Page 3 - CUAJ February 2019: Clean intermittent catheterization: Single use vs. reuse

Saadat et al

was statistically significant (p<0.001). Athletes from devel- of UTIs in the HC group and indicates the importance of
oping countries experienced higher UTI frequency com- catheter handling. Another explanation might be that the
pared to athletes from other countries (p=0.027). This was primary outcome of this study was not based on a standard
explained by the fact that 73% of those from developing definition of UTI; UTI was defined as positive leukocytes
countries reused their catheter, while this was the method plus UTI symptoms (instead of positive bacterial culture). 19
in only 17% of those from developed countries. The study Comparing single usage of HC catheters with reuse of
also showed that catheterization frequency per day did not PVC catheters was also addressed in a recently published
impact the UTI frequency. Compared to the previous study systematic review by Rognoni and Tarricone in adult
17
20
by Kanaheswari et al, this study might better account for and adolescent populations. The frequency of UTI was
the actual adherence to cleaning practices, simply due to shown to be lower with HC catheters (RR 0.84; 95% CI
its retrospective design. 18 0.75–0.94; p=0.003 for both analyses) and the estimated
The discredited Cochrane systematic review, published risk reduction with HC catheters was found to be 16%. 20
in 2014, stated, “There is still no convincing evidence that The mean age in all of the studies included in this review
the incidence of UTI is affected by use of aseptic or clean was above 37 years, which can justify the different results
technique, coated or uncoated catheters, single (sterile) or observed by Kiddo et al (mean age 10.6±6.2 years). 19
multiple-use (clean) catheters, self-catheterization or cath- A prospective, randomized control trial published in 2017
eterization by others, or by any other strategy.” 13,15 The abil- compared the advantage of HC catheters against single use
21
ity of this publication to influence clinical practice raised of UC catheters for one year. Interestingly, children were
many concerns, leading to an independent appraisal of this chosen as the target population, but the differences between
Cochrane review. This re-analysis revealed many flaws and this cohort and the population in the Kiddoo et al study 19
as a result of all the raised concerns, the Cochrane review is that dexterity testing of both hands was performed in this
was withdrawn from publication. 14,15 The reanalysis illustrat- trial (if the child was self-catheterizing). It was illustrated that
ed that if HC catheters are not considered separately, a small HC catheters were associated with a lower risk of UTI, even
but non-significant trend in favour of single usage vs. reuse if the UC catheter was used only once and then discarded
of catheters could be found (risk ratio [RR] 0.91;p=0.593). (9.1% vs. 51.5% UTIs per person-year; p=0.003). Comparing
When focusing on HC catheters, the appraisal showed a sig- the UTI rates during the year prior to the study with the
nificant reduction in the incidence of UTI compared to other rates during the study year showed that the HC group saw
catheters (RR 0.81; 95% confidence interval [CI] 0.65‒0.99; a drop from 16% to 5%, although this was not statistically
15
p=0.043). An important consideration to mention is that if significant. While the number of times that a UC catheter
UTI definition was to be adjusted for, only two trials (from was used before being discarded is not clear in this study,
1996 and 1999) could be considered for comparing HC the authors stated, “In our practice, uncoated catheters are
catheters with other types and no significant difference was ‘one-time’ use only and patients are never advised to wash
found regarding the incidence of UTI. 14,15 and reuse their catheters.” 21
In the same year (2014), a narrative review of the com- Further comparison of single-use HC and single-use non-
plications associated with single- or multiple-use catheters HC catheters was addressed in a separate subanalysis of the
was published. This review revealed that single-use HC cath- previously mentioned systematic review by Rognoni and
3
eters can reduce the risk of UTI by about 20‒30%. Based Tarricone. Once again, the frequency of UTI was lower
on the observational studies, this review estimated the risk of with single-use of HC catheters (RR 0.84; 95% CI 0.75–
UTI to be about 70‒80% in those who reused their catheter, 0.94; p=0.003 for both analyses), with the estimated risk
while the estimated risk with single-use catheters was about reduction found to be 16%. 20
40‒60%, based on review of randomized controlled trials. 3
Recently, more data has become available comparing Cleaning methods
HC catheters to other catheters. A prospective crossover
trial conducted by Kiddoo et al compared single-use HC If reusable urinary catheters are to be used for IC, the method
catheters and multiple-use PVC catheters in a pediatric and of sanitation becomes particularly important. Several meth-
19
young adult population with NBs. Each treatment period ods have been reported in the literature, including: cleaning
was 24 weeks, for a total duration of 48 weeks. The study with antibacterial soap and water; alcohol sterilization; using
showed that the risk of UTI was higher with the single-use HC aseptic solutions, such as chlorhexidine 1.5% and cetrimide
catheters as opposed to multiple-use PVC catheters (person- 15%, microwave sterilization; or simply rinsing with water
weeks of UTI were 3.42±4.67 and 2.20±3.23, respectively; and combinations of these methods. 22-25
p<0.001) The fact that 52% of the children in this study were A literature review in 2014 could not recommend a stan-
3
self-catheterizing, along with challenges in learning how to dardized method for cleaning reusable catheters and to our
use HC catheters might explain the increased person-weeks knowledge, no randomized controlled trials have compared

66 CUAJ • February 2019 • Volume 13, Issue 2