Tab. IV.
Characteristics and main findings of the primary studies included in our review.
| 1st Author, year [Ref.] | Study type | Sample size/population characteristics | Pathology treated with IC | Type/features of IC | Frequency of IC | UTIs (%) | UTIs risk factor | Main findings |
|---|---|---|---|---|---|---|---|---|
| Bolinger R, 2013 USA [7] |
Cross-sectional study | TOT: 44 patients M: 18 (%) F: 26 (59%) Median age: 56.6 |
NGB: 9 patients (20.5%) Prostate Cancer: 2 patients (0.05%) BHP: 1 patient (0.02%) MS: 21 patients (47.7%) SCI: 2 patients (0.05%) Tetraplegia: 1 patient (0.02%) Atonic bladder: 1 patient (0.02%) Kidney cancer: 1 patient (0.02%) Spina bifida: 1 patient (0.02%) |
CIC | - | 77.2% | Personal and environmental barriers that might have increased the risk for UTIs | UTIs is the most commonly reported complication associated with CIC. Skeletal muscle spasticity acted as a barrier to CIC in patients with MS. More studies are needed to examine the occurrence of UTIs in people who reuse their catheters multiple times versus those who use single-use catheters |
| Bohtig R, 2013 Germany [8] |
Longitudinal, prospective study | TOT: 133 patients M: 116 patients Age interval: 19-79 years (Mean age 45) F:17 patients Age interval: 32-75 years (Mean age 60) |
SCI | • ISC: 51 patients • IC by attendant (trained nurse): 63 patients |
- | Self IC group UTI = 13.72% UTI + SBU: 21.57% De novo UTI in patients with sterile urine: 3 patients (8.82%) UTI in patients with prior SBU: 4 (23.5%) patients IC by attendant: UTI: 15.87% UTI+SBU: 23.81% De novo UTI in patients with sterile urine: 6.67% UTI in patients with prior SBU: 38.89% |
• Elevated intravesical pressure • Incomplete voiding • Use of catheterization |
There were only minor differences between patients with ISC and IC by attendant (incidence of de-novo-UTIs, 8.82 and 6.67%, respectively) |
| Afsar SI, 2013 Turkey [9] |
Longitudinal, retrospective study | Baseline CIC group: 104 patients (63.4%) F: 34 (32.7%) M: 70 (67.3%) After follow-up CIC group: 60 patients (37.5%) |
SCI | CIC PVC catheters: 32 patients (53.3%) Hydrophilic catheter: 28 patients (46.7%) |
- | 3 UTIs frequency/year: • 93.3% • once a year for hydrophilic catheter users • 2 episodes per year for PVC catheter users |
- | At follow-up, 44 (42%) of the 104 patients stopped using CIC. The reasons for changing the method were recurrent symptomatic UTIs, incontinence, nephrolithiasis, dependence on caregivers and urethral strictures |
| Nyman M, 2013 Sweden [10] |
Randomised control trial | TOT: 170 patients IC group: 85 patients M: 37 (44%) F: 48 (56%) Mean Age (SD): 72.1 years |
Hip fracture: 57 patients (67%) Osteoarthritis: 28 patients (33%) |
IC | The median number of IC needed was 1 | UTIs related to IC: 8 patients (9.4%) | - | This study did not find any significant differences between IC and indwelling urinary catheterization in nosocomial UTIs |
| Yıldız N, 2014 Turkey [11] |
Cross-sectional study | TOT: 337 patients IC group: M: 178 (78.8%) F: 65 (75.6%) |
SCI | Aseptic IC | - | UTI related to IC: 51 patients (81.0%) IC group without UTI: 181 patients (76.1%) |
Method of urinary drainage | The frequency of symptomatic UTI was similar in the bladder management groups |
| Yilmaz B, 2014 Turkey [12] |
Cross-sectional, retrospective study | TOT CIC users: 207 Acute SCI group: 88 patients Chronic SCI group: 119 patients |
Acute and chronic SCI | CIC | - | Symptomatic UTIs: 76/207 (37%) Asymptomatics bacteriuria (ASB):131/207 (63%) |
- | Infection rates were higher in patients with SCI using an indwelling Foley catheter. Therefore, in order to reduce the rate of NAUTIs, the use of an indwelling catheter should be removed as soon as possible with CIC |
| Krassioukov A, 2014 Canada [13] |
Cross-sectional study | TOT: 61 paralympic wheelchair athletes F: 8 (13%) M: 53 (87%) |
SCI | CIC | 6 ± 2 times per day (ranging from 1 to 10 per day) | Re-use 4 ± 3 UTIs per year Single use: 1 ± 1 UTI per year |
Re-use of catheter | The frequency of daily catheterizations was not related to the frequency of UTIs. 19 individuals (31%) reported reuse of catheters with an average of 34 ± 50 times using the same single-use catheter (ranging from 2 to 200 times per catheter). There was a significant association between frequency (number per year) of UTIs and catheter reuse: individuals who reused catheters experienced UTI more frequently |
| Rabadi MH, 2014 USA [14] |
Longitudinal, retrospective study | TOT: 161 patients M: 157 (93.56%) F: 4 (6.44%) Median age: 59.5 ± 13.6 years (range 25-90 years) IC group: 40 patients |
SCI with NGB | CIC | - | UTI related to IC: 14 cases (35%) | Poor CIC technique | Patients with lumbosacral injury were able to self-void or use CIC in 76% of the cases, whereas patients with cervical and thoracic injury needed Foley or suprapubic catheterization |
| Mukai S, 2016 Japan [15] |
Longitudinal, retrospective study | TOT: 259 patients M: 220 (84.9%) F: 39 (15.1%) Median age: 47 (12-90) |
SCI associated NGB | CIC | Routinely: median value of 7 times per day | Number of febrile UTI: 67 patients (25.8%): | • Male gender; • Severity of spinal cord diseases (ASIA impairment scale C or more severe) |
Educating CIC patients on how best to decrease their risk of UTI is important and should be an ongoing mission. Many times of CIC with keeping clean technique leading to low rate of frequency of UTI occurrence |
| Krebs J, 2016 Switzerland [16] |
Longitudinal, retrospective study | IC group: 415/1418 patients M:100% Mean age: 41 years (range 19-74 years) |
NLUTD • Traumatic SCI: 92.4% |
IC | - | Approximately 70% of patients using IC suffered at least one symptomatic UTI per year ~ 30% of the patients using IC experienced more than two symptomatic UTIs per year |
- | The bladder evacuation method, rather than patient or injury characteristic, is the main predictor for the occurrence of symptomatic UTIs in individuals with NLUTD |
| Alavinia SM, 2017 Canada [17] |
Longitudinal study | TOT: 55 patients M: 42 (76.40%) F: 13 (23.60%) Median age: 48.31 ± 18.5 years IC group: 40 patients (72.70%) |
Subacute SCI | CIC
|
- | UTI related to IC: 26 (81.30%) cases
Bladder management method: • 72.70% of UTI was in those on CIC • 46% of UTI cases had nurses performing CIC |
• Learning time of IC technique by patients • Nursing care (i.e., hand washing, aseptic techniques, etc.) |
The time when individuals with SCI were learning CIC and were being assisted by nurses was associated with a higher likelihood of UTI. It is essential that nurses have the necessary expertise to provide optimal care and minimize the problems associated with routine CIC |
| Cox L, 2017 USA [18] |
Longitudinal, prospective study |
TOT: 22 patients | NB | ISC | - | Pre-intervention 4 UTIs in the preceding six-month period Post-intervention Fewer symptomatic UTI’s (median 4 vs 1 episode) and fewer courses of treatment with oral antibiotics after initiating gentamicin (median 3.5 vs 1) |
- | Symptomatic UTIs decreased significantly from four episodes to one in a six-month period |
| Crescenze I, 2018 USA [19] |
Longitudinal cohort study | TOT CIC users: 753 F: 32.9% (248/753) Median Age: 43.2 (18,0-86,0 years) |
Acquired SCI | IC Non self CIC (caregiver):10.9% (82/753) |
CIC was used for a median of 9.5 (0-44) years since the injury | > 4 UTIs per year: 27.8% UTI related hospitalization within 12 months:10.4% |
- | - |
| McClurg D, 2018 UK [20] |
Three-part mixed-method study: • prospective longitudinal cohort • longitudinal qualitative interviews • cross sectional, retrospective survey |
TOT: 56 patients Discontinuers CIC group: 13 patients F: 11 (85%) Mean Age (SD): 51.3 (10.1) Continuers CIC group (at 1-year follow-up): 43 patients F: 31 (72%) Mean Age (SD): 49.9 (12.5) |
MS | CIC | - | At baseline Discontinuers CIC group: 3 patients (23%) Continuers CIC group: 22 patients (51%) More UTIs at 8 months in those who discontinued CIC compared to those who continued |
- | Variables relating to the nature of MS as an illness (i.e. poor balance and dexterity) and those relating to the clinical and personal support available seemed to influence a person’s readiness to undertake CIC |
| Stillman MD, 2018 USA [21] |
Secondary analysis of data from a prospective clinical trial | M: 79% Mean age: 41 years |
SCI | IC At discharge 21% were using IC At 12 months follow-up, 27% were using IC |
Baseline: Prevalence of UTI: 13/35 (37%) At 12 months follow-up: 12/39 (31%) |
During the first year after discharge, 3- month prevalence rates of UTI were reported. Subjects with spontaneous voiding reported significantly fewer UTIs than those using IC or IDC, but there was no significant difference in UTIs between IC and IDC |
||
| Huang X, 2019 China [22] |
Longitudinal study | TOT: 80 patients M: 49 F: 31 QCC group: 40 patients M: 25 F: 15 Mean Age (SD): 56.7 ± 4.3 CG: 40 patients M: 24 F: 16 Mean Age (SD): 57.3 ± 4.8 |
SCI with NGB | CIC | - | QCC group: 4 patients (10%) CG group: 13 patients (32.5%) |
• Traditional nursing care of IC • Varied nursing expertise of nurse team • Timing of catheterization • Deviation in the understanding by patients and their families • Improper selection of urinary catheters • Irregular hand disinfection and lack of bladder training |
The active education of IC, demonstration and guidance of CIC and active communication with patients enable them to know and master disease knowledge, improving their self-management ability |
| Roth J.D., 2019 USA [23] |
Retrospective cross-sectional survey | TOT: 1479 patients CIC group: 753 patients M: 504 (66.9%) F: 248 (32.9%) Age mean (SD): 43.7 (13.1) |
SCI | CIC | Mean number of daily catheterizations: 5.94 (SD 1.81) | UTI rate based on CIC bladder management in the last year [N (%)]: • 0: 172 (22.8%) • 1-3: 372 (49.4%) • 4-6: 117 (15.5%) • > 6: 92 (12.2%) UTI hospitalization in the last year [N (%)]: 82 (10.9%) The adjusted odds of increased UTI frequency (reference: Void): 3.42 (2.25-5.18, p < 0.001) for CIC. The adjusted odds of UTI hospitalization: 2.06 (0.80-5.31) for CIC |
• Younger age • Female gender • In-home support |
- |
| Anderson CE, 2019 Switzerland [24] |
Longitudinal, prospective cohort study |
TOT: 369 patients F: 121 (32.8%) M: 248 (67.2%) |
SCI | Assisted-IC: 41 patients (11.1%) Self-IC: 32 patients (8.7%) |
- | • Patients with exactly 1 UTI: 97 (26.3%) F: 35 (36.1); M: 62 (63.9) IC assisted: 12 patients (12.4%) IC-self: 8 patients (8.2%) • Patients with 2 or more UTIs: 62 (16.8%) F: 8 (12.9); M: 54 (87.1) IC assisted: 13 patients (21.0); IC-self: 6 patients (9.7) |
Bladder emptying method | The incidence rate ratios of UTIs were: • assisted IC: 6.05 (95% CI 2.63-13.94); • self-IC: 5.16 (95% CI 2.31-11.52) |
| Henessey D, 2019 Australia [25] |
Longitudinal, prospective study | TOT: 143 patients M: 107 (75%) F: 36 (25%) Mean Age: 42 years (27-61) ISC group: 45 patients |
SCI | ISC | - | ISC: 12 patients (27%) UTI rate: 6.8/1000 inpatient days |
Male A protracted admission Delays in time to TROC UTI before TROC due to bacterial colonisation |
ISC and SPC are both associated with reductions in the UTI rate. However, the higher rate of UTI seen in ISC patients may be due to a combination of the learning curve, unfamiliarity with aseptic technique and a spectrum of neurological deficit, with some patients struggling to catheterize with sterility. |
| Nade ES, 2020 Tanzania [26] |
Cross-sectional study | TOT: 48 patients Performing CIC group: 23 (47.9%) Inpatients: 16 (80%) Outpatients: 7 (25%) |
SCI | CIC Individual performing CIC: 8 (16%) Family members performing CIC: 15 (31.3%) |
- | UTI with fever: 9 (39.2% of all patients performing CIC) Inpatients: 4 (25%) Outpatients: 5 (71%) |
- | The obstacles to perform CIC include inability to sit (31.3%), not access to CIC equipment (58.3%), insufficient hand function (29.2%) and spasticity (14.6%). |
| Berger A, 2020 Germany and The Netherlands [27] |
Longitudinal, retrospective chart review | TOT: 73 patients F: 11 (15.1%) M: 56 (76.7%) Missing: 6 patients (8.2%) < 60 years old: 64% |
SCI | Non self IC | - | UTI at baseline: 19 patients (26%) UTI during 3 months of follow up: 42 patients (57.5%), ranging from 13.7% to 45.2% UTI Rate: 31,5 UTIs per 100 PMs (5.3-22.7 per 100 PMs) |
Probably, history of colonization at baseline | One-half of patients developed UTI within 41 days initiating IC. |
| Patel DP, 2020 USA [28] |
Prospective longitudinal study | TOT: 176 patients M: 110 (63%) F: 66 (37%) Median age: 45.3 |
SCI | CIC | Discontinued CIC | Number of UTIs in the last year: • 0: 37 patients (21%) • 1-3: 79 patients (45%) • ≥ 4: 60 patients (34%) Hospitalization for UTI: 29 patients (16%) |
- | Convenience (36%), urinary leakage (20%), and the number of urinary infections (19%) were the most common reasons for CIC cessation. |
| Garbarino L, 2020 USA [29] |
Longitudinal prospective study | IC group: 285 patients (3.9%) Indwelling and IC group: 327 patients (4.5%) |
Hip arthroplasty | IC | - | UTI: 12.6% | - | Patients treated with urinary bladder catheterization, through any method, was significantly more likely to experience UTIs compared to patients not requiring catheterization. Patient requiring any form of catheterization were found to be at a statistically significantly higher risk for post-operative UTIs (p < 0.001). Indwelling catheterization was found to have an increased risk of postoperative urinary tract infections, with 17.0% of patients having this complication. Patients requiring IC (12.6%) and both indwelling and intermittent catheterization (22.6%) were found to have an increased risk |
| Neyaz O, 2020 India [30] |
Prospective longitudinal study | TOT: 31 patients M: 29 (93%) F: 2 (7%) Median age: 28.6 ± 9.2 years |
SCI | ISC | - | Mean UTI episode was 0.19 episodes/patient/month or 2.29 episodes per patient per year | Incomplete voiding Elevated intravesical pressure Catheter use |
UTI is more common in individuals with SCI. E. coli is the most common cause of UTI |
| Moussa M, 2021 Lebanon [31] |
Prospective trial | TOT: 119 patients M: 91 (76.5%) F: 28 (23.5%) Median age: 36 |
• NLUTD • SCI: 62.1% • Spina bifida: 8.4% • MS: 7.6% • Cerebro vascular accident: 7.6% • Parkinson’s disease: 7.6% • Degenerative disc disease: 6.7% |
CIC | - | Pre irrigation Symptomatic UTIs/year: 4 episodes: 33.6% 5 episodes: 47.1% > 5 episodes: 19.3% ED visits for UTI: • 3 visits: 4.2% • 4 visits: 29.4% • > 4 visits: 66.4% Inpatient hospitalizations for UTI, n (%): 1 hospitalization: 1.7% 2 hospitalizations: 7.6% 3 hospitalizations: 34.5% > 3 hospitalizations: 56.3% Post irrigation symptomatic UTIs/year: • 0 episode: 53.8% • 2 episodes: 32.8% • 3 episodes: 0.8% ED visits for UTI: • 0 visit: 16.8% • 1 visit: 58% -2 visits: 24.4% 3 visits: 0.8% Inpatient hospitalizations for UTI, n (%): 0 hospitalization: 28.8% -1 hospitalizations: 62.2% -2 hospitalizations: 8.4% -3 hospitalizations: 0.8% |
Urinary stasis High bladder pressure Bladder stones |
Individuals performing CIC have a 4-fold-increased risk of UTI compared to those who do not perform CIC |
| Walter M, 2021 Canada [32] |
Cross sectional study | TOT: 130 wheelchair athletes Age: 34 (28-41, 18-55) F: 18 (14%) M: 112 (86%) |
SCI | IC: 109/130 (84%) IC (transurethral): 93 (72%) IC (stoma): 3 (2%) Self-catheterization Catheterization through others Non hydrophilic catheters: 62%, (68/109) Single-use of catheters: 59%, (64/109) Lubrication: 61% (67/109) Size 14 Fr catheters: 57%, (62/ 109) Shape of catheter tip: straight tipped catheters 70% (77/109) |
Median duration of performing IC: 10 years (IQR 6-15, range 1-28). Median frequency of catheterizations per day: 5 (IQR 4.5-6, range 1-10) |
At least one episode of UTI during the last 12 months: 63% (69/ 109). Median number of self-reported UTIs per year: 1 (IQR 0-2, range 0-12). At least one course of antibiotic treatment for UTI during the last 12 months: 52% (57/109) Median number of antibiotic treatments for UTI per year: 1 (IQR 0-2, range 0-11) |
Probably re-use of catheter | Continued education remains a primary target to address and to attempt to reduce complications associated with IC (e.g., UTIs and urethral injuries). |
| Angermund A, 2021 Germany [33] |
Longitudinal retrospective study |
TOT: 1100 patients M: 511 (46%) F: 589 (54%) Median age: 57.3 |
• Urologic diseases: 516 patients (47%) • SCI: 180 patients (16%) • Other injuries affecting the spinal cord: 134 patients (12%) • MS: 107 patients (10%) • Other causes of paralysis: 63 patients (6%) • Stroke: 40 patients (4%) • Spina Bifida: 45 patients (4%) • Parkinson’s disease: 30 patients (3%) |
IC | - | UTI 1 year before index: 669 patients (61%) UTI in follow-up: year 1 60%; year 2 50%. |
- | UTIs were shown to increase the number of hospital admissions and length of stay. 13% of the German population (compared to 50% of IC users in this study) have at least one hospital stay per year and stay for on average of 7.3 days (compared to 10 days of IC users in the study). Individuals who perform IC were associated with a mean of 16 GP visits per year. Approximately one third visited a psychologist per year (before and after initial IC use). |
| BPH: Benign Prostatic Hyperplasia; CIC: Clean Intermittent Catheterization; CIF: Indwelling Foley Catheterization; CG: Control Group; HC: Hydrophilic Catheters; IC: Intermittent Catheterization; ISC: Intermittent Self-Catheterization; MS: Multiple Sclerosis; NGB: Neurogenic Bladder; NHC: Non-Coated Catheters; NLUTD: Neurogenic Lower Urinary Tract Dysfunction; QCC: Quality Control Circle; SCI: Spinal Cord Injury; TROC: Trial Removal of Catheter; UTI: Urinary Tract Infection. | ||||||||