Select Committee on Science and Technology Written Evidence

Memorandum by Bard Limited

  In making this submission, John Murray Consulting represents the interests of Bard Limited, which is the biggest supplier of urethral catheters to the NHS and a leader in nosocomial urinary tract infection.


  A number of reports in recent years have highlighted the resurgence of health care associated infection and its impact in morbidity and mortality, the growth of antimicrobial resistant organisms and efficiency and costs.

  In the Chief Medical Officer's strategy for infectious diseases, Getting Ahead of the Curve, ten key changes to public policy are identified, including intensified control measures to reduce health care associated infection.

  The NHS Executive has previously acknowledged that it should be possible to reduce the incidence of hospital acquired infection by 15 per cent or more, avoiding costs of some £150 million per annum and saving lives. In its forty second report, the Public Accounts Committee commented that such progress would be essential for the NHS to meet its duty and commitment to patients.


  If, until the advent of MRSA, health care associated infection struggled to gain the attention it deserves, urinary tract infection has been almost entirely lost to sight. This is surprising given its prevalence. Indeed, the PHLS report on the socio-economic burden of hospital acquired infection found that 34.6 per cent were UTIs, with multiple infections the next largest category at 18.4 per cent, followed by lower respiratory tract infection at 15.5 per cent and surgical wound infection at 12.3 per cent.

  Furthermore, looking at prevalence by specialty, elderly care came top with 23.9 per cent, followed by surgery and gynaecology with 17.5 per cent and 16.5 per cent respectively. UTI is especially common among the elderly. The Government Actuary Department's projections for the UK population show the 60-74 year old category rising by 1.5 million or 6.02 per cent between 2000-11 and the population in the 75 and over group rising by 350,000 or 7.65 per cent. In the absence of more effective control, the dominance of UTIs as the most numerous category of health care associated infection could therefore grow.


  Although UTIs were found by the PHLS study to be relatively inexpensive to treat at £1,327 each, their number makes them the most expensive category at £124 million per annum (low £81 million High £167 million). Furthermore, as the Public Accounts Committee noted, the study only covered 70 per cent of adult non-day cases. If a pro-rata adjustment is made, the burden of in-patient costs related to UTI rises to £177 million to treat some 133,000 cases per annum.

In turn, this has an adverse impact on the efficiency of bed use within the NHS. PHLS found that UTIs extended the mean length of hospital stays by six days. UTI may therefore be accounting for an extra 798,000 bed days each year; a very significant diversion of resources away from the objectives set out in the NHS Plan.


  Although much UTI is relatively mild in nature, studies suggest that between one to five per cent of patients will develop a secondary bacteraemia. The Nosocomial Infection National Surveillance Scheme's (NINSS) report on hospital acquired bacteraemia for the period May 1997 to March 2002 found that the majority of cases were device-related, with central IV catheters accounting for 27.4 per cent and urethral catheters the next biggest source of infection at 8.5 per cent. Overall, seven per cent of enterococci were resistant to vancomycin, varying from three per cent for Enterococcus faecalis to 17 per cent for Enterococcus faecium.


  80 per cent of UTIs are associated with catheterisation. This is reflected in the national evidence-based (epic) guidelines for preventing hospital-acquired infections, which make recommendations on:

    1.  assessing the need for catheterisation;

    2.  selection of catheter type;

    3.  aseptic catheter insertion; and

    4.  catheter maintenance.

  The guidelines note studies finding that silver alloy—but not silver oxide—coated catheters are associated with a lower incidence of bacteriuria but observe that these are not available in the UK.

  This about to change, with the UK launch of Bard's silver alloy product in May 2003.


  An economic model to assess the cost and benefits of the routine use of silver alloy coated urinary catheters[23] found that they produced financial benefits given a reduction in UTIs of 14.6 per cent or more in catheterised medical patients and 11.4 per cent or more in catheterised surgical patients. The underlying assumptions included a cost differential of £9 between silver alloy and conventional catheters and an average 3.6 days extra hospitalisation arising from infection.

  Bard intends to market the product in the UK with a price differential of not more than £2, while the PHLS study found UTI to increase average bed stay by six days. The breakeven point for usage may therefore be significantly lower than the model's estimates.

  In interpreting the results of the model, the authors noted that doubt had been cast on some of the published results showing a reduction in the incidence of UTIs but that a recent study conducted on a relatively large scale had found a 32 per cent reduction (see table below) in the risk of getting a UTI through use of silver alloy coated catheters[24].


UTI per 100
Silver-coated catheters2.13
Uncoated catheters3.12
Relative risk0.68
95 per cent Confidence interval0.54-0.86

*Excludes infections that occurred with catheters inserted on nonstudy wards or at outside hospitals. UTI indicates urinary tract infection.

  No large scale trials have been conducted in the UK but a performance improvement project at Ashford and St Peters Hospital Trust in Middlesex found that UTIs reduced 60.6 per cent by using silver alloy coated devices—from 7.4 to 2.9 infections per 1,000 catheter days[25].


  An effective national strategy for combating infection must tackle UTI as the single biggest category of health care associated infection.

  In addition to good standards of nursing practice, the arrival of silver alloy coated catheters presents a cost effective opportunity to achieve a large reduction in the prevalence of UTI and thereby health care associated infection.

  In concluding their 1998 report on resistance to antibiotics and other microbial agents, their Lordships commented that:

    "purchasers and commissioning agencies should put infection control and basic hygiene where they belong, at heart of good hospital management and practice, and should redirect resources accordingly."

January 2003

23   Plowman R, Graves N, Esquivet J and Roberts J A. An economic model to assess the cost and benefits of the routine use of silver alloy coated urinary catheters to reduce the risk of urinary tract infections in catheterized patients. Journal of Hosp Infection (2001) 48: 33-42. Back

24   Karchmer T et al A randomized crossover study of silver-coated urinary catheters in hospitalized patients Arch Intern Med 2000; 160: 3294-3298. Back

25   A Roadhouse The prevention of in-dwelling, catheter-related urinary tract infections-the outcome of a performance improvement project British Journal of Infection Control: publication tbc. Back

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