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Can silver alloy catheters reduce infection rates?

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 J O C N
Journal Name
3 5 6 1
Manuscript No. B Dispatch: 9.10.10
Author Received:
Journal: JOCN CE: Gayathri
No. of pages: 11 PE: Ilamathi

1
2
3 REVIEW
4
5 Silver alloy vs. uncoated urinary catheters: a systematic review of the
6
7
literature
8
9
Michelle Beattie and Julie Taylor
10
11
12 Aims and objectives. This systematic review aimed at determining whether there was enough evidence in the literature to
13 conclude that silver-alloy urinary catheters indeed reduce catheter-associated urinary tract infections in comparison with the use
14 of silicone or latex urinary catheters in adult inpatients.
15 Background. Previous systematic reviews into the effectiveness of silver-coated urinary catheters have offered limited oppor-
16 tunity to transfer their findings into practice. These studies have been on American products only, of generally poor quality, or
17 indeed several years since their completion (Cochrane Database Systematic Reviews, 1, 2004, CD004013; Johnson 2005).
18 Design. A systematic review of the literature was deemed the most appropriate research method to apply as there had already
19 been several studies (Archives of International Medicine, 160, 2000, 2670; American Journal of Infection Control, 30, 2002,
20 221; The Journal of Urology, 173, 2005, 846) relating to the subject in question, although there were some queries regarding
21 their methodological rigour.
22 Methods. Randomised control trials, systematic reviews and meta-analysis were identified by searching relevant databases.
23 Relevant papers were judged against predefined inclusion and exclusion criteria. Ten per cent of papers were assessed by a second
24 reviewer. Following the application of a numerical filtering tool, six papers were rejected and eleven papers were retained.
25 Results. Of the 11 papers retained, there were eight studies, because of some studies publishing more than one paper. The
26 integrated results did present a consistent pattern favourable towards the efficacy of silver-alloy urinary catheters to reduce
27 catheter-associated urinary tract infection.
28 Conclusion. The collective evidence divulged an emerging pattern favouring the efficacy of silver-alloy urinary catheters to reduce
29 catheter-associated urinary tract infection. Owing to the poor quality of some individual studies included in other systematic
30 reviews and the inability to carry out meta-analysis because of significant heterogeneity, definitive conclusions cannot be drawn
31 from the study.
32 Relevance to clinical practice. Given the significant prevalence of catheter-associated urinary tract infection, early indications of
33 improved infection rate outcomes using silver-alloy urinary catheters should not be dismissed.
34
35 Key words: catheter-associated urinary tract infection, nurses, nursing, silver, systematic review, urinary catheter
36
37 Accepted for publication: 19 August 2010
38
39
40
million annually in Scotland (NHS Quality Improvement
41 Introduction
Scotland 2005). Because of the current high profile of patient
42 Health care-associated infections (HCAI) are estimated to safety and significant media coverage of ‘dirty’ hospitals,
43 effect approximately 33,000 people per year and cost £186 HCAI is high on both the public and Government agenda.
44
45
Authors: Michelle Beattie, BSc, MSc, RN, Lecturer, Department of Correspondence: Michelle Beattie, Lecturer, Department of Nursing
46
Nursing and Midwifery, University of Stirling, Highland Campus, and Midwifery, University of Stirling, Highland Campus, Centre for
47
Centre for Health Science, Inverness; Julie Taylor, BSc, MSc, PhD, Health Science, Old Perth Rd, Inverness IV2 3JH, Scotland, UK.
48 RN, RNT, Professor, Head of Strategy and Development (Physical Telephone: 01463 255622.
49 Abuse in High Risk Families), NSPCC, Centre for Learning, Child E-mail: michelle.beattie@stir.ac.uk
50 Protection Unit, Edinburgh, Scotland, UK

Ó 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing 1

doi: 10.1111/j.1365-2702.2010.03561.x
 M Beattie and J Taylor

1 There is consistent evidence that catheter-associated urinary
2 tract infections (CAUTI) account for a significant number of
3 HCAIs (NHS Quality Improvement Scotland 2004, Pratt
4 et al. 2007, Madeo et al. 2009). These infections are often
5 associated with an increased period of hospitalisation and
6 morbidity, resulting in poor outcomes for patients and their
7 families, as well as significant economic cost to the National
8 Health Service (NHS). The purpose of this systematic review
9 was to establish whether or not the use of silver-alloy urinary
10 catheters can reduce the incidence of CAUTI.
11 Silver has been used for medicinal purposes since Greek
12 and Roman times. By the early 1900s, silver was used for its
13 wide-spectrum antimicrobial properties until the discovery of
14 penicillin in 1928. Silver-impregnated dressings have been
15 used over the decades to reduce infection in burn wounds.
16 The use of silver-coated urinary catheters was first introduced
17 in the United States approximately 10 years ago and approx-
18 imately five years ago in the UK (Dawson, personal commu-
19 2 nication). There have been some claims that silver-coated
20 urinary catheters reduce biofilm formation and or reduce
21 colonisation by releasing silver ions into the urinary tract
22 (Centre for Evidence-Based Purchasing 2006). Urinary cath-
23 eters can be coated in silver alloy or silver oxide. Studies
24 involving silver oxide catheters, however, have not been
25 found to reduce CAUTI in comparison with other catheter
26 types (Saint et al. 1998) and have subsequently been removed
27
28
LOW RESOLUTION FIG
from the market (Brosnahan et al. 2004). The use of silver- 3
coated catheters has been sporadic in clinical practice,
probably because of the debatable evidence associated with
their effectiveness as well as significant cost implications.
Silver-coated catheters are significantly more expensive at
approximately £5Æ50 per catheter in comparison with Teflon
catheters at £0Æ86.
Aims and methods
The aim of this systematic review was to examine current
studies, as well as build on existing reviews, to determine
whether or not there is evidence to conclude that silver-alloy
urinary catheters reduce CAUTI in comparison with the use
of standard silicone or latex urinary catheters in short-term
hospitalised adult patients. Only adult patients requiring
short-term (< 2 weeks) catheter use were included because
of the prevalence of bacteraemia in all long-term catheterised
patients. This systematic review only considered urethral
catheterisation as supra-pubic catheterisation has different
risk factors (Robinson 2005). A flow diagram was created to
plan the review (Fig. 1).
Although there is no definitive hierarchy of evidence, there
is a general consensus that systematic reviews and meta-
analysis of primary research are the highest ranked methods.
Randomised controlled trials (RCT) follow closely behind

29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49 Figure 1 Flowchart of planned systematic 41
50 review process.

2 Ó 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing

 Review Silver alloy vs. uncoated urinary catheters 1

1 systematic reviews and are acknowledged as the ‘gold All UK catheter suppliers and known experts were
2 standard’ for testing interventions (Sheffield University contacted to identify potential research papers. The only
3 2008). When methods lower down on the hierarchy are commercial company producing silver-alloy catheters was
4 used, there is an increased risk of bias, although utilising Bard, of which seven papers were received. The University
5 these methods are often wholly appropriate depending on the Library database of postgraduate student’s thesis was also
6 research question being asked. A systematic review was searched, and no papers were found on the subject area. In
7 selected not because of its prestige, but because it was best total, the search yielded 148 papers. All duplicate papers
8 suited to the intervention question. The aim is to use the were then removed by hand – resulting in 97 papers.
9 methodology highest on the hierarchy to suit the research Inclusion and exclusion criteria were predetermined to
10 question. As the method provides a succinct overview of minimise bias and to target relevant papers. It is essential that
11 several studies, it is particularly useful for busy practitioners once the criteria are identified, they are adhered to reduce the
12 who strive to use evidence-based practice, but would not have risk of introducing bias (CRD 2009). An inclusion selection
13 the time to access all the individual studies. form was devised to standardise the process (Fig. 2). When
14 The initial question was formulated using the PICO the inclusion and exclusion criteria were applied to all
15 acronym for Patient, Intervention, Comparison and Outcome abstracts, 14 were accepted, three were undecided and 80
16 (Lang 2004). The question was refined to ‘In short-term were rejected (Table 2). The three abstracts undecided
17 hospitalised adult patients, do silver-alloy urinary catheters (Karchmer et al. 1997, 1998, Maki et al. 1998) required full
18 reduce CAUTI in comparison with the use of standard papers to be retrieved as there was insufficient data to apply
19 silicone or latex urinary catheters?’ the inclusion and exclusion criteria. Following retrieval of the
20 The following databases were scrutinised to obtain rele- remaining three papers, they were accepted. In total, 17 were
21 vant studies – Medical Literature Analysis and Retrieval accepted and 80 were rejected.
22 System Online, Cumulative Index to Nursing and Allied As applying the criteria requires a judgement to be made by
23 Health Literature, British Nursing Index, Excerpta Medica the reviewer, it is recommended that two reviewers indepen-
24 Database, Database of Abstracts of Reviews of Effectiveness, dently review papers to reduce bias (CRD 2009). Ten per cent
25 Cochrane Database of Systematic Reviews, Cochrane Central of all papers (97/10 = 9Æ7, rounded to 10) were reviewed
26 Register of Control Trials, Meta Register Clinical Trial and independently by a second reviewer (JT) using the predeter-
27 the FADE Library of grey literature. Full details and results of mined inclusion and exclusion criteria. The ten papers were
28 the search strategy are detailed in Table 1. randomly selected using the ‘random’ function within Excel.
29
30
Table 1 Search strategy 30
31
32 Search Final
33 Ovid database function Key word searched Restrictions results
34 MEDLINE (R) – 1950 – March Advanced Silver AND urinary catheter$ (92) RCT and from year 1990 (15) 15
35 week 4 2008
36 CINHAL – 1982 – February Advanced Silver AND urinary catheter$ (32) From year 1990 no limits for RCT 31
37 week 5 2008
BNI & Archive – 1985 – February 2008 Advanced Silver AND urinary catheter$ (7) From year 1990 no limits for RCT 7
38
EMBASE – 1980 – week 14 2008 Advanced Silver AND urinary catheter$ (52) From year 1990 no limits for RCT 50
39 DARE – 14 March 2008 Basic Silver AND urinary catheter$ (11) No limits for RCT restriction/year 11
40 CDSR – first quarter 2008 Advanced Silver AND urinary catheter$ (4) No restrictions applied 4 31
41 CENTRAL – first quarter 2008 Advanced Silver AND urinary catheter$ (18) No restrictions applied 18
42 MRCT – 14 March 2008 Basic Silver AND urinary catheter! (3) No restrictions applied 3
FADE – 20 March 2008 Basic Silver AND urinary catheter$ (69) From year 1990 & research 2
43
BARD Via post Silver-coated urinary catheters No restrictions applied 7
44
Dundee University Library database Postgraduate students thesis searched No restrictions applied 0
45 Total 148
46
BNI, British Nursing Index; CDSR, Cochrane Database of Systematic Reviews; CENTRAL, Cochrane Central Register of Control Trials;
47
CINHAL, Cumulative Index to Nursing and Allied Health Literature; DARE, Database of Abstracts of Reviews of Effectiveness; EMBASE,
48 Excerpta Medica Database; MEDLINE, Medical Literature Analysis and Retrieval System Online; MRCT, Meta register of Controlled Trials;
49 RCT, randomised controlled trials.
50 Duplicates were removed by hand searching abstracts. There were 51 duplicates removed (148 51 = 97).

Ó 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing 3

 M Beattie and J Taylor

1 MB as the intervention was not silver-alloy urinary catheters;

LOW RESOLUTION FIG

2 however, JT had excluded the paper as it was not a

3 randomised control trial, systematic review or meta-analysis.
4 Agreement was reached that the reason for exclusion should
5 be that the paper was not a randomised control trial,
6 systematic review or meta-analysis as this appeared first on
7 the Inclusion Selection Form (see Fig. 2). Therefore, both
8 reviewers were in agreement 100% of the time whether or
9 not a paper should be included or excluded; however, there
10 were initial discrepancies on the reasons for excluding a
11 paper, which were resolved by consensus.
12 One study (N’Dow 2007) was rejected because of loss to
13 follow-up, although it would have met the inclusion criteria,
14 as the study was not completed. References of remaining
15 studies were examined to determine whether there were
16 further relevant studies by applying the inclusion and
17 exclusion criteria. Two further studies were identified (Lied-
18 berg & Lundeberg 1993 and Takeuchi et al. 1993). Once the
19 full papers (18) were reviewed, one paper was rejected as it
20 would not have met in the inclusion criteria as it was not an
21 RCT or systematic review (Saint et al. 2000). Final results
22 from secondary references were 80 rejected and 17 accepted.
23 Papers were then assessed for quality using a numerical
24 scoring system adapted from the Cochrane (Cochrane Col-
25 laboration 2006). A numerical tool was chosen to aid the
26 filtering process to attain specific, high-quality studies to be
27 included in the systematic review. The numerical tool by the
28 42 Figure 2 Inclusion selection form. Cochrane Collaboration was selected as the tool focused on
29 detecting potential bias, a key element to quality assessment.
30 Table 2 Results of application of inclusion and exclusion criteria As the tool was devised for RCTs, adaptations were required
31 to ensure applicability to systematic reviews and meta-
97 papers = 80 rejected and 17 accepted
32 analyses (Table 3).
33 Number of There are currently no empirical evidence demonstrating
34 Reasons for those rejected papers the effects of measuring bias, although it appears logical to
35 Not a randomised controlled trials, meta-analysis 67 categorise bias into the following four sources: selection bias,
36 or systematic review performance bias, attrition bias and detection bias (Bornhoft
37 The population was not adults 2 et al. 2006). The quantitative assessment tool scored indi-
The intervention was not silver-alloy urinary 9
38 vidual studies on these four categories of bias. Selection bias
catheters
39 The silver-alloy catheter was not being used for 1
can be introduced whenever participants are not randomly
40 short-term use (< 2 weeks) allocated, or in the case of SRs, when searching for studies.
41 Other-lost to follow-up 1 Performance bias refers to the potential of differences in care
42 provided, other than the intervention. In the case of system-
43 atic reviews, performance bias may be introduced when
44 The first ten papers generated from the random list were inclusion and exclusion criteria are not made explicit at the
45 selected. Independently, both reviewers agreed on the reason outset of the study. Where there are significant differences in
46 for rejection or retention of a paper on eight out of ten the reasons for withdrawals between the different interven-
47 occasions (80%). Reviewers discussed differences in opinion tions, this is known as attrition bias. The validity of
48 on the remaining two papers. Reviewers agreed that both systematic reviews may be questioned when inclusion and
49 papers should be excluded, but initially excluded them for exclusion criteria are not applied consistently to all studies.
50 different reasons. For example, one paper was excluded by Detection bias is when there are differences in outcome

4 Ó 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing

 Review Silver alloy vs. uncoated urinary catheters 1

1 Table 3 Numerical quality filtering tool

2 Bias type Indicators (randomised controlled trials) Indicators (systematic reviews/meta-analyses) Score
3
4 Selection Differences in comparison groups Inadequate searching of resources
Performance Differences in care provided apart from intervention Ambiguous inclusion and exclusion criteria
5
being evaluated
6 Attrition Systematic differences in withdrawals from trial Inconsistent application of inclusion and exclusion
7 criteria
8 Detection Systematic differences in outcome assessment Systematic differences in outcome assessment
9 Total score
10 Key: A numerical score must be allocated for each bias type: 1 = bias; 0 = no bias detected. Total score: 0–1, Low risk bias = A; 2–3, Moderate
11 risk bias = B; 4, High risk bias = C.
12 Adapted from the Cochrane Handbook of Systematic Reviews and Interventions, 4Æ2Æ6 September 2006, The Cochrane Collaboration, p. 80. 32
13
14 assessment between comparison groups, i.e. where different Table 5 Results of numerical scoring system
15 outcomes occur and only one is reported. A similar bias in a Paper Numerical score Grade
16 systematic review would be when the outcome measure,
Brosnahan and Kent (2004) 1 A 33
17 which is usually stipulated in the study questions, is variable,
Brosnahan, Jull and Tracy (2008) 0 A
18 i.e. definition of infections, and these results are considered 34
Di Filippo and DeGaudio (2003) 4 C
19 heterogeneously. Dunn, Pretty, Reid and Evans (2000) 4 C 35
20 Each paper scored either 0 or 1 point for each of the four Johnson et al. (2006) 0 A
21 biases. The best score would be 0 (indicating no bias Karchmer et al. (1997) 4 C
22 identified), the poorest score would be four highlighting a Karchmer et al. (1998) 4 C
Karchmer et al. (2000) 4 C
23 high risk for bias (Table 4). A second reviewer (JT) obtained
Liedberg and Lundeberg (1990) 3 B
24 approximately 10% of the 17 papers (2) and applied the Liedberg et al. (1990) 3 B
25 numerical scoring system to the studies independently. The Liedberg and Lundeberg (1993) 3 B
26 two papers were randomly handpicked from the 17 available. Maki et al. (1998) 4 C
27 4 Both reviewers gave the same score for the two papers. On Niel-Weise et al. (2002) 1 A
Rosier (2004) 1 A
28 applying the numerical score, 6 papers were rejected and 11
Saint et al. (1998) 0 A
29 papers were retained (Table 5). Of the 11 papers retained,
Thibon et al. (2000) 0 A
30 there were eight studies, as some studies had published more Verleyen et al. (1999a/b) 3 B 36
31 than one paper. Of the eight studies, four were RCT, three
32 were systematic reviews and one meta-analysis (Table 6).
Table 6 Study methodologies of retained papers
33 To structure the analysis of the remaining papers, the
34 critical analysis tools devised by the Critical Appraisal Skills Systematic reviews/Meta-analysis Randomised controlled trials

35 Programme (CASP 2006a) were used. The tools produced by Brosnahan & Kent (2004)* Liedberg and Lundeberg (1990) 
36 this unit were selected as they have been developed from Brosnahan, Jull and Tracy Liedberg et al. (1990)
37 guides produced by an expert panel at McMaster University (2008)*
Rosier (2004)* Liedberg and Lundeberg (1993)  37
38 and have been rigorously piloted (Oxman et al. 1993). The
Niel-Weise et al. (2002) Thibon et al. (2000)
39 Systematic Review Tool (CASP 2006b) was used to structure Johnson et al. (2006) Verleyen et al. (1999a/b)
40 the critique on studies that have used this methodology. Saint et al. (1998)
41 Likewise, the RCT tool (CASP 2006c) was used to critique
*All denote the same study and will be referred to in subsequent text
42 studies that used RCT or meta-analysis.
as the updated version of Brosnahan, Jull and Tracy (2008).
43  
Two papers on the same study and will be referred to in subsequent
44 text as the original version Liedberg and Lundeberg (1990).
Table 4 Numerical scoring system to detect bias
45
46 0–1 Low-risk bias Scoring A
2–3 Moderate-risk bias Scoring B
Results
47
48 4 High-risk bias Scoring C The eight studies retained were scrutinised using the appro-
49 All papers scoring C’s were rejected and those scoring A or B were priate CASP (2006b,c) critical analysis tools by MB. The
50 retained. analysis highlighted that there was significant heterogeneity

Ó 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing 5

 M Beattie and J Taylor

1 38 Table 7 Randomised controlled trials results

2 Statistical significance
3 of efficacy of silver-alloy Statistical
4 Study Results catheters methodology
5
Liedberg and Lundeberg (1990) Six (10%) patients with a silver-alloy urinary catheter p < 0Æ01 Chi square
6 developed bacteriuria compared to control group were statistically significant Fishers exact test
7 22 (37%) developed bacteriuria. Kaplan–Meier
8 Liedberg et al. (1990) Three patients (10%) with silver-coated catheter, p < 0Æ002 Chi square
9 10 (33%) with hydrogel catheter and 15 (50%) patients statistically significant Fishers exact test
with non-coated catheter developed bacteriuria Kaplan–Meier
10
Thibon et al. (2000) Nine patients with silver-coated catheter and 13 patients p-value results not given Student’s t-test
11 with non-coated catheter developed bacteriuria Not significant Chi square
12 Fishers exact test
13 Kaplan–Meier
14 Mantel–Cox test
39 Verleyen et al. (1999a/b) 50% with silver-coated catheter and 53Æ3% with No p-value given Chi square
15
non-coated catheter developed bacteriuria Not significant
16
40 Verleyen et al. (1999a/b) 6Æ3% of silver-coated cath group had bacteriuria and Statistically significant Chi square
17 11Æ9% in the uncoated cath group p = 0Æ003 Kaplan–Meier
18 Mantel–Cox test
19
20
21 between studies; therefore, statistical meta-analysis was not pooled as data were not available prior to crossover. Silver-
22 feasible. Details of the study results will now be discussed and alloy catheters were found to significantly reduce the
23 the collective evidence considered. incidence of asymptomatic bacteriuria (RR 0Æ54, 95% CI
24 Three out of five RCTs (Liedberg & Lundeberg 1990, 0Æ43–0Æ67) in hospitalised patients catheterised for <1 week.
25 5 Liedberg et al. 1990, Verleyen et al. 1999a/b) demonstrated At > 1 week, silver-coated urinary catheters were still
26 with statistical significance that patients with silver-alloy effective at reducing the risk of asymptomatic bacteriuria –
27 urinary catheters were less likely to develop bacteriuria than RR 0Æ64, 95% CI 0Æ51–0Æ80. They concluded that silver-alloy
28 those with uncoated catheters (Table 6). The overall quality urinary catheters appear more effective than standard cath-
29 of the studies needs to be considered when interpreting these eters at reducing bacteriuria in patients who require short-
30 results. Given that only one study (Thibon et al. 2000) scored term catheterisation. Results should, however, be interpreted
31 an A for quality assessment, the results of the RCTs were with caution as trails were generally of poor quality.
32 generally of less quality than the SRs.
33 Only two out of four systematic reviews included carried
Johnson et al. (2006)
34 6 out meta-analysis (Saint et al. 1998, Brosnahan et al. 2008),
35 which established efficacy of silver-alloy urinary catheters in Johnson et al.’s (2006) systematic review assessed the efficacy
36 reducing CAUTI. Three out of five RCTs (Liedberg & of anti-microbial urinary catheters for the prevention of
37 Lundeberg 1990, Liedberg et al. 1990, Verleyen et al. 1999a/ CAUTI. Anti-microbials included nitrofurazone and silver-
38 b) demonstrated with statistical significance that patients alloy urinary catheters. Risk ratios were calculated for
39 with silver-alloy urinary catheters were less likely to develop individual studies; however, quantitative pooling of results
40 bacteriuria than those with uncoated catheters. No studies was not performed because of extensive heterogeneity
41 included intention-to-treat analysis. amongst studies. The review concludes that a definitive
42 recommendation for anti-microbial catheters, including silver
43 alloy, cannot be made because of lack of quality evidence.
Brosnahan et al. (2008)
44
45 7 The systematic review by Brosnahan, Jull and Tracy (2008)
Saint et al. (1998)
46 compared many catheter types, but for the purpose of this
47 review, only the results comparing silver-alloy catheters with Saint et al. (1998) performed meta-analysis to estimate the
48 standard catheters will be considered. Meta-analysis was effectiveness of silver-coated urinary catheters in compari-
49 performed using a fixed effect model. One randomised son with uncoated catheters for bacteriuria outcomes.
50 8 crossover study’s results (Karchmer et al. 2000) were not They calculated odds ratios for individual studies and the

6 Ó 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing

 Review Silver alloy vs. uncoated urinary catheters 1

1 overall odds ratio result. The odds ratio for bacteriuria was patients to each arm of the trial threatened the studies’
2 0Æ59 (95% CI, 0Æ42–0Æ84) indicating a significant benefit internal validity and therefore results.
3 for patients with silver-coated urinary catheters. They con- Despite the fact that an estimation of sample size is
4 clude that silver-alloy urinary catheters may be worth the essential in the planning of an RCT, only one study (Thibon
5 extra cost as CAUTI is a common cause of nosocomial et al. 2000) actually documented a power calculation (Moher
6 infection. et al. 1995). Thibon et al. (2000) based their estimation on a 9
7 UTI incidence of 37%, estimating that 90 subjects per group 10
8 would be needed to demonstrate a 50% reduction in
Niel-Weise et al. (2002)
9 incidence with the coated catheter, with a risk of 5% and a
10 Niel-Weise et al. (2002) evaluated the literature to determine power of 90%. However, the overall incidence rate was
11 the effectiveness of silver-coated vs. uncoated catheters for 11Æ1% and therefore larger numbers would be needed than
12 the prevention of CAUTI. Only the results pertaining to they originally predicted.
13 silver-alloy catheters were considered for this systematic All RCTs used Chi square and Fisher’s exact tests to analyse
14 review. They calculated the relative risk with 96% CI for their results. Chi square is used to determine whether observed
15 each study as well as the relative risk of subgroups (i.e. frequencies are different to those that would occur by chance.
16 gender) where information was available. They did not carry In these studies, the formula was used to calculate whether the
17 out meta-analysis to combine results as only one of their rate of bacteriuria was significantly different depending on
18 included studies achieved a high-quality score. The one high- whether a silver-alloy or uncoated urinary catheter was used.
19 quality study did not show efficacy of silver-coated catheters. The Chi square needs to have enough data to be greater than a
20 They concluded that there was insufficient evidence to two by two table. When samples are small, which was
21 recommend the use of silver-coated urinary catheters. apparent in some of the RCTs, the researchers appropriately
22 used Fisher’s exact test. As the name suggests, the process is
23 exact; therefore, it can be used regardless of sample numbers
Synthesis of results
24 or characteristics. All RCTs used Kaplan–Meier plots to
25 Meta-analysis of the results of this systematic review would visually demonstrate bacteriuria over time. Data are presented
26 be inappropriate because of significant heterogeneity between on an x and y axis, where x represented number of days and y
27 included studies. Heterogeneity was apparent in study design, axis number of patients, which enabled easy interpretation.
28 population, types of uncoated catheters used as comparisons, Kaplan–Meier is used to estimate the probability of an event
29 urine sampling methodologies and definitions of outcome over time, but where competing risks are present, the results
30 measures. There was, however, consistency among studies for are not interpretable (Harris & Taylor 2003). Competing
31 statistical methods used – risk ratios calculated in the risks such as gender, catheter types, co-morbidities etc are
32 systematic reviews and Chi square, Fischer’s exact test and apparent in the population studied.
33 Kaplan–Meier estimator used in all RCTs. All systematic reviews reported relative risk ratios. Relative
34 Of the systematic reviews which concluded that silver-alloy risk is a ratio of the probability of the event occurring in the
35 urinary catheters did reduce the incidence of bacteriuria exposed group vs. a non-exposed group. Appropriately, the
36 (Saint et al. 1998 and Brosnahan et al. 2008), there were studies used this measure to compare the risk of bacteriuria
37 questions over their validity. Both systematic reviews numer- between patients receiving silver-alloy catheters and those
38 ically combined the results of each study despite acknowl- receiving uncoated catheters. All reviews calculated confi-
39 edgement that some were of poor quality and there was dence intervals using a fixed effect model. Fixed effect models
40 significant heterogeneity between studies. Saint et al.’s (1998) take account of variation between each study (heterogeneity).
41 combined odds ratio results showed 0Æ59 (95% CI 0Æ42–0Æ84) The model can only control variation which is fixed, i.e.
42 indicating a significant benefit for silver-coated catheters. factors that do not change over time, such as gender. This
43 Brosnahan et al. (2008) was of good quality, although they would not take account of other evolving variables such as
44 suggested that their results should be interpreted with caution co-morbidities, although these would be unlikely to change
45 because of the general poor quality of some included studies. over the length of time of the study, i.e. 14 days.
46 Of the RCTs that did show statistical significance, there In summary, the studies were either unable to demonstrate
47 were questions over their validity. Both studies by the statistical significance or drew conclusions with caution
48 Liedberg group had small sample numbers, and both studies because of significant heterogeneity or poor-quality studies.
49 were carried out in the same institution. Verleyen et al. No study was able to clearly demonstrate statistically and
50 (1999a/b) lack of concealment and their methods of allocating with validity that in short-term hospitalised adult patients,

Ó 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing 7

 M Beattie and J Taylor

1 silver-alloy urinary catheters reduce CAUTI in comparison
2 with the use of standard silicone or latex urinary catheters.
3 Collectively, the results of this systematic review show there
4 is a consistent pattern emerging supporting the effectiveness
5 of silver-alloy urinary catheters over uncoated catheters to
6 reduce CAUTI.
7 their research. Ideally, where insufficient information led to
8 an assumption of omission, this should have been clarified by
Discussion
9 contacting original authors. The limitation of time did not
10 Although this review was unable to draw any definitive
11 conclusions, the integrated results did present an emerging
12 pattern favourable towards the efficacy of silver-alloy urinary
13 catheters. The purpose of research in health care is to evolve
14 patient care by transferring findings into practice (Davies
15 2002). Before integrating evidence into practice, however, the
16 quality of this systematic review needs to be assessed and
17 any limitations of the study acknowledged.
18 The CASP tool for reviews (CASP 2006a) was used as a
19 11 framework to assess the quality of this SR as it has been
20 rigorously piloted. Applying scrutiny to this review, as was
21 applied to the retained studies, helped to ensure equity and a
22 transparent process. The details of the literature search have
23 been well documented that would enable another researcher
24 to repeat the process and allocate the same papers. Unfor-
25 tunately, the same could not be said for some of the
26 systematic reviews included in this study. Limitations of this
27 review are mainly related to the moderate evidence and
28 significant heterogeneity of the studies included.
29 If the review were to be replicated, the author would ensure
30 that the quality assessment included ethical considerations as
31 these issues are fundamental in health care research. One
32 Japanese study (Takeuchi et al. 1993) was excluded from the
33 study because of translation costs and their results may have
34 positively influenced the outcome of this review, had the
35 study been valid and reliable. Although probably more a
36 learning point than a weakness of the study; where there is
37 more than one study, it is advisable to refer to the earliest
38 version (Dwan et al. 2008). The author did not know this
39 until the review was nearly complete and the latest version of
40 Brosnahan et al. (2008) study was referred to rather than
41 their original paper in 2004. There were, however, no major
42 differences between studies. The main difference between the
43 2004–2008 version was an updated literature review; there-
44 fore, using the latest version would not have changed the
45 outcome of this review.
46 The numerical quality filtering tool used to critique the
47 studies was adapted from the Cochrane Collaboration (2006)
48 as it was intentionally designed for RCTs and not SRs. The
49 tool rigorously assessed the studies for bias; however, the tool
50 made the assumption that if details were not published, then
they did not occur. For example, if a study did not stipulate
that their participants were blinded to the intervention, then
it was assumed that this did not take place and the study
would therefore score poorly for bias. This may have resulted
in studies being harshly criticised because of the lack of
information they had published rather than the quality of
allow further probing to attain further information, however.
This lack of information when publishing research has been
acknowledged and led to the creation of the Consolidated
Standards for Reporting Trials statement, which aims to
improve the transparency of reporting RCTs (Moher et al.
2001). Although this would not improve the reporting of
SRs, these standards have been adapted for use in reporting
other research (Altman et al. 1991). When considering the 12
quality of this systematic review, however, utilising a strin-
gent tool would only increase confidence in the overall results.
Sample sizes also need to be large enough from which to
generalise. Only one study (Thibon et al. 2000) determined a
power calculation for their study. To determine a power
calculation, researchers need to know the frequency of an
event – in this case, the frequency of CAUTI. Most probably,
the frequency of CAUTI is not known because of the
significant variation in defining and therefore reporting
CAUTI. No studies measured symptomatic CAUTI, however,
most likely because of the subjectivity involved in interpreting
symptoms. Many of the symptoms in symptomatic CAUTI
would rely on the patients’ description of their symptoms, for
example, painful urination. Pain is a subjective experience
and differs considerably between individuals, which causes
considerable complexity when attempting to measure.
All studies reported asymptomatic CAUTI (bacteria in the
urine without other symptoms) as their outcome measure.
The definitions of bacteriuria varied amongst their trials from
105–108 CFU/l, or involved a combination of variables.
Although more complex to measure, further accuracy of
catheter effectiveness would be achieved by measuring
symptomatic CAUTI as bacteriuria increases for every day
an individual has a catheter in place (Pratt et al. 2007). Only
patients with symptomatic bacteriuria would be treated,
whereas those with asymptomatic bacteriuria would not be
treated because of the risk of antibiotic resistance. As patients
with asymptomatic bacteriuria would not normally be
treated, they are not usually counted as a CAUTI, which
makes it difficult, if not impossible, to determine the fre-
quency. To determine power calculations for future research,
universal definitions are required for both symptomatic and
asymptomatic bacteriuria. When a RCT is started without a

8 Ó 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing

 Review
1 power calculation, the results could well be meaningless as
2 they may be too small from which to generalise.
3 Given the large number of patients requiring urinary cathe-
4 ters, there could be a significant reduction in HAI, as well as 13
Conclusion
5 improvement in the quality of patient care. Not all heath care
6 The collective evidence divulged a pattern developing which
7 begin to favour the efficacy of silver-alloy urinary catheters to
8 reduce CAUTI. As flaws were detected in the individual
9 studies demonstrating efficacy of silver-alloy catheters, how-
10 ever, it was inappropriate to arrive at definitive conclusions.
11 The results of many SRs are inconclusive (Alderson &
12 Roberts 2000). This is not to say that the evidence should be
13 dismissed, but rather it should be interpreted with caution.
14 Although no decisive conclusions were drawn from this
15 review, there is confidence in the results because of the high
16 quality of scrutiny applied to included studies. Taking a
17 critical look at research studies could well detect flaws in the
18 majority (Pattison 2000).
19 This review highlights that even carrying out what appears
20 to be straightforward research, where the question was a
21 direct comparison of one intervention with another, there are
22 complexities in the process. As clinical trials need to be clear
23 of a direct causal relationship between silver-alloy urinary
24 catheters and CAUTI, all other influencing factors need to be
25 controlled. Despite known facts, such as women are more at
26 risk of urinary infection, these were rarely considered in the
27 papers included for review. CAUTI origin and control is
28 complex and inextricably linked to other variables such as
29 chronic health conditions, location of the patient, catheter
30 insertion technique and general infection control measures.
31 As there is an awareness of these risk factors, clinical trials
32 should ensure parallel groups are used for each arm of the
33 interventions and multivariate analysis can be used to control
34 variables when analysing statistics. No studies used CAUTI as
35 an outcome measure, instead bacteriuria or asymptomatic
36 bacteriuria was used. As asymptomatic bacteriuria would not
37 be treated for in usual practice, it may be easier to transfer
38 findings into practice if symptomatic CAUTI were the
39 outcome measure used. Other important outcomes such as
40 bacteraemia need to considered in future studies because of
41 the associated morbidity and mortality (Pratt et al. 2007).
42 Given that the efficacy of other medical equipment has not
43 all been proved by quality RCTs, it is likely that one of the
44 barriers to implementation of silver-alloy urinary catheters is
45 indeed cost. Given that the economic benefit of silver-alloy
46 catheters has been estimated to be between 3Æ3–35Æ5%, their
47 use warrants further exploration (Brosnahan et al. 2008,
48 p.2). This review highlights the potential benefits of silver-
49 coated urinary catheters and supports the need for a large-
50 scale RCT, which is currently underway.
Ó 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing
Silver alloy vs. uncoated urinary catheters 1
Relevance to clinical practice
acquired infection is avoidable, but a significant proportion is
preventable (Pratt et al. 2001). 14
Silver-coated urinary catheters are not yet available
through standard purchasing in most NHS hospitals,
although substantive evidence of their effectiveness is likely
to change this. Purchasing policies are generally driven on a
demand and supply basis. If the use of silver-coated urinary
catheters becomes commonplace, their availability would
increase. Nurses, who often hold budgets locally, are there-
fore in a unique position to influence purchasing policies. A
change in practice could reduce catheter-associated infection,
subsequently reducing the patients stay in hospital as well as
long-term patient outcomes, which will ultimately improve
patient care.
Although the results of this systematic review have
potential implications for a multitude of health care practi-
tioners and managers, nurses most commonly insert urinary
catheters and care for patients postprocedure. Whilst involv-
ing the patient, nurses generally make the decision as to
urinary catheter selection. Nurses are uniquely placed to
apply evidence of catheter type into practice. One of the
reported barriers to nurses implementing research findings
into practice was insufficient authority to instigate change
(Glacken & Chaney 2004). As nursing discourse moves
towards independent practice, with role development of
nurse practitioners, perhaps this is the time for nurses to be
instigating the transferability of research into practice. If this
is indeed the right time and context, nurses may in the future
have an ideal opportunity to advocate the potential use of
silver-alloy urinary catheters. Watch this space!
Acknowledgements
The review, part of an MSc qualification had no financial
support and was not affiliated with any commercial com-
pany.
Contributions
Study design: MB, JT; data collection and analysis: MB and
manuscript preparation: MB, JT.
Conflict of interest
There are no conflicts of interest.
9
 M Beattie and J Taylor

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Ó 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing 11

 Author Query Form
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