Policies for replacing long-term indwelling urinary catheters in adults

Background information

A urinary catheter is a tube that is inserted into the bladder from the end of the urethra to drain urine from the bladder. Usually, urinary catheters are only required for a few days, such as after an operation. However, there are some medical conditions that may require bladder drainage on a long-term basis. There are many different ways to care for and maintain a long-term urinary catheter. In this review we refer to these different care methods as health-care 'policies'. Examples of policies that relate to the replacement of a long-term catheter include: time between catheter replacements; use of antibiotics during replacement; use of cleaning solutions or lubricants during replacement; and personnel, environment and techniques used at replacement. This review aimed to identify which policies at the time of long-term catheter replacement were most effective in improving patient care.

The main findings of the review

This review identified that there is currently insufficient high-quality evidence which evaluates the effectiveness of different policies for replacing long-term urinary catheters. Only three randomised clinical trials, which included a total of 107 participants, were eligible and included in this review.

These trials evaluated: (i) different time intervals for catheter replacement, (ii) the use of antibiotics to prevent infection and (iii) the use of different cleaning solutions. There was insufficient evidence to suggest that replacing the catheter monthly and when there was a clinical reason to do so reduced bacteria in the urine compared to replacing the catheter only when there was a clinical reason to do so. However, there was not enough evidence to say whether using antibiotics at the time of replacing the catheter for prevention of infection was effective or whether using water to cleanse during catheter replacement was as effective as an anti-bacterial washing solution.

Adverse effects

None of the trials reported any adverse effects relating to the policies investigated.

Any limitations of the review

All three trials which were included in this review were very small with methodological flaws. Therefore new trials are needed in order to definitely answer this research question. The evidence in this review is current up to 19 May 2016.

Authors' conclusions: 

There is currently insufficient evidence to assess the value of different policies for replacing long-term urinary catheters on patient outcomes. In particular, there are a number of policies for which there are currently no trial data; and a number of important outcomes which have not been assessed, including patient satisfaction, quality of life, urinary tract trauma, and economic outcomes. There is an immediate need for rigorous, adequately powered randomised controlled trials which assess important clinical outcomes and abide by the principles and recommendations of the CONSORT statement.

Read the full abstract...
Background: 

Long-term indwelling catheters are used commonly in people with lower urinary tract problems in home, hospital and specialised health-care settings. There are many potential complications and adverse effects associated with long-term catheter use. The effect of health-care policies related to the replacement of long-term urinary catheters on patient outcomes is unclear.

Objectives: 

To determine the effectiveness of different policies for replacing long-term indwelling urinary catheters in adults.

Search strategy: 

We searched the Cochrane Incontinence Specialised Trials Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 19 May 2016), and the reference lists of relevant articles.

Selection criteria: 

All randomised controlled trials investigating policies for replacing long-term indwelling urinary catheters in adults were included.

Data collection and analysis: 

At least two review authors independently performed data extraction and assessed risk of bias of all the included trials. Quality of evidence was assessed by adopting the GRADE approach. Any discrepancies were resolved by discussion between the review authors or an independent arbitrator. We contacted the authors of included trials to seek clarification where required.

Main results: 

Three trials met the inclusion criteria, with a total of 107 participants in three different health-care settings: A USA veterans administration nursing home; a geriatric centre in Israel; and a community nursing service in Hong Kong. Data were available for three of the pre-stated comparisons. Priefer and colleagues evaluated different time intervals between catheter replacement (n = 17); Firestein and colleagues evaluated the use of antibiotic prophylaxis at the time of replacement (n = 70); and Cheung and colleagues compared two different types of cleaning solutions (n = 20).

All the included trials were small and under-powered. The reporting of the trials was inadequate and as a result, risk of bias assessment was judged to be unclear for the majority of the domains in two out of the three trials. There was insufficient evidence to indicate that (i) there was a lower incidence of symptomatic UTI in people whose catheter was changed both monthly and when clinically indicated (risk ratio (RR) 0.35, 95% confidence interval (CI) 0.13 to 0.95; very low quality evidence) compared to only when clinically indicated, (ii) there was not enough evidence to assess the effect of antibiotic prophylaxis on reducing: positive urine cultures at 7 days (RR 0.91, 95% CI 0.79 to 1.04); infection (RR 1.41, 95% CI 0.55 to 3.65); or death (RR 2.12, 95% CI 0.20 to 22.30; very low quality evidence), (iii) there was no statistically significant difference in the incidence of asymptomatic bacteruria at 7 days (RR 0.80, 95% CI 0.42 to 1.52) between people receiving water or chlorhexidine solution for periurethral cleansing at the time of catheter replacement. However, none of the 16 participants developed a symptomatic catheter-associated urinary tract infection (CAUTI) at day 14.

The following outcomes were considered critical for decision-making and were also selected for the 'Summary of findings' table: (i) participant satisfaction, (ii) condition-specific quality of life, (iii) urinary tract trauma, and (iv) formal economic analysis. However, none of the trials reported these outcomes.

None of the trials compared the following comparisons: (i) replacing catheter versus other policy e.g. washouts, (ii) replacing in the home environment versus clinical environment, (iii) clean versus aseptic technique for replacing catheter, (iv) lubricant A versus lubricant B or no lubricant, and (v) catheter user versus carer versus health professional performing the catheter replacement procedure.

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