Clinical Scenario: Your orthopedist supervising physician has asked you to help out with the research on a presentation she is to give next week on urinary catheter use in adult post-op total hip replacement patients.
“In a related question, the unit’s nurse manager has been advocating that instead of placing indwelling urinary catheters, post-op orthopedic patients who cannot use a bedpan should be “straight cathed” (using an as needed straight catheter which is only placed to empty the bladder at that time and then removed). What can you tell the chief of the service about this question?”
Clinical Question: Does the use of straight catheters as opposed to indwelling urinary catheters reduce the likelihood of infection in female patients over 40 years old?
P – postoperative patients
I – straight catheter
C – indwelling catheter
O – urinary tract infection
- Indwelling catheter in post-op total hip replacement female patients
- Foley catheter in post-op total hip replacement female patients
- PubMed: Search criteria gave 103 results which were not specifically applied to our clinical question.
- Cochrane: Search criteria gave 7 results which were not relevant at all
- Trip Database: Search criteria gave 62 results which were narrowed down to 4 after filtering for randomized control studies
Articles Chosen for Inclusion
- Effect of a hospital-associated urinary tract infection reduction policy on general surgery patients [Harris et. al, 2018]
Harris SK, Mitchell EL, Lasarev MR, Attia F, Hunter JG, Sheppard BC. Effect of a hospital-associated urinary tract infection reduction policy on general surgery patients. Am J Surg. 2018 Apr;215(4):658-662. doi: 10.1016/j.amjsurg.2017.11.025. Epub 2017 Dec 14. PMID: 29275909.
- Indwelling versus Intermittent Urinary Catheterization following Total Joint Arthroplasty: A Systematic Review and Meta-Analysis [Zhang et. al, 2015]
Brosnahan J, Jull A, Tracy C. Types of urethral catheters for management of short-term voiding problems in hospitalised adults. Cochrane Database Syst Rev. 2004;(1):CD004013. doi: 10.1002/14651858.CD004013.pub2. Update in: Cochrane Database Syst Rev. 2008;(2):CD004013. PMID: 14974052.
- Overuse of the indwelling urinary tract catheter in hospitalized medical patients [Jain et. al, 1995]
Jain P, Parada JP, David A, Smith LG. Overuse of the indwelling urinary tract catheter in hospitalized medical patients. Arch Intern Med. 1995 Jul 10;155(13):1425-9. PMID: 7794092.
- The Effect of Bladder Catheterization Technique on Postoperative Urinary Tract Infections After Primary Total Hip Arthroplasty [Garbarino et al., 2020]
Zhang W, Liu A, Hu D, Xue D, Li C, Zhang K, Ma H, Yan S, Pan Z. Indwelling versus Intermittent Urinary Catheterization following Total Joint Arthroplasty: A Systematic Review and Meta-Analysis. PLoS One. 2015 Jul 6;10(7):e0130636. doi: 10.1371/journal.pone.0130636. PMID: 26146830; PMCID: PMC4492963.
- Treatment of urinary complications after total joint replacement in elderly females. [Carpiniello et. al, 1988]
Carpiniello VL, Cendron M, Altman HG, Malloy TR, Booth R. Treatment of urinary complications after total joint replacement in elderly females. Urology. 1988 Sep;32(3):186-8. doi: 10.1016/0090-4295(88)90381-0. PMID: 3413910.
Summary of the Evidence:
|Author (Date)||Level of Evidence||Sample/Setting (# of subjects/ studies, cohort definition etc. )||Outcome(s) studied||Key Findings||Limitations and Biases|
|Harris et. al (2017)||Retrospective Cohort Study||General surgery patients from 2006-2015||Frequency of hospital-associated UTIs in surgery patients after recommendations for reducing indwelling catheter days.||Females had significantly higher risk of HA-UTIs While number of straight catherterizations increased, there was no significant change in HA-UTIs||Hospital policy only looked to reduce indwelling catheter days, did not account for provider education of placement and best infection prevention practices.|
Did not account for initial indwelling catheter days of patients with CA-UTI after policy implementation
|Zhang et al. (2015)||Meta Analysis||1771 post total joint othoplasty patients||compare the rates of UTI and POUR in patients undergoing total joint arthroplasty after either indwelling urinary catheterization or intermittent urinary catheterization.||No significant difference in the rates of UTIs between foley and intermittent catheters Lower rate of POUR in the foley group vs the intermittent group||No precise definition of POUR even amongst urologistsBecause only 9 RCTs were used, it became impossible to stratify according to surgical site.Unable to identify whether the two groups were comparable with respect to the use of opiates and antibiotics because most authors did not report sufficient data in this regard.|
|Garbarino et al. (2020)||Retrospective Cohort Study||7306 THA patients across 15 hospitals between Nov 28, 2016 – April 1, 2019||Incidence of infection in various post operative bladder catheterizations.||A significantly higher risk of developing UTI’s was seen in patients with both indwelling and intermittent catheters. A lower risk was seen in the use of indwelling alone and an even lower risk was associated with intermittent catheterization.||Since the patient data was collected via EMR, patients who sought external follow up were usually lost. However, most infections were seen during the initial stay and this lowers the risk of missed data. The study was also unable to gather the exact duration of urinary bladder catheterization Sample was collected based on billing codes which may have been erroneously added (coding error within 15 different institutions)|
|Jain P. Parada (1995)||Prospective Cohort Study||202 ICU patients||Infection vs. No Infection after use of indwelling catheter||Continued catheterization was found to be unjustified in 47% of patients ( causing complication).||Results recorded by human observer → human error is a possibilityNo parameters on gender or ageLimited to one hospital setting → may skew results based on procedures performed in the hospital and demographic of community|
|Carpiniello, et. al (1988)||Randomized control study||77 patients undergoing total joint replacement||Incidence of urinary tract infection and retention||-Patients who received an indwelling Foley catheters preoperatively and for 24 hours postoperatively had a reduced incidence of infection as opposed to patients who received straight catheterization in the recovery room alone||Small sample size of 77 patients Study was performed in 1988, over 20 years ago Limited to patients receiving spinal anesthesia only, not general anesthesia Patients were given prophylactic antibiotics for 3 days post-op which were not controlled. They were given either clindamycin or cefazolin|
In postoperative patients, indwelling catheters demonstrated to increase the risk of infection. In contrast, intermittent or straight catheters demonstrated a lower risk of infection and is the recommended treatment option.
Clinical Bottom Line:
- The category of research question was risk of infection.
- 5 studies were critically appraised.
- 1 prospective, 1 retrospective, 1 randomized controlled trial, 1 meta-analysis, 1 cohort study]
- 4 out of the 5 articles showed the indwelling catheters presented with the risk of infection.