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Chapter 15. Prevention of Nosocomial Urinary Tract Infections (continued)

Subchapter 15.2. Use of Suprapubic Catheters

Background

As discussed in Subchapter 15.1, the use of indwelling urethral catheters results in substantial morbidity and mortality. Given the medical and social morbidity associated with urethral catheters, many clinicians have considered suprapubic catheterization as an alternative to catheterization via the urethra. Suprapubic catheters are inserted in the lower abdomen, an area with less bacterial colonization than the periurethral region, so that the risk for infection is thought to be lower than with urethral catheters. Furthermore, although the suprapubic placement of urinary catheters represents a minor surgical procedure, patients may find the result more comfortable8,9 and, as reviewed below, the development of infectious complications is reduced. Subchapter 15.1 discusses the use of silver alloy urinary catheters. The focus of this chapter is the use of suprapubic catheters as compared with standard urethral indwelling catheters in adults.

Practice Description

Suprapubic catheterization typically involves the percutaneous placement of a standard urinary catheter directly into the bladder. The procedure is performed by urologists using sterile technique. It is generally performed in the operating room and is considered minor surgery.

Prevalence and Severity of Target Problem

In addition to the infectious complications (and their associated costs) discussed in Subchapter 15.1, the use of urethral catheters causes substantial patient discomfort. In a recent study at a Veteran Affairs Medical Center, 42% of catheterized patients surveyed reported that the indwelling catheter was uncomfortable, 48% complained that it was painful, and 61% noted that it restricted their activities of daily living.7 Restricted activity reduces patient autonomy and may promote other nosocomial complications, such as venous thromboembolism and pressure ulcers. In addition, 30% of survey respondents stated that the catheter's presence was embarrassing, and in unsolicited comments that supplemented the structured questionnaires several noted that it "hurts like hell."7

Opportunities for Impact

Since catheter-related urinary tract infection (UTI) is the leading cause of nosocomial infection in the United States and is associated with increased morbidity and costs, any intervention that reduces the incidence of catheter-related UTI is potentially important. Currently, it is unknown what proportion of patients who require indwelling urinary catheters receive suprapubic catheters, however, this practice is uncommon.

Study Design

There have been twelve prospective studies,8,9,11-17 all but one randomized,15 comparing the efficacy of suprapubic catheters with standard, non-coated catheters (Table 15.2.1). In all of these studies, the patient was the unit of analysis. The patient populations for these studies varied but generally included patients with acute urinary retention and those undergoing various surgical procedures. Since most of the patients evaluated resided in acute care hospitals, the average duration of catheterization was generally less than 14 days.

Study Outcomes

All the trials focused on the outcome of bacteriuria. Several of the studies also assessed patient satisfaction and the incidence of mechanical complications. The definition of bacteriuria varied somewhat in the studies. However, low-level growth from a catheterized specimen (i.e., 102 colony forming units (CFU)/mL) usually progresses within days to concentrations of greater than 104 CFU/mL, unless antibiotic therapy is given.18 Unfortunately, none of the studies was adequately powered to detect a significant difference in the clinically more important outcomes of catheter-related bacteremia or death. Though bacteriuria is a surrogate endpoint,19 it is probably appropriate to use since it is a component of the only causal pathway in the disease process between suprapubic catheterization and an important clinical outcome (e.g., symptomatic UTI or catheter-related bacteremia).

Evidence for Effectiveness of the Practice

As shown in Table 15.2.1, studies comparing suprapubic catheterization with urethral catheterization have produced mixed results.8,9,11-17,20-22 Six trials reported lower rates of bacteriuria in patients with suprapubic catheters,11,13,15,16,21,22 and 4 trials indicated greater patient satisfaction with suprapubic as opposed to urethral catheters.8,13,16,20 In 3 of the studies, however, mechanical complications were higher in those receiving suprapubic catheters.12,15,16 Of note, 3 studies found that patients given suprapubic catheters have significantly decreased incidence of urethral strictures compared with patients who received urethral catheters.15,23,24 However, the use of prophylactic antibiotics in patients receiving urethral catheters for transurethral resection of the prostate has been shown to significantly reduce the incidence of strictures in the anterior urethra.25

Potential for Harm

As stated above, the primary problem associated with suprapubic catheter use involves mechanical complications associated with insertion, most commonly catheter dislodgement or obstruction, and failed introduction. The safe insertion of suprapubic indwelling urinary catheters depends on trained personnel.

Costs and Implementation

The cost of each suprapubic urinary catheter tray is comparable to the cost of each standard, non-coated urethral catheter tray. However, the overall initial costs of using suprapubic catheters will no doubt be greater since procedure-related costs are substantially higher for suprapubic than urethral catheters. Nurses are able to place urethral catheters at the bedside, but urologists must place suprapubic catheters, and the procedure typically occurs in the operating room. Additionally, it is unclear whether urologists are currently proficient at the insertion of suprapubic catheters given how infrequently they are used. If suprapubic catheters are shown to be effective, they may have a positive impact on patient care. The cost of training individuals in inserting and maintaining the suprapubic catheter is likely to be substantial.

Comment

When compared with standard urethral indwelling catheters, suprapubic urinary catheters may reduce urinary catheter-related bacteriuria. Additionally, patient satisfaction may be greater with suprapubic catheters, although there is also evidence that patients placed with suprapubic catheters more frequently experience certain mechanical complications. On the other hand, urethral catheters are likely to lead to a higher incidence of urethral strictures. Given these mixed results, conclusions regarding the overall benefit of routine suprapubic catheterization cannot currently be made. However, it would be reasonable to consider conducting a formal meta-analysis of the published trials to answer the question, "Compared with urethral indwelling catheters, are suprapubic catheters less likely to lead to UTI (as measured by bacteriuria) and more likely to lead to enhanced patient satisfaction?" Using explicit inclusion criteria and accepted quantitative methods, a meta-analysis26-28 can often help clarify the features of individual studies that have divergent results.29 In addition, a possible interaction between gender of the patient and type of catheter is of interest since different pathophysiologic mechanisms underlie the development of urethral catheter-related infection in men and women.30 The possibility of adequately evaluating effects within subgroups (e.g., those undergoing certain surgical procedures) because of an increased sample size is one of the benefits of meta-analysis.31

If formal meta-analysis suggests that suprapubic catheters are less likely to lead to urinary tract infection and more likely to enhance patient satisfaction, at least in some clinical settings, then these catheters should be considered in the management of certain patients. On the other hand, if the meta-analysis finds that urethral catheters are superior to suprapubic catheters, then use of suprapubic catheters, albeit currently quite limited, should be further reduced.

Table 15.2.1. Prospective studies comparing suprapubic with urethral catheters

StudyDesign, OutcomesPatient Population*Bacteriuria (%)bOdds Ratio (95% CI)bCommentsc
SuprapubicUrethral
Shapiro, 198216Level 1, Level 2General surgical patients with urinary retention2/25 (8)21/31 (68)0.04
(0.01-0.24)
Pseudorandomized (urethral catheters used in every third patient) study; suprapubic group had less pain but more mechanical complications
Andersen, 198513Level 1, Level 2Women undergoing vaginal surgery10/48 (21)20/44 (45)0.32
(0.11-0.86)
Patients rated acceptability of suprapubic catheters greater
Ichsan, 19879Level 1, Level 2Patients with acute urinary retention3/29 (10)11/37 (30)0.27
(0.04-1.22)
None of the suprapubic group complained of discomfort compared with 17 of the patients given urethral catheters
Sethia, 198711Level 1, Level 2General surgical patients requiring urine output monitoring2/32 (6)16/34 (47)0.08
(0.01-0.41)
Decrease in bacteriuria was more significant in women than in men
Schiotz, 198912Level 1, Level 2Women undergoing vaginal surgery8/38 (21)5/40 (12)1.87
(0.48-8.01)
26% of suprapubic group versus 5% of urethral group had mechanical complications
Horgan, 199215Level 2, Level 2Men with acute urinary retention due to prostatic enlargement10/56 (18)12/30 (40)0.33
(0.11-0.99)
21% of suprapubic group versus 3% of urethral group had dislodgement; 0% of suprapubic group versus 17% of urethral group developed urethral strictures
O'Kelley, 19958Level 1, Level 2General surgical patients requiring abdominal surgery3/28 (11)3/29 (10)1.04
(0.13-8.51)
Study design unclear, but probably not randomized; suprapubic catheters caused significantly fewer days of catheter-related pain
Ratnaval, 199614Level 1, Level 2Men undergoing colorectal surgery1/24 (4)3/26 (12)0.33
(0.01-4.60)
Suprapubic group had fewer voiding difficulties
Bergman, 198721Level 1, Level 2Women undergoing vaginal surgery for stress incontinence4/24 (17)17/27 (63)0.26
(0.10-0.68)
Length of hospital stay was significantly less (by 1 day) in the suprapubic catheter group
Abrams, 198020Level 1, Level 2Men with urinary retention21/52 (40)13/50 (26)1.6
(0.88-2.75)
12% of suprapubic catheter group found catheter uncomfortable compared with 64% in the standard urethral catheter group (p<0.001)
Vandoni, 199422Level 1, Level 2Patients requiring surgery for various indications0/19 (0)6/24 (25)0
(0-0.95)
All patients given pre-catheterization antibiotics; slight decrease in pain and discomfort in suprapubic group but not significant (authors do not provide actual satisfaction data)
Perrin, 199717Level 1, Level 2Patients undergoing rectal surgery12/49 (24)29/59 (49)0.34
(0.13-0.83)
12% of suprapubic group reported catheter discomfort compared with 29% of urethral group

* Studies enrolled both men and women unless otherwise noted.

a Indicates the ratio of patients who developed bacteriuria to the total number of participants assigned to each group.

b Odds of developing bacteriuria in the suprapubic versus urethral catheter groups; CI indicates confidence interval.

c Mechanical complications consisted of failed introduction of catheter, and catheter dislodgement or obstruction.

References

1. Kunin CM. Urinary Tract Infections: Detection, Prevention, and Management. 5th ed. Baltimore: Williams and Wilkins; 1997.

2. Saint S. Clinical and economic consequences of nosocomial catheter-related bacteriuria. Am J Infect Control 2000;28:68-75.

3. Tambyah PA, Maki DG. Catheter-associated urinary tract infection is rarely symptomatic: a prospective study of 1,497 catheterized patients. Arch Intern Med 2000;160:678-82.

4. Platt R, Polk BF, Murdock B, Rosner B. Mortality associated with nosocomial urinary-tract infection. N Engl J Med 1982;307:637-642.

5. Platt R, Polk BF, Murdock B, Rosner B. Reduction of mortality associated with nosocomial urinary tract infection. Lancet 1983;1:893-897.

6. Saint S, Veenstra DL, Sullivan SD, Chenoweth C, Fendrick AM. The potential clinical and economic benefits of silver alloy urinary catheters in preventing urinary tract infection. Arch Intern Med 2000;160:2670-2675.

7. Saint S, Lipsky BA, Baker PD, McDonald LL, Ossenkop K. Urinary catheters: What type do men and their nurses prefer? J Am Geriatr Soc 1999;47:1453-1457.

8. O'Kelly TJ, Mathew A, Ross S, Munro A. Optimum method for urinary drainage in major abdominal surgery: a prospective randomized trial of suprapubic versus urethral catheterization. Br J Surg 1995;82:1367-1368.

9. Ichsan J, Hunt DR. Suprapubic catheters: a comparison of suprapubic versus urethral catheters in the treatment of acute urinary retention. Aust NZ J Surg 1987;57:33-36.

10. Krieger JN, Kaiser DL, Wenzel RP. Nosocomial urinary tract infections: secular trends, treatment and economics in a university hospital. J Urol 1983;130:102-106.

11. Sethia KK, Selkon JB, Berry AR, Turner CM, Kettlewell MG, Gough MH. Prospective randomized controlled trial of urethral versus suprapubic catheterization. Br J Surg 1987;74:624-625.

12. Schiotz HA, Malme PA, Tanbo TG. Urinary tract infections and asymptomatic bacteriuria after vaginal plastic surgery. A comparison of suprapubic and transurethral catheters. Acta Obstet Gynecol Scand 1989;68:453-455.

13. Andersen JT, Heisterberg L, Hebjorn S, Petersen K, Stampe Sorensen S, Fischer Rasmussen W, et al. Suprapubic versus transurethral bladder drainage after colposuspension/vaginal repair. Acta Obstet Gynecol Scand 1985;64:139-143.

14. Ratnaval CD, Renwick P, Farouk R, Monson JR, Lee PW. Suprapubic versus transurethral catheterization of males undergoing pelvic colorectal surgery. Int J Colorectal Dis 1996;11:177-179.

15. Horgan AF, Prasad B, Waldron DJ, O'Sullivan DC. Acute urinary retention. Comparison of suprapubic and urethral catheterization. Br J Urol 1992;70:149-151.

16. Shapiro J, Hoffmann J, Jersky J. A comparison of suprapubic and transurethral drainage for postoperative urinary retention in general surgical patients. Acta Chir Scand 1982;148:323-327.

17. Perrin LC, Penfold C, McLeish A. A prospective randomized controlled trial comparing suprapubic with urethral catheterization in rectal surgery. Aust N Z J Surg 1997;67:554-556.

18. Stark RP, Maki DG. Bacteriuria in the catheterized patient. What quantitative level of bacteriuria is relevant? N Engl J Med 1984;311:560-564.

19. Fleming TR, DeMets DL. Surrogate end points in clinical trials: are we being misled? Ann Intern Med 1996;125:605-613.

20. Abrams PH, Shah PJ, Gaches CG, Ashken MH, Green NA. Role of suprapubic catheterization in retention of urine. J R Soc Med 1980;73:845-848.

21. Bergman A, Matthews L, Ballard CA, Roy S. Suprapubic versus transurethral bladder drainage after surgery for stress urinary incontinence. Obstetrics & Gynecology 1987;69:546-549.

22. Vandoni RE, Lironi A, Tschantz P. Bacteriuria during urinary tract catheterization: suprapubic versus urethral route: a prospective randomized trial. Acta Chir Belg 1994;94:12-16.

23. Hammarsten J, Lindqvist K, Sunzel H. Urethral strictures following transurethral resection of the prostate. The role of the catheter. Br J Urol 1989;63:397-400.

24. Hammarsten J, Lindqvist K. Suprapubic catheter following transurethral resection of the prostate: a way to decrease the number of urethral strictures and improve the outcome of operations. J Urol 1992;147:648-651.

25. Hammarsten J, Lindqvist K. Norfloxacin as prophylaxis against urethral strictures following transurethral resection of the prostate: an open, prospective, randomized study. J Urol 1993;150:1722-1724.

26. Yusuf S. Obtaining medically meaningful answers from an overview of randomized clinical trials. Stat Med 1987;6:281-294.

27. Light RJ. Accumulating evidence from independent studies: what we can win and what we can lose. Stat Med 1987;6:221-231.

28. Hennekens CH, Buring JE, Hebert PR. Implications of overviews of randomized trials. Stat Med 1987;6:397-409.

29. Sacks HS, Berrier J, Reitman D, Ancona Berk VA, Chalmers TC. Meta-analyses of randomized controlled trials. N Engl J Med 1987;316:450-455.

30. Daifuku R, Stamm WE. Association of rectal and urethral colonization with urinary tract infection in patients with indwelling catheters. JAMA 1984;252:2028-2030.

31. Gelber RD, Goldhirsch A. Interpretation of results from subset analyses within overviews of randomized clinical trials. Stat Med 1987;6:371-388.

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Current as of July 2001
Internet Citation: Chapter 15. Prevention of Nosocomial Urinary Tract Infections (continued). July 2001. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/evidence-based-reports/services/quality/er43/ptsafety/chapter15b.html