The use of urinary catheters within the healthcare setting is a common practice designed to assist patients with the elimination of urine. The use of urinary catheters calls for nurses to utilize sterile techniques as a result of the significant risk for infection when inserting an instrument into the body. Although healthcare institutions have proper practices in place to address the real issue of urinary tract infections, there is still a strong need for better options to prevent the occurrence of UTIs. Karchmer et al (2000) points out that in the US that there is approximately 2 million hospital associated infections each year and out of that 900,000 infections are UTIs. Such a significant number of urinary tract infections is a major issue because urinary tract infections especially those occurring in developed countries leads to avoidable illnesses and sky-rocketing healthcare cost (Pickard et al, 2012). With the many challenges that UTIs present, it calls for the need for research intervention designed to reduce and ideally prevent the occurrence of UTIs all together.
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For this literature review, articles that focused on tackling the issue of urinary tract infections were selected. Whether or not the strategies explored in each article successfully reduced the occurrence of UTIs were irrelevant. The studies were found by using the QXMD application and google scholar search engine. The studies ultimately chosen were completed as far back as 30 years ago and all of the studies chosen were randomized control trials. This review aims to show how the nursing body of knowledge have grown over the years with regards to exploring the issue the of urinary tract infection, and identify methods/ strategies constructed to provide healthcare professional with improved ways of preventing UTIs.
Overview/ Assessment of Studies
In early studies completed over 30 years ago researchers explored the use of novel techniques in order to address the issue of urinary tract infections. Liedberg et al 1990 for instance explored the use of silver alloy coated on both the outer and inner surfaces of urinary catheters. This technique had not been implemented prior and serve to provide a new methodology that could be incorporated into clinical practice. The results from this study did show that by applying the silver alloy coating reduce the incidence of urinary tract infection (Liedberg et al, 2000). However, the study did not discuss whether or not the patients experience discomfort with use of this technique or address if the length of time of catheterization impacted the overall effectiveness of this technique.
A later study by Huth et al 1992 further explored the antimicrobial use of silver this time in the form of cream to determine whether this form of treatment could reduce or prevent catheter associated infections. The study specifically used silver sulfadiazine and unlike Liedberg et al 1990, the silver sulfadiazine was applied to the urethral meatus in order to explore its effectiveness in preventing catheter associated urinary tract infections (Huth et al, 1992). The study utilized a relatively large sample size consisting of over 696 patients. In this randomized controlled trial the researchers found that the use of silver sulfadiazine cream did not reduce or prevent the occurrence of the catheter associated urinary tract infections in the short term (Huth et al, 1992). The lack of success of the application of silver sulfadiazine to reduce the incidence of urinary tract infections as result of catheter usage helps to inform the healthcare field that this form of treatment should be avoided within the clinical setting. Additionally, Huth et al, 1992 points out that other sources that can cause infections such as antibiotics usages or a compromised immune system could be attributed to the occurrence of UTIs and also helps to shift some focus away from targeting just organisms present in or around the urethral meatus. Furthermore, the researcher’s decision not to specifically sample cultures from urinary bag limited their ability to specifically identify the source of bacteria (Huth et al, 1992).
Findings from these two studies provides valuable information that later studies can build upon and explore further and learn from as well. In Karchmer et al 2000, the studies explores the effectiveness of silver alloy hydrogel-coated latex catheters in reducing the incidence of urinary tract infections associated with catheter usage. The study utilized a sample size consisted of 27848 patients and out of that number 343 patients were infected with hospital associated urinary tract infections (Karchmer et al, 2000). Additionally, the large number patients available for this study allows for statistical significance to be observe within the findings. The findings from this study revealed that the use of silver alloy hydrogel coated latex catheters significantly reduce the number of catheter associated urinary tract infections among both men and women (Karchmer et al, 2000). Findings also more specifically revealed that approximately 21% of randomized patients on the study ward saw a reduction in risk for infection and another 32% of patients in which silver coated catheters were used saw a decline in the occurrence of infection. Findings from this study completed by Karchmer et al, 2000 proved to be in a sense consistent with the findings obtained by Liedberg et al 1990 discussed earlier. Both studies showed that the impregnation or coating of catheters with silver alloy proved to be able to reduce catheter associated infections. Additionally, Karchmer et al 2000 points to the cost of using silver alloy coating and according to this study the use of silver is less expensive versus using other forms of treatment or prevention.
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Knowledge about the impact silver alloy impregnation have on catheter associated infections revealed by both Liedberg et al 1990 and Karchmer et al 2000 studies encouraged further research into its efficacy by later studies. In a study completed by Pickard et al 2012, the researchers looked to identify whether or not antimicrobial catheters which included silver alloy catheters, nitrofural catheters, and polytetraﬂuoroethylene catheter can reduce the incidence of the catheter associated urinary tract infections. The study had a sample size that consisted of over 7102 patients. Out of the 7102 patients enrolled in the study, 708 were randomly entered into the necessary study groups (Pickard et al, 2012). The overall findings from this study proved to be quite interesting because in this study, it is shown that the use of silver alloy catheter did not prove to be effective against reducing or preventing catheter associated infections (Pickard et al, 2012). Additionally, the results from this study did not show that use of nitrofural catheter was effective in reducing the presence of catheter associated infections (Pickard et al, 2012). The findings from this study is particularly interesting because earlier studies discussed by Liedberg et al 1990 and Karchmer et al 2000 explored the effectiveness of silver alloy coated catheter on reducing catheter associated infections and found that its use was effective enough to be incorporated into clinical practice. However, Pickard et al, 2012 have determined that the use of silver alloy coated catheter should not be routinely used in clinical practice based on their findings. The Lack of efficacy of the antimicrobial catheters noted in Pickard et al, 2012 brings to attention the need for research to explore other means to address the issue of catheter associated infections.
Research completed by Wilde et al 2016 explores another avenue aimed at reducing catheter associated infection, particularly those occurring during long-term indwelling catheter usage. In this study, the Orem theory of self-care is incorporated to understand the impact of introducing self-management interventions in reducing the occurrence of catheter associated infection in patients that have utilized long-term indwelling catheters. The study utilized the sample size of 202 participants and randomization and blinding was properly used to ensure that bias can be limited in this study. In this study interventions included the use of educational booklets, diary, and other form of educational modules to provide participants with the necessary knowledge needed to meet the self-care goals with regards to catheter care (Wilde et al, 2016). The generalized estimating equations model was used to measure interventions and the measures in the study showed that the blockage outcome favored the experimental group in the first six months of the study (Wilde et al, 2016). However, the study did not find any difference among the control and experimental group after the 12-month period (Wilde et al, 2016). The researchers noted that improvements were observed in both the control and experimental groups in decreasing the rate of catheter associated urinary tract infections (Wilde et al, 2016). The findings from this study show that self-care management could provide an additional strategy for reducing catheter associated infection.
The review of these five different studies shows that the goal of reducing catheter associated infections have been evolving overtime. Early randomized controlled studies have shown that silver alloy coating on catheter can be effective in decreasing the catheter associated infection. While other studies reveal that the use silver products such as silver sulfadiazine and silver alloy coating may not be effective in reducing catheter associated infection because of other variables that may be involved such as antibiotic usage and as a result feel that the use of these products may not be efficacious in clinical practices. Finally, the latest studies are exploring the incorporation of self-management in order to tackle the issue of catheter associated infections. The exploration into building and improving self-management interventions for catheter care and reduction of infection risk can be play a critical role in re-engaging patients. Ultimately, synthesis of these studies demonstrate the need for further research into identify strategies that can significantly reduce catheter associated urinary tract infections and be incorporated into clinical practice. Research is the foundation for building and improving nursing body of knowledge and studies such as the ones focused in this review are needed so that the quality of care patients receive continue to improve.
- Huth, T. S., Burke, J. P., Larsen, R. A., Classen, D. C., & Stevens, L. E. (1992). Randomized Trial of Meatal Care with Silver Sulfadiazine Cream for the Prevention of Catheter-Associated Bacteriuria. Journal of Infectious Diseases, 165(1), 14-18. doi:10.1093/infdis/165.1.14
- Karchmer, T. B., Giannetta, E. T., Muto, C. A., Strain, B. A., & Farr, B. M. (2000). A Randomized Crossover Study of Silver-Coated Urinary Catheters in Hospitalized Patients. Archives of Internal Medicine, 160(21), 3294. doi:10.1001/archinte.160.21.3294
- Liedberg, H., & Lundeberg, T. (1990). Silver Alloy Coated Catheters Reduce Catheter-associated Bacteriuria. British Journal of Urology, 65(4), 379-381. doi:10.1111/j.1464-410x.1990.tb14760.
- Pickard, R., Lam, T., Maclennan, G., Starr, K., Kilonzo, M., Mcpherson, G., . . . Ndow, J. (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), 1927-1935. doi:10.1016/s0140-6736(12)61380-4
- Wilde, M. H., Mcmahon, J. M., Mcdonald, M. V., Tang, W., Wang, W., Brasch, J., . . . Chen, D. (. (2016). Self-Management Intervention for Long-Term Indwelling Urinary Catheter Users. Nursing Research, 64(1), 24-34. doi:10.1097/nnr.0000000000000071
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