Catheter-Associated Urinary Tract Infection: A Literature Review

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LITERATURE REVIEW
Literature review is the process of gathering information and data from different
authentic and reliable sources to be able to meet the set criteria for the search. The
main purpose of a literature review is to examine, gather, evaluate and inform the
issue that is being studied (Aveyard, 2014). It is a tool for secondary research that
helps in proper assimilation of data and evaluation as per the purpose. Literature
review has its reliability and validity set by means of a good critical appraisal tool
used. Here Caldwell (2005) critical appraisal framework is used because it enables
to critically evaluate the primary research based on the methods used and
examination of qualitative and quantitative data.
This review presents the evaluation and summarization of ten studies from which
half have been conducted using qualitative design of research and other five used
the quantitative or numerical evaluation method of research. As per Ostlud (2010)
the use of both qualitative and quantitative designs for development of the research
in nursing and social sciences is common as it helps the researcher to draw the
results and provide recommendations on the basis of data and figures extracted.
Ethics in research play a major role in determining the authenticity and reliability of
the research as the ethical considerations in any primary research has to be well
maintained and followed to develop the study with plausible evidence. Ethical
consent from the participants is must in primary studies and was sought in majority
of the studies reviewed in here. One of the studies was devoid of clause or obligation
to achieve ethical compliance and others did not have any ethical breach followed.
As the aim of ethical consent is to safeguard the rights, dignity and respect of the
participants and secure the health and wellbeing by pre information of the study and
singed consent off voluntary participation.
Catheters are the common device used in health and social care to support the
natural phenomenon of the patient while on rest or under bed care. Various
professionals has argued over the fact that antimicrobial catheter use is more
advisable and safe over the standard polytetra fluoroethylene catheterization. May of
the nursing researchers believe that use of antimicrobial catheter helps in obstructing
the development of any catheter associated UTI, not much of the evidence till date

suggest that antimicrobial catheter can be used as the gold standards practice to
prevent CAUTI. A study conducted by Pickard et al (2012), “Antimicrobial catheters
for reduction of symptomatic urinary tract infection in adults requiring short-term
catheterisation in hospital: a multicentre randomised controlled trial” aimed at
discussing and experimenting the effect of anti-microbial catheter for reduction of
symptomatic urinary tract infection. The authors indicated how the CAUTI is the
major preventable harm to patients in the hospital settings. The study used a three
group parallel randomized control trial where the adults more than 16 years of age
were recruited who required short term that is less than 14 days catheterization in 24
hospitals and the UK. The participants were recruited and sorted by random
sampling by computer aids with ration of 1:1:1 where they were eligible to receive an
alloy silver coated catheter, nitrofural impregnated catheter and PTFE catheter. The
ethical consents from these participants were achieved retrospectively. The staff and
patients were unmasked for the trail and the data was collected by the staff and
questionnaire from the patient after 6 weeks. From total number of 7120 randomly
allocated patient 708 were not catheterized due to some consent issues. The
primary outcome was incidence of UTI due to catheterization. The 263 from 2097
participants from the control group of with silver alloy catheter showed primary
outcomes and 228 in nitroflural group overall rate of UTI in nitrofural group were
higher than other groups. The trial was inadmissible of the fact that the antimicrobial
catheter use helped in reduction of CAUTI. The geographic restriction of the study
disables the generalizability of the findings. The other limitations include the erosion
of the sample and self-reporting that may incorporate bias. One of the strong points
of this study is comparative design of using different catheters that helped knowing
the efficacy of each.
Saint et al (2016), conducted a study “A program to prevent catheter-associated
urinary tract infection in acute care” in Columbia, and Puerto Rico with the main aim
to reduce rates of the UTI catheter associated infection. The authors suggested that
the cathether associated UTI are the common device associated infection and hs a
rising prevalence in hspital based patient care. Some factors such as infection
control, appropriate cathether use, socio economic status and culture, technical
factorrs and behaviour are respnsible for the prevalence and prveention of this
infection. The study used national Comprehensive Unit based SSafety Program to

gather that catheter associated UTI rates from 926 units from two regions and 603
hospitals where the units both ICU and no ICU in nature were involved. The results
of the study idetified that the UTI rates with cathether use decreased from 2.82 to
2.19 infections per 1000 cathether days. Also it was evident that the rate of
catherther use UTI were not reduced to much higher levels in ICU. The study
concluded how the prevention rogramme was successful in reducing the rates of UTI
in non ICU but not successful in reducing the rates in ICU. The study desing is
clearly identified and is qualitative in nature with an appropriate multi regional basis
and smple size. The sample is clearly described and is reflective enough of the
provided hypothesis. The data is collected through the hospital data is reliaable and
valid source used here. Also the study provides a well stuctured concept and
appropriate discussion and conclusion on basis of the data analysis. Some
limitations of the study are identified that includes the design of the study is not
randomized trial and so the confounding variables will hamper the fidnings, the
participation to the programme was voluntary and the findings cannot be
generalized, incomplete data collection was identified in quality imporvement
projects, also the hospital units were allowed to tailor the ways that they used to
implement the interventions.
Another beneficial study by McClurg et al (2018), “Participant experiences of clean
intermittent self-catheterisation, urinary tract infections and antibiotic use on the
ANTIC trial–A qualitative study” aimed at conduction of the research that is a
descriptive qualitative study using 26 semi structured interviews of individuals
recruited from ANTIC trial from the UK. The participants of the study were
intermittent self-catheter user of 18 years and above age. Interviews of self-
experiences took place with these recruits. The study was motivated from the
background that the UTI due to catheterization is a common issue faced by the
individual using intermittent self-catheterization. This study identified gap in literature
showing the lack of knowledge, use, antibiotic use and experiences of people and
impact on their lives. The data was collected and thematically analysed and specific
themes emerged including the experiences of thee self-catheterization as
(normalization or perceived burden), attitude toward antibiotics for UTI (ambivalence
attitude, nonchalant attitude) and experiences of low dose prophylaxis antibiotics
(habitual behaviour and supportive accountability). The study concluded that the

burden of catheter use was significant on the participants and their behaviour and
knowledge regarding antibiotic use for UTI was as per the need and purpose.
Certain aspects the study limits ad is identified as the interviewing of specific sample
that had views regarding this antibiotic use but the findings cannot be used
universally. The study included only the participants that included self-use of
intermittent clean catheter developing repeated UTI and their perceptions may differ
from the people not getting UTI with the use. Narrow sampling framework was used
that hamper the quality of evidence. The research provides some basic and
fundamentally effective evidences for the nursing professionals to review that helps
in understanding the psychological impact of the CAUTI on the patient.
Dawson, Gallo and Prevc (2016) in their study “TWOC around the clock: a
multimodal approach to improving catheter care” highlighted that urinary tract
infection are the second largest group of heath care associated infections in world.
The study aimed at examining the effectiveness of the Saving Lives Urinary Catheter
Care Bundle to reduce catheter associated urinary tract infections in a NHS trust
hospital. The study used four basic interventions and aids to examine the
improvement in catheter care. These four domains include catheter care pathways,
HOUDINI checklist, catheter magnets and use of bladder ultrasound scanners. The
multimodal approach was utilized as this work is based on quality improvement and
care initiative it did not require any ethical consent or approval from the patient the
NHS trust of over 1 million in patient base was chosen for this and the program was
run from 2014 to 2015. The four interventions and evaluation pathways were
implemented that resulted in identification of reduce rate of CAUTI in the hospital
from 2012 to 2013 and 2014 to 2015 from 3.5% to 2.3%. The tools of the prevention
and reduction were identified as education, measurement, feedback and provision
standards. The multimodal method ensured that the reduction in CAUTI prevalence
can be achieved by using different measuring and improvement tools. The study did
not provide an appropriate sample size or reflexivity to the topic by the presentation
of the sample. The findings are constricted to specific region and cannot be
generalized universally.
Hutton et al (2018), conducted the study “Economic Evaluation of a Catheter
‐
Associated Urinary Tract Infection Prevention Program in Nursing Homes” with the
objective of assessing the economic effects and cost effectiveness of a targeted

catheter associated urinary tract infection prevention interventions in the nursing
setting. The study used a randomized control trial that is effective and appropriate
design to conduct a comparative study. The 12 community based NHS centres were
chosen for the study, including 418 participants from the centres. The intervention
that was examined in the study included standard care versus infection prevention
program involving barrier precautions, NH staff education and surveillance. The
measurement of the following was done by determining the cost of the intervention,
cost of the disease and health outcomes. The study took place for the span of 3 year
and analysed the data gathered and provides level II evidence. The results showed
that the average cost of the 120 bed NHS trust centre annually is around $54,316
that can be reduced to $34,037 and most of the cut off was determined from the
reduction in CAUTI hospitalization. The intervention also helped in achieving 0.197
quality adjusted life years. The overall result indicated that the intervention if 85%
cost saving. One of the limitations identified was the assumption of readings of the
participants that did not provide consent in the program. The intervention has also
underestimated the effect of CAUTI prevention in other ways and only focused on
financial aspects of cost effectiveness. The research is helpful in providing evidence
for training and skill building for the practitioners and health and social care
professionals.
Carter et al (2015), “Emergency department catheter-associated urinary tract
infection prevention: role of the clinical nurse. In Open Forum Infectious Diseases”
aimed at describing the role of an emergency department nurse in catheter
associated urinary tract infection prevention programs. The study stated that
emergency department is the major setting of urinary tract infection due to catheter
placement and the role of nurse in this setting is crucial to be studied. The method of
the study is qualitative cross sectional where 400 emergency departments were
identified and screened for nationwide survey. From these 6 emergency departments
were chosen where 52 semi structured interviews and 9 focus groups with 102
participants were involved. The data was gathered by audio recordings and
transcribed verbatim. The conventional content analysis was used by the authors of
the study. The results of the study indicated several themes that were related to
determining the role of the nurses in CAUTI prevention. The nurses reported they
owns the catheter program and prevention and plays role in its prevention and

storage. Protocols were developed for asepsis and infection control. It was hence
concluded that among early adopted ED the prevention program were derived by
nurses and ere nurse centric. The study had certain limitations that being the cross
sectional in nature the confounding variables were not identified well as well as
sample size being constricted to one geographical area and limited size had
disability to be generalized.
Another important and good quality evidence providing research by Carter et al
(2016), “Emergency department catheter-associated urinary tract infection
prevention: multisite qualitative study of perceived risks and implemented strategies”
that aimed at describing the knowledge, motivation, perceived risks and CAUTI
acquisition in emergency department. The study used qualitative comparative case
study method to conduct this research. The study used early adopted Emergency
department’s data and included 6 different emergency departments where 52 semi
structured interviews were conducted and 9 focus groups with the participants in the
ED. The program for CAUTI prevention was the chief centre in the research and was
believed to be beneficial for positive patient outcomes. The evaluation of the work
flow in the ED determined four potential factors that cause risk to the CAUTI
development that were 1 Inappropriate reason for urinary catheter placement, 2
Pattern of catheter overuse, 3 Limited involvement of physicians in placement
decisions and 4 Poor insertion techniques. The study identified need to develop
protocol to use and implement the catheter use in the ED and the following steps
were taken 1 staff is required to specify the reason and medical reason to use
catheter, 2 making physician responsible for determination of catheter use, 3 use
alternative for catheter and 4 use proper insertion techniques. The study maintained
strong methodological rigour throughout the course, also the systemic coding by 3
investigators enhances the quality. The study limits in the area that the CAUTI
prevention risk, and strategies lack generalizability because the sample contained
positive deviant.
Barbadoro et al (2015), aimed at conducting a study under the title “Catheter-
associated urinary tract infection: Role of the setting of catheter insertion” the study
had chief objective to describe the epidemiology of catheter associated urinary tract
infection in patients admitted to a surgical ward in the region in Central Italy. The
study used an active surveillance program for CAUTI examination in patient who was

catheterized for more than 48 hours. There were 641 patients catheterized and
monitor for the onset of any symptoms of CAUTI. Among the sample around 40
people caught CAUTI. It was also seen that the patients who were older and had
high frequency and duration of catheterization were affected more than those who
were not affected. The study concluded that hand hygiene; infection control and
aseptic measures were important determinants of onset of CAUTI examined through
insertion technique and process. The major limitation of these findings includes the
exclusion of possibility and examination of potential aspects that can be responsible
for the infection development or the comorbidities that could influence the risk of
infection. Also the cross sectional design has made the confounding variables limited
and has provided single sightedness for the research.
Parker et al (2017), stated that urinary tract infection are most common type of
health care associated infection that accounts for about 36% of the infections
associated due to devices and health care. Catheter associated urinary tract
infection accounts for up to 80% of the total health care associated UTI’s. The
evidence based practice is crucial element in every sector similarly in health and
social care. The main aim of the study is to examine how the education and
evidence based practice led by nursing staff leads to reduction in development of
CAUTI. The study used a multifaceted examination method and a novel design for
the research. The design of pre and post intervention control design was put up by
the authors to examine the success of the interventions. The design provides phased
approach that provides build in control mechanism. Feedbacks from the staff and the
service user will be achieved to ensure proper results. 500 participants were
recruited from the hospitals in Australia. The study resulted that the prevalence of
UTI due to catheter use can be cut down and reduced to provide reduced burden,
costs, hospitalization and education. The study had certain limitations that included
the generalizability of the findings and the inability of the study to provide universal
results.
Jain et al (2015), argued that the knowledge and understanding of the CUATI
prevention and development risk among the health care professionals is one of the
reason for increased cases of UTI due to catheter placements. This was claimed and
studied in their study “Knowledge and attitude of doctors and nurses regarding
indication for catheterization and prevention of catheter-associated urinary tract

infection in a tertiary care hospital”. The study used a prospective questionnaire
based quantitative research. A well-structured questionnaire with 41 items was
provided to the health care staff regarding examining their knowledge and
understanding for CAUTI and it prevention. The total number of recruits was 159
from which 54 doctors and 105 nurses were involved. Statistical correlation using
computer software was done for analysing the results. The results indicated that the
mean experience of the individual in the study was 6.8 years but only 57% of the
individual could respond appropriately to all the measures that prevent CAUTI. Also
it was found that the knowledge of better preventive measures for CAUTI among
doctors was better than among nurses but the major decisions of catheter placement
were done by the nurses. The results indicated that knowledge was suboptimal
among the staffs that highlight the requirement of the better education program for
prevention of CAUTI. The study limits in the area that the comparison of any
alternative method is not placed making the evidence better and more concrete also
the sample size was not adequate and the narrow sampling framework was used.

REFERENCES
 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.
 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 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.
 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.
 Dawson, C., Gallo, M. and Prevc, K. 2016. TWOC around the clock: a
multimodal approach to improving catheter care. Journal of Infection
Prevention, 18(2), pp.57-64.
 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.
 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.
 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.
 Barbadoro, P., Labricciosa, F.M., Recanatini, C., Gori, G., Tirabassi, F.,
Martini, E., Gioia, M.G., D'errico, M.M. and Prospero, E., 2015. Catheter-

associated urinary tract infection: Role of the setting of catheter
insertion. American Journal of infection control, 43(7), pp.707-710.
 Parker, V., Giles, M., Graham, L., Suthers, B., Watts, W., O’Brien, T. and
Searles, A., 2017. Avoiding inappropriate urinary catheter use and catheter-
associated urinary tract infection (CAUTI): a pre-post control intervention
study. BMC health services research, 17(1), p.314.
 Jain, M., Dogra, V., Mishra, B., Thakur, A. and Loomba, P.S., 2015.
Knowledge and attitude of doctors and nurses regarding indication for
catheterization and prevention of catheter-associated urinary tract infection in
a tertiary care hospital. Indian journal of critical care medicine: peer-reviewed,
official publication of Indian Society of Critical Care Medicine, 19(2), p.76.

Appendix 1
# Studies
included
Design Country
of
publicati
on
Sam
ple
size
Study aims 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. infecti
on control &
hospital
epidemiology, 3
7(2), pp.156-162.
Cross
sectional
qualitativ
e
America 154 The study
aimed at
describing the
role of an
emergency
department
nurse in
catheter
associated
urinary tract
infection
prevention
programs.
The results of
the study
indicated
several
themes that
were related
to determining
the role of the
nurses in
CAUTI
prevention.
The nurses
reported
they owns
the catheter
program
and
prevention
and plays
role in its
prevention
and
storage.
Protocols
were
developed
for asepsis
and
infection
control. It
was hence
concluded
that among
early
adopted ED
the

# Studies
included
Design Country
of
publicati
on
Sam
ple
size
Study aims Key
findings
prevention
program
were
derived by
nurses and
ere nurse
centric.
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.
Qualitativ
e
comparat
ive case
study
America 154 study aimed at
describing the
knowledge,
motivation,
perceived
risks and
CAUTI
acquisition in
emergency
department
The
evaluation
of the work
flow in the
ED
determined
four
potential
factors that
cause risk
to the
CAUTI
developme
nt that were
1
Inappropriat
e reason for
urinary
catheter
placement,
2 Pattern of
catheter
overuse, 3