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
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
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
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
1. assessing the need for catheterisation;
2. selection of catheter type;
3. aseptic catheter insertion; and
The guidelines note studies finding that silver
alloybut not silver oxidecoated 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
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.
UTI: ANALYSIS BY
|UTI per 100|
|95 per cent Confidence interval||0.54-0.86
*Excludes infections that occurred with catheters inserted
on nonstudy wards or at outside hospitals. UTI indicates urinary
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 devicesfrom 7.4 to 2.9 infections per
1,000 catheter days.
An effective national strategy for combating infection must
tackle UTI as the single biggest category of health care associated
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
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:
Karchmer T et al A randomized crossover study of silver-coated
urinary catheters in hospitalized patients Arch Intern Med
2000; 160: 3294-3298. Back
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