter
group
reported
primary
outcome
(difference
−0·1% [95%

23
LITERATURE REVIEW
# Studies included Country
of
publicatio
n
Study aims Design:
Sample:
Data collection:
Analysis
methods:
Key findings
CI −2·4 to
2·2]); 228
(10·6%) of
2153
participants
of nitrofural
catheter
group also
reported the
same (−2·1%
[−4·2 to
0·1]).
9 Saint, S., Greene, M.T.,
Krein, S.L., Rogers, M.A.,
Ratz, D., Fowler, K.E.,
Edson, B.S., Watson, S.R.,
Meyer-Lucas, B., Masuga,
M. and Faulkner, K., 2016.
A program to prevent
catheter-associated urinary
tract infection in acute
care. New England Journal
of Medicine, 374(22),
pp.2111-2119.
United
Kingdom
To formulate
a program
that helps in
preventing
CAUTI in
acute care
settings
Design-
experimental
study
Sample- 603
hospitals located
across 32 States
Data collection-
data use of
catheters and
rates of CAUTI
during baseline,
implementation,
and
sustainability
Reduction in
u-adjusted
CAUTI rates
from 2.82-
2.19
infections/10
00 days.
Reduction in
CAUTI rates
from 2.40-
2.05/1000
days. Use of
catheters also
decreased to

24
LITERATURE REVIEW
# Studies included Country
of
publicatio
n
Study aims Design:
Sample:
Data collection:
Analysis
methods:
Key findings
period
Data analysis-
Use of
multilevel
negative
binomial model
18.8% from
20.1% among
non ICU
patients. No
significant
difference
observed in
ICU.
1
0
Singha, P., Locklin, J. and
Handa, H., 2017. A review
of the recent advances in
antimicrobial coatings for
urinary
catheters. Actabiomaterialia,
50, pp.20-40.
United
Kingdom
To collect
evidences on
the recent
progress that
has been
made in
relation to
use of
antimicrobia
l coatings in
urinary
catheters
Design-
narrative review
Sample- 150
scholarly articles
Data collection-
collection of
evidences from
the articles
Data analysis-
critical appraisal
Findings-
Foley
catheters are
considered
uncomfortabl
e for the
patient.
Nelatone
catheters
have proved
effective in
the process.
Silver alloy
catheters
have less
microbial
efficiency,
when

25
LITERATURE REVIEW
# Studies included Country
of
publicatio
n
Study aims Design:
Sample:
Data collection:
Analysis
methods:
Key findings
compared to
antibiotics
Summary table of articles reviewed and included in the literature review
Discussion:
The above portion of the literature review can be seen to discuss different important
aspects for the effective prevention of CAUTI that can make nurses more effective and develop
their skills and knowledge accordingly. For a long period, healthcare organizations have argued
on the fact antimicrobial catheters provides better protection than that of the standard catheters
(Roney et al. 2017). However, nurses need to search for more evidences on this aspect to find out
the reliability of the information and then introduce it to their own practices. One of the papers
analyzed in this paper had stated that the antimicrobial materials used in the catheters did not
result in comparable effective outcomes (Brown et al. 2016). Therefore, nurses need to be more
accountable on the decisions of the type of catheters they use and hence they need to undertake
more evidence based searches to find out the correct information and then decide on the catheter
type that needs to be used. This would help in developing the efficiency of their practices and
help in controlling the rates of CAUTI.
A number of important criteria need to be kept in mind by the nurses in order to reduce
the rates of CAUTI and thereby increase the efficiency of the care they provide to patients.One

26
LITERATURE REVIEW
of the most important aspects that had emerged out from the critical review of the different
papers is that use of the catheter should be reduced in case of different patients wherever
possible to reduce the suffering of the patient due to the pain resulting from CAUTI (Mody et al.
2015). Moreover, effective maintenance of the catheter post insertion is also not done in proper
manners by many of the nurses and hence chance of CAUTI increases. Therefore, nurses need to
develop their efficiency in this aspect as well. Another important arena where the nurses need to
be extra careful is during the time of insertion and during the time of taking it out from the
patient (Barry et al. 2017). These moments are highly vulnerable for the entry of microbes and
hence nurse needs to be highly skillful and swift during this time.
Often development of important CAUTI prevention training sessions is important by
which nurses might be made aware about the ways they can enhance their abilities and skills for
preventing CAUTI successfully. Many of the papers had focused on the use of different
evidence based studies for developing their knowledge on the topic of prevention (Carter et al.
2016). However, one paper had focused on the utilization of the cloud-based technology for
developing knowledge on the prevention of CAUTI and this has been seen to save more time for
the nurses than the evidence-based papers in a manual procedure. Therefore, the hospital
authority can arrange for this procedure for developing efficiency of the nurses (Campbell,
2016).
Moreover, many of the studies have proposed of different strategies that can be adopted
by the nurses to develop their skills as well as their knowledge. Firstly, they should undertake
daily assessment of the presence of and need for an indwelling urinary catheter (Trautner et al.
2017). Secondly, another way is avoiding the use of the indwelling urinary catheter by
considering the alternative urine collective methods.Third, the nurses also need to emphasize the

27
LITERATURE REVIEW
importance of the different aseptic techniques during the catheter insertion as well as proper
maintenance after insertion. Many of the others studies also provide many other strategies like
nurse leaders providing feedback to the clinical nurses regarding the urinary catheter use as well
as the CAUTI rates and help them develop their skills (McNeil, 2017). They can also help in
addressing the identified gaps in the nurses regarding the knowledge of the urinary management
procedures that would help nurses to develop their skills.
Implications in nursing and limitations to application in practice:
It has been found that huge number of strategies had been proposed by different studies
regarding the ways by which nurses can develop their efficiency and bridge their knowledge gap.
All the above-mentioned strategies can help nurses to become not only knowledgeable and
skillful but also make them self-sufficient and responsible for prevention of CAUTI. When the
above-mentioned strategies would be implemented, the rates of CAUTI would reduce and it
would ultimately help in excessive expenditure of the healthcare resources that could be used in
some other critical healthcare issues successfully (Carter et al. 2016). Moreover, reduction of
rates of CAUTI can also lessen the chances of pain and sufferings of the patient and accordingly
they would not suffer from depression and anxiety. Nurses will be able to provide safe and
quality care that would enhance the patient satisfaction (Peter et al. 2018). One of the most
important limitationsis that application of so many training programs, CAUTI prevention
programs, changing of the infrastructures and many others would require huge allocation of
healthcare funds that might not be possible for the healthcare centers (Carr et al. 2017). Many of
the centers have tight budgets and hence allocating friends for them might become a big barrier.
One of the strategies like the application of evidence-based studies are also quite time consuming

28
LITERATURE REVIEW
and can impact care (Hernandez, 2016). All such limitations need to be managed in order to
successfully develop skills of nurses in managing CAUTI.
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Implementing a Two Person Insertion Technique and Indwelling Urinary Catheter Insertion
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Journal of Infection Control, 45(6), p.S60.
Brown, D.E., Eguia, S., Rodriguez, C., Conde, D., Josue, A.M., Kopecky, C., Kuriachan, V. and
Zimmerman, C., 2016. Implementing Cauti Prevention Bundle in the PACU. Journal of
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Brown, H., 2017. Reducing Catheter-Associated Urinary Tract Infections Through Evidence-
Based Practice.
Campbell, S., 2016. Preventing Catheter-Associated Urinary Tract Infections in Medical-
Surgical/Telemetry Units: Five Units, Five Cultures, One Goal.
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310.

29
LITERATURE REVIEW
Carter, E.J., Pallin, D.J., Mandel, L., Sinnette, C. and Schuur, J.D., 2016. A qualitative study of factors
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Davis, T.E. and Knowlden, M., 2016. Let's Talk About That Foley: Engaging Staff to Reduce
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Hernandez, M.A., 2016. Impact of a catheter-associated urinary tract infection (CAUTI) education
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LITERATURE REVIEW
Krein, S.L., Harrod, M., Collier, S., Davis, K.K., Rolle, A.J., Fowler, K.E. and Mody, L., 2017.
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Kuriachan, V., Eguia, S., Brown, D.E., Rodriguez, C., Conde, D., Josue, A.M., Kopecky, C.,
Carroll, B., Zimmerman, C. and Galicia, A., 2017. Sustaining a CAUTI Prevention
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31
LITERATURE REVIEW
Mody, L., Greene, M.T., Meddings, J., Krein, S., Trautner, B.W., Mcnamara, S., Ratz, D., Stone,
N.D., Schweon, S.J., Rolle, A.J. and Olmsted, R., 2016, December. Preventing catheter-
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Mody, L., Greene, M.T., Saint, S., Meddings, J., Trautner, B.W., Wald, H.L., Crnich, C.,
Banaszak-Holl, J., McNamara, S.E. and King, B.J., 2016. Comparing catheter-associated urinary
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Mody, L., Krein, S.L., Saint, S., Min, L.C., Montoya, A., Lansing, B., McNamara, S.E., Symons,
K., Fisch, J., Koo, E. and Rye, R.A., 2015. A targeted infection prevention intervention in
nursing home residents with indwelling devices: a randomized clinical trial. JAMA internal
medicine, 175(5), pp.714-723.
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and Saint, S., 2015. Enhancing resident safety by preventing healthcare-associated infection: a
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OConnell, K., Neale, R., Oliver, L., Quirk, D., WIlcox, V., Donilon, D., Uustal, K., Bird, B. and
Insana, C., 2017. Our Journey to Zero Catheter-Associated Urinary Tract Infections through a
Multidisciplinary Approach. American Journal of Infection Control, 45(6), p.S107.
Parienti, J.J., Mongardon, N., Mégarbane, B., Mira, J.P., Kalfon, P., Gros, A., Marqué, S.,
Thuong, M., Pottier, V., Ramakers, M. and Savary, B., 2015. Intravascular complications of

32
LITERATURE REVIEW
central venous catheterization by insertion site. New England Journal of Medicine, 373(13),
pp.1220-1229.
Pashnik, B., Creta, A. and Alberti, L., 2017. Effectiveness of a nurse-led initiative, peer-to-peer
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Walton, K., Buckley, B. and Glazener, C., 2012. Antimicrobial catheters for reduction of symptomatic
urinary tract infection in adults requiring short-term catheterisation in hospital: a multicentre randomised
controlled trial. The lancet, 380(9857), pp.1927-1935.
Purvis, S., Kennedy, G.D., Knobloch, M.J., Marver, A., Marx, J., Rees, S., Safdar, N. and
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33
LITERATURE REVIEW
Richards, B., Sebastian, B., Sullivan, H., Reyes, R., D’Agostino, J.F. and Hagerty, T., 2017.
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Saint, S., Greene, M.T., Krein, S.L., Rogers, M.A., Ratz, D., Fowler, K.E., Edson, B.S., Watson, S.R.,
Meyer-Lucas, B., Masuga, M. and Faulkner, K., 2016. A program to prevent catheter-associated urinary
tract infection in acute care. New England Journal of Medicine, 374(22), pp.2111-2119.
Singha, P., Locklin, J. and Handa, H., 2017. A review of the recent advances in antimicrobial coatings for
urinary catheters. Acta biomaterialia, 50, pp.20-40.

34
LITERATURE REVIEW
Teal, L., Sickbert-Bennett, E., Wolak, E. and Hedges, C., 2017. Fueling Dramatic Reductions in
Catheter-Associated Urinary Tract Infections with Actionable Compliance Metrics. American
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