Intermittent self-catheterisation (ISC) is commonplace for those with long-term urinary retention issues. An intermittent catheter device is inserted regularly to void urine and it carries a lower risk of infection than an indwelling catheter (National Institute for Health and Care Excellence (NICE), 2017).
Those using an intermittent self-catheter device for more than 28 days were found by NICE (2017) to benefit most from reusable non-coated catheters, which are currently defined as single use. However, in order to make an ‘off-license’ recommendation to use this type of catheter device, higher quality evidence is required measuring incidence of infection, bacteraemia, mortality, comfort and preference, as well as quality of life, urethral damage and costs (NICE, 2017).
The three main types of intermittent self-catheters are: coated, non-coated and pre-lubricated (Bladder and Bowel Community, 2017). Coated catheters come with a hydrophilic coating that creates a lubricated surface when run under water prior to use to ease insertion. Non-coated catheters are the traditional intermittent catheters and also seem to be the most preferred (NICE, 2017). They can be washed and reused, and are made of polyvinyl chloride (PVC), silicone, silver or stainless steel, the latter two being only suitable for women due to the urethra length (Bladder and Bowel Community, 2017). Reusable catheters are less frequently used as they require cleaning. Pre-lubricated catheters are ready to use straight from the packet, requiring no additional preparation, and are already packed in a water-soluble gel, making the device easier to use. This is often preferred by someone who lives independently, as it is far less time-consuming and is generally easier to use, particularly when clean water and facilities are not always available (Bladder and Bowel Community, 2017).
Antibiotic prophylaxis
Pickard et al (2018) examined antibiotic prophylaxis in intermittent self-catheterisation, noting that people carrying out clean intermittent self-catheterisation (CISC) in order to void their bladder often have urinary tract infections (UTIs). They also noted that, despite a lack of knowledge regarding effectiveness, it is often advised to give patients antibiotic prophylaxis on a once-daily low-dose basis. Pickard et al (2018) therefore looked at the benefits, harms and cost-effectiveness of prescribing prophylactic antibiotics to prevent infection in those carrying out CISC, and conducted a 1-year randomised trial exploring each allocated intervention with a 3-monthly follow-up, with NHS patients participating from 52 different sites.
The researchers looked at 404 adults using CISC who had been predicted to continue the practice for at least another 12 months, who had suffered at least two UTIs in the last year or had been hospitalised for a urinary tract infection in the previous year. The experimental group was prescribed either 50 mg Nitrofurantoin, 100 mg Trimethoprim or 250 mg Cephalexin once daily, to be taken orally. There was a control group of 201 for comparison, who had not been prescribed prophylaxis for 12 months.
Pickard et al (2018) found that frequency of infection was reduced by 48% in those using antibiotic prophylaxis. There was an absolute reduction of UTI episodes over the course of a year from two individuals in the group receiving no prophylaxis, to one individual in the group taking antibiotics. Some antimicrobial resistance to Escherichia coli (E. coli) was noted in perianal swabs, as well as to some pathogens that were not associated with urine. Prophylaxis incurred an extra cost of £99 to prevent one infection, although this did not account for costs incurred relating to increased antimicrobial resistance.
The emotional and practical burden of CISC and UTI did influence wellbeing, although health status measured over 1 year was similar between all groups, and did not particularly worsen with the infection. The team observed that participants were willing to take the antibiotic without anxiety over development of antimicrobial resistance. There was a clear benefit with the use of antibiotic prophylaxis, in terms of reducing frequency of infection in those using CISC, and antibiotic prophylaxis appears to be safe in the first 12 months. However, resistant pathogens could present a public health concern through creating a pattern of recurring infections despite prophylaxis in the longer term. Therefore, the researchers agreed that longer term studies of resistance and non-antibiotic strategies are required.
Methenamine hippurate
Alternatives to antibiotic prophylaxis have been explored in recent years, such as the study by Harding et al (2022). This study tested and compared the efficacy of methenamine hippurate for the prevention of recurrent urinary tract infections, with the standard low-dose daily antibiotic prophylaxis. The trial was open label, randomised and multi-centre-across 8 centres in the UK, who recruited participants between 2016 and 2018. The study focused on women only, aged over 18, who had a history of recurrent UTIs, thereby requiring prophylaxis. The study took place over the course of 12 months, with two groups; one taking antibiotics (n=120) and one taking methenamine hippurate (n=120) over the year. The modified intention-to-treat analysis comprised 205 (85%) participants (antibiotics, n=102 (85%); methenamine hippurate, n=103 (86%)).
Incidence of antibiotic-treated UTIs during the 12-month treatment period was found to be 0.89 episodes per person per year in the antibiotics group and 1.38 in the methenamine hippurate group, with an absolute difference of 0.49, confirming non-inferiority. Adverse reactions were reported by 34/142 (24%) in the antibiotic group and 35/127 (28%) in the methenamine group, but most reactions were observed to be mild. The researchers concluded that the use of methenamine hippurate as an alternative to an antibiotic may be suitable for women with a history of recurrent UTIs, which can be better informed by patient preference and by what is deemed appropriate, with antibiotic stewardship influencing available choices.
Overall, ISC is commonplace and relatively low risk, with various options of catheter choices, and there exists an ongoing assessment of what is best regarding prophylaxis for infections and alternatives to antibiotics for this purpose.