Reducing unnecessary urinary catheter use and other strategies to prevent catheter-associated urinary tract infection: an integrative review

Abstract

Background: Catheter-associated urinary tract infections (CAUTI) are costly, common and often preventable by reducing unnecessary urinary catheter (UC) use.

Methods: To summarise interventions to reduce UC use and CAUTIs, we updated a prior systematic review (through October 2012), and a meta-analysis regarding interventions prompting UC removal by reminders or stop orders. A narrative review summarises other CAUTI prevention strategies including aseptic insertion, catheter maintenance, antimicrobial UCs, and bladder bundle implementation.

Results: 30 studies were identified and summarised with interventions to prompt removal of UCs, with potential for inclusion in the meta-analyses. By meta-analysis (11 studies), the rate of CAUTI (episodes per 1000 catheter-days) was reduced by 53% (rate ratio 0.47; 95% CI 0.30 to 0.64, p<0.001) using a reminder or stop order, with five studies also including interventions to decrease initial UC placement. The pooled (nine studies) standardised mean difference (SMD) in catheterisation duration (days) was -1.06 overall (p=0.065) including a statistically significant decrease in stop-order studies (SMD -0.37; p<0.001) but not in reminder studies (SMD, -1.54; p=0.071). No significant harm from catheter removal strategies is supported. Limited research is available regarding the impact of UC insertion and maintenance technique. A recent randomised controlled trial indicates antimicrobial catheters provide no significant benefit in preventing symptomatic CAUTIs.

Conclusions: UC reminders and stop orders appear to reduce CAUTI rates and should be used to improve patient safety. Several evidence-based guidelines have evaluated CAUTI preventive strategies as well as emerging evidence regarding intervention bundles. Implementation strategies are important because reducing UC use involves changing well-established habits.

Keywords: Health Services Research; Implementation Science; Infection Control; Patient Safety; Quality Improvement.

Figure 1

Lifecycle of the urinary catheter. This conceptual model illustrates four stages of the urinary catheter lifecycle as targets for interventions to decrease catheter use and catheter-associated urinary tract infection.

Figure 2

Meta-analysis of rate ratios for catheter-associated urinary tract infection episodes per 1000 catheter days, for intervention versus control groups, stratified by type of intervention to prompt catheter removal.

Figure 3

Meta-analysis of risk ratios for percentage of patients who developed catheter-associated urinary tract infection, for intervention versus control groups, stratified by type of intervention to prompt catheter removal.

Figure 4

Meta-analysis of the standardised mean difference in days of urinary catheter use, for intervention versus control groups, stratified by type of intervention to prompt catheter removal.