Systematic Review of Interventions to Reduce Urinary Tract Infection in Nursing Home Residents

Abstract

BACKGROUND

Urinary tract infections (UTIs) in nursing homes are common, costly, and morbid.

PURPOSE

Systematic literature review of strategies to reduce UTIs in nursing home residents

DATA SOURCES

Ovid MEDLINE, Cochrane Library, CINAHL, Web of Science and Embase through June 22, 2015.

STUDY SELECTION

Interventional studies with a comparison group reporting at least one outcome for: catheter-associated UTI (CAUTI), UTIs not identified as catheter-associated, bacteriuria, or urinary catheter use.

DATA EXTRACTION

Two authors abstracted study design, participant and intervention details, outcomes, and quality measures.

DATA SYNTHESIS

Of 5,794 records retrieved, 20 records describing 19 interventions were included: 8 randomized controlled trials, 10 pre-post non-randomized interventions, and 1 non-randomized intervention with concurrent controls. Quality (range 8-25, median 15) and outcome definitions varied greatly. Thirteen studies employed strategies to reduce catheter use or improve catheter care; nine studies employed general infection prevention strategies (e.g., improving hand hygiene, surveillance, contact precautions, reducing antibiotics). The nineteen studies reported 12 UTI outcomes, 9 CAUTI outcomes, 4 bacteriuria outcomes, and 5 catheter use outcomes. Five studies showed CAUTI reduction (1 significantly); nine studies showed UTI reduction (none significantly); 2 studies showed bacteriuria reduction (none significantly). Four studies showed reduced catheter use (1 significantly).

LIMITATIONS

Studies were often underpowered to assess statistical significance; none were pooled given variety of interventions and outcomes.

CONCLUSIONS

Several practices, often implemented in bundles, appear to reduce UTI or CAUTI in nursing home residents such as improving hand hygiene, reducing and improving catheter use, managing incontinence without catheters, and enhanced barrier precautions.

INTRODUCTION

Given the limited number of geriatricians in the U.S., hospitalists commonly manage nursing home residents admitted for post-acute care.^1–4 Urinary tract infection (UTI) is one of the most common infections in nursing homes, often leading to sepsis and readmission to acute care.⁵ Inappropriate use of antibiotics to treat asymptomatic bacteriuria is both common and hazardous to nursing home residents.⁶ Up to 10% of nursing home residents will have an indwelling urinary catheter at some point during their stay.^7–9 Residents with indwelling urinary catheters are at increased risk for catheter-associated urinary tract infection (CAUTI) and bacteriuria, with an estimated 50% of catheterized residents developing symptomatic CAUTI.⁵ While urinary catheter prevalence is lower in nursing homes than in the acute care setting, duration of use is often prolonged.^{7, 10} In a setting where utilization is low, but use is prolonged, interventions designed to reduce UTI in acutely ill patients¹¹ may not be as helpful for preventing infection in nursing home residents.

Our objective was to review the available evidence to prevent UTIs in nursing home residents, to inform both bedside care and future research. Two types of literature review and summary were performed. First, we conducted a systematic review of individual studies reporting outcomes of UTI, CAUTI, bacteriuria or urinary catheter use after interventions for reducing catheter use, improving insertion and maintenance of catheters, and/or general infection prevention strategies (e.g, improving hand hygiene, infection surveillance, contact precautions, standardizing UTI diagnosis and antibiotic use). Second, a narrative review was performed to generate an overview of the evidence available and published recommendations in both the acute care and nursing home settings to prevent UTI in catheterized and non-catheterized older adults, that is provided as a comprehensive reference table for clinicians and researchers choosing and refining interventions to reduce UTIs.

METHODS

The systematic review was performed according to the criteria of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis recommendations. The protocol was registered at the PROSPERO International Prospective Register of Systematic Reviews, (CRD42013005787). The narrative review was performed using the articles obtained from the systematic search and a targeted literature review by topic for a comprehensive list of interventions, including other interventions previously summarized in published reviews and guidelines.

Eligibility Criteria Review

Study Design

To address the breadth and depth of literature available to inform interventions to prevent UTI in nursing homes, broad eligibility criteria were applied with the expectation of varied designs and outcomes. All included studies for the systematic review were published manuscripts reporting a comparison group. We included randomized controlled trials as well as non-randomized trials (pre-test/post-test, with or without concurrent or non-concurrent controls), with any duration of post-intervention follow-up. Observational and retrospective studies were excluded.

Participants

We were interested in interventions and outcomes reported for nursing homes, defined as facilities providing short-stay skilled nursing care and/or rehabilitation, as well as long-term care. We also included evidence derived from rehabilitation facilities and spinal cord injury programs focused on reducing CAUTI risk for chronically catheterized residents. We excluded long-term acute care hospitals, hospice, psychiatric/mental health facilities, pediatric, and community dwelling/outpatient settings.

Interventions

We included interventions involving urinary catheter use such as improving appropriate use, aseptic placement, maintenance care, and prompting removal of unnecessary catheters. We included infection prevention strategies with a particular interest in hand hygiene, barrier precautions, infection control strategies, infection surveillance, use of standardized infection definitions, and interventions to improve antibiotic use. We included single and multiple interventions.

Outcomes

1. Healthcare-associated urinary tract infection: UTI occurring after admission to a healthcare facility, not identified specifically as catheter-associated. We categorized UTI outcomes with as much detail as provided, such as whether the reported outcome only included non-catheter-associated UTIs, the time required after admission (e.g., >2 days), and whether the UTIs were defined by only laboratory criteria, clinically diagnosed infections, symptomatic, or long-term care specific surveillance definitions.

2. Catheter-associated urinary tract infection: UTI occurring in patients during or immediately after use of a urinary catheter. We noted whether CAUTI was defined by laboratory criteria, clinical symptoms, provider diagnosis, or antimicrobial treatment for case identification. We were primarily interested in CAUTI developing after placing an indwelling urinary catheter, commonly known as a Foley, but also in CAUTI occurring with other catheter types such as intermittent straight catheters, external or “condom” catheters, and suprapubic catheters.

3. Bacteriuria: We included the laboratory-based definition of “bacteriuria” as an outcome to include studies that reduced asymptomatic bacteriuria.

4. Urinary catheter use measures: This includes measures such as urinary catheter utilization ratios (catheter days/patient days), prevalence of urinary catheter use, or percentage of catheters with an appropriate indication.

Study Characteristics for Inclusion

Our systematic search included published papers in the English language. We did not exclude studies based on the number of facilities included or eligible, residents/patients included (based on age, gender, catheter use or type, or antibiotic use), intervention details, study withdrawal, loss to follow-up, death, or duration of pre-intervention and post-intervention phases.

Data Sources and Searches

The following data sources were searched: Ovid MEDLINE (1950–June 22, 2015), Cochrane Library via Wiley (1960–June 22, 2015), CINAHL (1981–June 22, 2015), Web of Science (1926–June 22, 2015), and Embase.com (1946–June 22, 2015). Two major systematic search strategies were performed for this review (Figure 1). Systematic search 1 was designed broadly using all data sources described above to identify interventions aimed at reducing all UTI events (defined under “Outcomes” above) or urinary catheter use (all types), focusing on interventions evaluated in nursing homes. Systematic search 2 was conducted in Ovid MEDLINE to identify studies to reduce UTI events or urinary catheter use measures for patients with a history of long-term or chronic catheter use, including nursing homes and other post-acute care settings such as rehabilitation units or hospitals and spinal cord injury programs, which have large populations of patients with chronic catheter needs. To inform the completeness of the broader systematic searches, supplemental systematic search strategies were performed for specific topics including hydration (supplemental search 1), published work by nursing home researchers known to the authors (supplemental search 2), and contact precautions (supplemental search 3). Search 1 is available at http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42013005787. Full search strategies for search 2 and supplemental searches are available upon request.

Figure 1.

Study Flow Diagram. NH=nursing home; UTI=urinary tract infection; CAUTI=catheter-associated urinary tract infection.

Study Selection (Figure 1)

One author performed an initial screen of all records retrieved by the systematic searches by title and abstract and applied the initial exclusions (e.g., non-human, no outcomes of interest), identified duplicate records, and assigned potentially relevant studies into groups such as review articles, epidemiology, interventions, and articles requiring further text review before categorization. After initial screening, clinician author JM reviewed the records by title/abstract. Reference lists were reviewed for potential articles for inclusion. Full text article review informed the selection of those for dual-abstraction and quality scoring performed by 2 authors, with discrepancies resolved by a third author. We requested additional information from authors from whom our search had only generated an abstract or brief report, or when additional information was needed such as pre-intervention data.^12–18

Data Extraction and Quality Assessment

Relevant data regarding study design, participants, inclusion/exclusion criteria, outcomes, and quality criteria were abstracted independently by two authors. Methodological quality scores were assigned using a modification of the Quality Index checklist developed by Downs and Black appropriate for assessing both randomized and non-randomized studies of healthcare interventions.¹⁹ We also reviewed study funding sources and other potential quality concerns.

Data Analysis

Due to large trial heterogeneity among these studies with respect to interventions and outcomes reported, outcome data could not be combined into summary measures for meta-analysis to give overall estimates of treatment effects.

RESULTS

Systematic Search Results and Study Selection

As detailed in the study flow diagram (Figure 1), 5,794 total records were retrieved by systematic search 1 (4,697 studies), search 2 (909 studies), and supplemental searches (188 studies). Hand searching of reference lists of 41 reviews (including narrative and systematic reviews) yielded 77 additional studies for consideration. Twenty-nine records on interventions that were the focus of prior systematic reviews, including topics of cranberry use, catheter coatings, antimicrobial prophylaxis, washout/irrigation strategies, and sterile versus clean intermittent straight catheterization, were excluded from dual abstraction. Two records were excluded after team discussion of the dual-abstraction results, because 1 study did not meet criteria as an intervention study and 1 study’s setting was not applicable in nursing homes. A total of 20 records^{15, 20–38} (in which 19 studies were described) were selected for final inclusion for detailed assessment and reporting for the systematic review.

Characteristics of Included Studies

Table 1 describes the 19 intervention studies in terms of design, participants, setting, and whether the study included specific categories of interventions expected to decrease UTI or catheter use. These studies included 8 randomized controlled trials (4 with cluster-randomization at the facility or unit level), 10 pre-post non-randomized interventions, and 1 non-randomized intervention with concurrent controls. Twelve studies included participants with or without catheters (i.e., not limited to only catheterized patients) in nursing homes.^{15, 20–31} Seven^32–38 studies included only catheterized patients or settings with high expected catheterization rates; settings for these studies included spinal cord units (N=3), nursing homes (N=2), rehabilitation ward (N=1) and VA hospital (N=1) including acute care, nursing home and rehabilitation units. Total quality scores for the studies ranged from 8 to 25 (median 15), detailed in Appendix Table 1.

Table 1.

Characteristics of included studies

First Author, Year, Country	Study Design	Participants/Described setting Total N if provided	Interventions to reduce UTI, CAUTI or urinary catheter use*			Reported Outcomes Types**
			Strategies to reduce or improve catheter use	Infection prevention strategies	Other strategies
Studies including participants that could be with or without urinary catheterization (i.e., not limited to only catheterized patients)
Ahlbrecht, 1999, US20	Pre-post NRT	Residents of a 220- bed community nursing home	Maintenance.	Antibiotic review. Hand hygiene. Infection control. Standardize UTI diagnosis. Surveillance.	Improve resident/patient hygiene	UTI
Brownhill, 2013, United Kingdom15	Pre-post NRT	Residents of 47 care homes	Maintenance. Catheter Securement. Standard Supplies. Incontinence Care. Other: more leg/night bag sizes, improve urine sampling	Antibiotic use review. Standard UTI diagnosis definitions.	Programs to reduce falls and pressure ulcers	UTI, CAUTI
Cools, 1988, The Netherlands21	Pre-post NRT	320-bed skilled nursing facility	Appropriate indications. Prompt removal. Incontinence care.	Antibiotic guide. Hand hygiene. Infection control. Standardize UTI definitions. Surveillance.	Weekly data and new patient review by physicians, improve ventilation by chairs, exercise, physiotherapy	UTI, Catheter use
Fendler, 2002, US22	NRT with concurrent internal & external controls	Residents of a 275- bed extended care facility providing rehabilitation and sub-acute care	None specified	Hand hygiene	None specified	CAUTI
Klay, 2005, US23	Pre-post NRT of same patients	42 female residents with urinary incontinence in 1 extended care facility	Incontinence care.	None specified	Family education on incontinence	UTI
Lin, 2013, Taiwan24	Pre-post NRT with external controls	Incontinent residents of 6 nursing homes	None specified	None specified	Increase hydration	Bacteriuria
McConnell, 1984, US25	Pre-post NRT	102 residents of nursing home	Appropriate indications. Prompt removal. Incontinence care.	None specified	Increase hydration, ambulation program	UTI
Mentes, 2003, US26	RCT-cluster (randomized at facility level)	42 elderly residents from 4 nursing homes: 2 VA nursing homes, 2 community nursing homes	None specified	None specified	Increase hydration	UTI
Miller, 2014, US27	Pre-Post NRT panel survey of stratified proportionate random sample of nursing directors and administrators compared to resident outcomes	824 nursing homes in large study on implementation of culture change between 2005–2010	Comprehensive culture change program anticipated to improve measures including percentage on bladder training programs and reduction of UTI events	None Specified	Introduction of “culture change practices,” as quantified by a culture change practice score reflecting 3 domains: nursing home environment, resident- centered care involving bladder training programs, staff empowerment.	UTI
Stuart, 2015, Australia28	Pre-post NRT	Residents in 2 urban aged care facilities.130 beds	None specified	Nurse-led antibiotic stewardship program, infection control and surveillance programs.	Nurse-physician communications about antibiotics and data	UTI
Van Gaal, 2011, The Netherlands29, 30	RCT-cluster (randomized at ward level)	392 residents from 10 wards from 6 nursing homes	Hand hygiene/gloves for catheter/bag contact. Appropriate indications. Standard catheter supplies. Maintenance. Catheter Securement. Prompt removal. Incontinence care.	Surveillance	Fall, pressure ulcer, UTI prevention programs with nurse education/feedback	UTI Catheter use
Yeung, 2011, China31	RCT-cluster (randomized at facility level), unblended	1268 elderly residents in 6 nursing homes	None specified	Hand hygiene	None specified	UTI
Darouiche, 2006, US32	RCT single-blind	127 adults with spinal cord injury with long-term indwelling catheters. 4 hospitals	Catheter securement by StatLock device	None specified	None specified	CAUTI
Evans, 2013, US33	Pre-post NRT	22 VA acute care spinal cord injury units	None specified	MRSA bundle of surveillance, contact precautions, hand hygiene	Institutional culture change	UTI
Mody, 2015, US34	RCT-cluster (randomized at facility level)	418 residents with devices (catheters or feeding tubes) in 12 community nursing homes	Hand hygiene promotion including gown/gloves when working with indwelling devices	Standardize UTI diagnosis. Hand hygiene/gown/gloves with morning/evening patient care, splashing activity. MDRO active surveillance, pre-emptive barrier precautions if device	Staff program education	CAUTI
Priefer, 1982, US35	RCT	17 male residents with indwelling catheters in 1 VA nursing home	Scheduled catheter change (monthly + for block/infection) compared to change only for block/infection	None specified	None specified	CAUTI
Saint, 2006, US36	RCT unblinded	75 men >40 years old requiring a urinary collection device in 1 VA hospital’s units (medicine, neuro, rehab, nursing home).	Condom catheterization vs. indwelling Foley catheterization	None specified	None specified	Bacteriuria, and Composite of Bacteriuria or CAUTI or Death.
Suardi, 2001, Italy37	Pre-post NRT, for same patients	20 spinal cord injury rehab patients with neurogenic bladder with intermittent catheterization	Time-volume dependent catheterization using bladder scanner	None specified	None specified	Catheter use
Tang, 2006, China38	RCT	81 females with urinary retention in geriatric rehab ward.	Comparing intermittent vs. indwelling catheters. Bladder scan protocol	None specified	None specified	CAUTI, Bacteriuria

Table 1 Abbreviations:

NRT: non-randomized trial, RCT: randomized controlled trial; VA: Veterans Affairs;

MRSA: methicillin-resistant Staphylococcus aureus; MDRO: multi-drug resistant organism.

^*Appendix Table 2 provides details of the interventions, duration of study, and measure collection details.

^**Outcome Abbreviations: UTI: urinary tract infection not identified specifically as catheter-associated; CAUTI: catheter-associated urinary tract infection, Bacteriuria: bacteriuria, not otherwise identified as UTI or CAUTI. Outcome results provided in Table 2.

As detailed in Table 1 and Appendix Table 2, 7 studies^{22, 24, 26, 31, 32, 35, 36} involved single interventions and 12 studies^{15, 20, 21, 23, 25, 27–30, 33, 34, 37, 38} included multiple interventions. Interventions to impact catheter use and care were evaluated in 13 studies, including appropriateness of use,^{21, 25, 29, 30} improving catheter maintenance care,^{15, 20, 29, 30} securement,^{15, 29,30, 32} prompting removal of unnecessary catheters,^{21, 25, 29, 30} improving incontinence care,^{15, 21, 23, 25} bladder scanners,^{37, 38} catheter changes,³⁵ and comparing alternatives (condom catheter or intermittent straight catheter) to use of an indwelling catheter.^{36, 38} None focused on improving aseptic insertion. General infection control practices studied included improving hand hygiene,^{20–22, 29–31, 33, 34} improving antibiotic use,^{15, 20, 21, 28, 34} initiation of infection control programs,^{20, 21, 28} interventions to improve identification of UTIs/CAUTIs using infection symptom/sign criteria,^{15, 20, 21, 34} infection surveillance as an intervention,^{28–30, 33, 34} and barrier precautions,^{33, 34} including preemptive precautions for catheterized patients.³⁴ Hydration was assessed in 3 studies.^24–26

Outcomes of Included Studies

Table 2 describes the studies’ outcomes reported for UTI, CAUTI, or bacteriuria.^{15, 20–38} UTI and CAUTI outcome definitions varied widely. Only two studies^{22, 39} reported UTI outcomes using definitions specific for nursing home settings such as McGeer’s criteria;⁴⁰ a detailed review and comparison of published CAUTI definitions used clinically and for surveillance in nursing homes is provided in Appendix Table 3. Two studies reported symptomatic CAUTIs per 1,000 catheter-days.^{32, 34} Another study²² reported symptomatic CAUTIs per 1,000 resident-days. Three reported symptomatic CAUTIs as counts.^{35, 38} Saint et al.³⁶ reported CAUTIs as part of a combined outcome (bacteriuria, CAUTI, or death).

Table 2.

Summary of outcomes from included studies

First Author, Year	UTI, CAUTI, Bacteriuria measures	Comparison Group	Intervention	Urinary catheter use measures	Comparison Group	Intervention
Studies including participants that could be with or without urinary catheterization (i.e., not limited to only catheterized patients)
Ahlbrecht, 199920	Overall UTI rate/1000 resident days	1.18 (CI:0.36,2.01)	1.14 (CI:0.94,1.34),p=0.65	None reported
	UTIs in non-ambulatory females without indwelling catheters/1000 resident days	2.40 (CI:1.96,2.84)	3.06(CI:2.19,3.93),p=0.05	Not applicable
Brownhill+, 201315	Mean UTI/month	55 UTIs	18.8 UTIs	Not reported
	Mean CAUTI/month	18.3 CAUTIs	4.3 CAUTIs	Not reported
Cools, 198821	UTIs treated with antimicrobials (includes with and without catheters)	0.49 (256 UTIs in 515 residents) in year 1	0.125 (66 UTIs in 527 residents in year 6	Prevalence (%) of indwelling catheters	Year 1 = 21% (109/515)	Year 6 = 10% (52/527)
Fendler, 200222	CAUTIs per 1,000 patient-days, by symptomatic infection 1991 McGeer criteria42	0.77 (133 CAUTIs per 172,897 patient-days)	0.63 (51 CAUTIs per 81,036 patient-days).	Not reported
Klay, 200523	Number of UTIs (not defined further by symptom or catheter-association)	31 UTIs	6 UTIs	Not reported
Lin, 201324	Asymptomatic bacteriuria in patients without indwelling catheters	Control group:	Intervention group:	Not reported
		Baseline: 16.7% (N=5 of 30)	Baseline: 38.6% (N= 17 of 44)
		Follow-up: 10% (N=3 of 30)	Post-intervention: 22.7% (N=10 of 44)
		“No significant bacteriuria for either group.”
McConnell, 198425	Number of UTIs (unclear if restricted to symptomatic; population seems to include both those with and without catheters)	Monthly rates of 3–9 UTIs in months Jun–Nov 1982 (before full implementation in Dec 1982)	Monthly rates of 1–3 UTI in Dec–June 1982 (after Dec 1982 full implementation)	Not reported
Mentes, 200326	Hydration-linked event of UTI diagnosed by a provider (unclear if symptoms, catheter use or other criteria), proceeded by urine specific gravity of >=1.010 + decreased fluid intake	1 UTI (4.1% of 24 control patients)	0 UTI (0% of 25 treatment patients)	Not reported
Miller, 201427	Percentage of residents with UTI in last 30 days reported in Minimum Data Set:	531 NHs in bottom 3 quartiles of culture change composite score:	207 NHs in top quartile of culture change composite score	Not reported
		Baseline period: 8.4% +/− 5.6 (SD)	Baseline period: 8.8% +/− 4.9 (SD)
		Follow-up period: 8.9% +/− 5.4 (SD)	Follow-up period: 8.6% +/− 5.1 (SD)
		Coefficient +0.72 (SE 0.28), meaning higher UTI rates, p=0.01	Coefficient −0.06 (SE 0.54), p=0.92
Stuart, 201528	UTI rates form surveillance data using McGeer’s criteria	Data not provided, but text indicates surveillance infection rates surveillance data remained stable over the 2 data collection periods		Not reported
Van Gaal, 201129, 30	Symptomatic UTI confirmed by physician, reported as incidence rate per patient per week	Baseline period: N=28 UTIs for 127 patients, occurring at rate of 0.03 per patient per week	Baseline period: N=23 UTIs for 114 patients, occurring at rate of 0.03 per patient per week	% Patients with indwelling catheters with a correct indication	Usual care: Baseline: 16%	Intervention: Baseline: 34%
		Follow-up period: N=57 UTIs for 196 patients, occurring at rate of 0.02 per patient per week	Follow-up period: N=58 UTIs for 196 patients, occurring at rate of 0.02 per patient per week		Follow-up: 34%	Follow-up: 32%
		Overall UTI outcome for this study, reported as Ratio of UTIs in intervention versus usual care group: 0.85 with 96% CI: 0.43–1.67
Yeung, 201131	UTIs requiring hospitalization, unclear if with or without catheters	Baseline period: 3 UTIs per 32,726 resident-days, calculated as 0.09 per 1,000 resident-days	Baseline period: 6 UTIs per 21,862 resident-days, calculated as 0.27 per 1,000 resident-days	Not reported
		Follow-up period: 22 UTIs per 81,177 resident-days, calculated as 0.27 per 1,000 resident-days. p=0.06	Follow-up period: 8 UTIs per 50,441 resident-days, calculated as 0.16 per 1,000 resident-days). p=0.30
Studies including only catheterized participants or in settings where very high urinary catheterization rates expected
Darouiche, 200632	Number of symptomatic CAUTIs in patients with Foley or suprapubic catheters.	14 CAUTIs (24.1% of 58 patients followed)	8 CAUTIs (13.3% of 60 patients followed). RR=0.55, 95% CI: 0.25–1.22; p=0.16	Not reported
	Symptomatic CAUTI rate as CAUTIs per 1,000 device days	4.9 CAUTI per 1,000 device days	2.7 CAUTI per 1,000 device days. p=0.16 but study not powered to detect significant change	Not reported
Evans, 201333	MRSA hospital-associated UTIs	Actual N’s and rates were not provided in report.	Quarterly UTI rates declined by 33% (p=0.07)	Not reported
Mody, 201534	Clinically-defined (Symptomatic) first new CAUTIs per 1,000 device days	10.0 CAUTIs per 1,000 device days	5.2 CAUTIs per 1,000 device days (HR 0.54 (95%CI 0.30, 0.97), p=0.04*	Not reported
	Clinically-defined (Symptomatic) all new CAUTIs (includes recurrent) per 1,000 device days	9.2 CAUTIs per 1,000 device days	5.9 CAUTIs per 1,000 device days (HR 0.69 (95%CI 0.49, 0.99), p=0.045*	Not reported
Priefer, 198235	Number (%) of patients with symptomatic CAUTI in patients with indwelling catheters	Control group: 6 of 7 (83%) men	Experimental 3 of 10 (30%) men	Not reported
	Number of symptomatic CAUTIs per patient in 6 months in indwelling catheter patients	Control group: 1.0 +/− 0.6	Experimental: 0.4 +/− 0.7 p>0.05	Not reported
Studies including only catheterized participants or in settings where very high urinary catheterization rates expected
Saint, 200636 (continued)	Number with bacteriuria (>=103 CFUs per mL of single/predominant species)	Indwelling catheters: N=17 (SE 41.5)	Condom catheter group: N=13 (SE 38.2)	Not reported
	Bacteriuria per 1,000 patient-days (95%CI)	Indwelling catheters: 111/1,000 patient-days. 95%CI (69–178)	Condom catheter group: 61/1,000 patient-days with 95%CI (35–104), p=0.11	Not reported
	Composite Outcome: Number with bacteriuria or CAUTI (defined by bacteriuria and >=1 UTI sign/symptom) or Death	Indwelling catheters: N=20 (48.8%)	Condom catheter group: N=15 (44.1%)	Not reported
		HR: 2.11 (95%CI 1.03–4.31), p=0.04 comparing this event in those with indwelling vs. condom catheters.
	Composite Outcome: Combined event (bacteriuria or CAUTI or Death) per 1000 patient-days	Indwelling catheters: 131 per 1,000 patient-days with 95%CI (85–203)	Condom catheter group: 70 per 1,000 patient-days with 95%CI (42–116), p=0.07	Not reported
Suardi, 200137	Not reported			Number of intermittent catheterizations and indwelling catheters used	No N’s reported	No N’s reported. By text, reduced indwelling catheters, p<0.001*
Tang, 200638	Symptomatic CAUTI by day 14	Indwelling catheter group: 0	Intermittent catheter group: 1. p=0.400	Days to become catheter-free	Indwelling catheters: 9.2 +/− 4.0 days.	Intermittent catheters: 8.6 +/− 3.3 days. p=0.609
	Bacteriuria by day 14	Indwelling catheter group: 21 of 34 (61.8%) p=0.888	Intermittent catheter group: 14 of 22 (63.6%)	Number patients catheter-free by day 14 with post-void residual <150mL	Indwelling catheters: 27 of 39 (69.2%),	Intermittent catheters: 16 of 27 (59.3%) p=0.403

Abbreviations for Table 2: UTI: urinary tract infection not specified as catheter-associated; CAUTI: catheter-associated urinary tract infection. NH: nursing home. SD: standard deviation. SE: standard error.

⁺: Study author provided outcome data not in published article. CI: 95% confidence intervals.

^*: result statistically significant, p<0.05

The nineteen studies (Table 2) reported 12 UTI outcomes, ^{15, 20, 21, 23, 25–31, 33} 9 CAUTI outcomes, ^{15, 22, 32, 34, 35, 38} 4 bacteriuria outcomes, ^{24, 36, 38} and 5 catheter use outcomes. ^{21, 29, 30, 37, 38} Five studies showed CAUTI reduction^{15, 22, 32, 34, 35} (1 significantly³⁴); nine studies showed UTI reduction^{13, 18, 19, 21, 23–25, 27, 28, 31} (none significantly); 2 studies showed bacteriuria reduction (none significantly). One study³⁶ reported 2 composite outcomes including bacteriuria or CAUTI or death, with statistically significant improvement reported for 1 composite measure. Four studies reported catheter use, with all showing reduced catheter use in the intervention group, however only 1 achieved statistically significant reduction.³⁷

Synthesis of Systematic Review Results

Overall, many studies reported decreases in UTI, CAUTI, and urinary catheter use measures but without statistical significance, with many studies likely underpowered for our outcomes of interest. Often, the outcomes of interest in this systematic review were not the main outcome for which the study was designed and originally powered. The interventions studied included several currently implemented as part of CAUTI bundles in the acute care setting such as improving catheter use and care and infection control strategies. Other included interventions target common challenges specific to the nursing home setting such as removing indwelling catheters upon admission to the nursing home from an acute care facility^{21, 25} and applying interventions to address incontinence by either general strategies^{21, 23, 25, 30, 38} or the use of an incontinence specialist²³ to provide individual treatment plans. The only intervention which demonstrated a statistically significant reduction in CAUTI in chronically catheterized patients employed a comprehensive program to improve antimicrobial use, hand hygiene (including hand hygiene and gloves for catheter care), and preemptive precautions for patients with devices, along with promotion of standardized CAUTI definitions and active multi-drug resistant organism surveillance.³⁴

Narrative Review Results

Table 3 includes a comprehensive list of potential interventions that have been considered for prevention of UTI or CAUTI (including those in acute care and nursing home settings), as summarized from this systematic review and prior narrative or systematic reviews.

Table 3.

Comprehensive list of interventions considered for prevention of Urinary Tract Infection (UTI) and Catheter-associated Urinary Tract Infection (CAUTI)

This table includes a comprehensive list of potential interventions that have been considered for prevention of UTI or CAUTI (including those in acute and long-term settings), as summarized from this evidence report, and prior comprehensive narrative^43–57 or systematic reviews.^{11, 58–68} Gray-shaded cells describe interventions that are not recommended based on available evidence or rationale. Non-shaded cells describe interventions that have some evidence of benefit (not always from controlled-intervention studies) at least for certain populations and settings.

Interventions	General summary of available evidence and recommendations provided
INTERVENTIONS FOR PATIENTS REGARDLESS OF URINARY CATHETER STATUS
Hand hygiene	Interventions to improve hand hygiene have been studied as single interventions22, 31 and part of bundles12, 21, 33, 34 for prevention of UTI and CAUTI in LTC settings with decreased (without statistical significance) CAUTI rates in Fender et al22 with no clear benefit in UTIs require hospitalization in Yeung et al,31 marked decrease in MRSA UTIs33 and CAUTIs34 in a multi-intervention studies33, 34 including contact precaution interventions.
Encourage fluid intake/hydration to reduce infection	Studied as single interventions24, 26 and part of bundles25 for the LTC setting with no significant benefits demonstrated regarding infection prevention.
Improve general patient hygiene to reduce infection	Studied only as part of CAUTI bundles in the LTC setting including one with marked decreases in unspecified CAUTIs without statistical significance noted12 and one20 without improvement in symptomatic UTIs.
Cranberry product as prophylaxis	The use of cranberry-containing products (e.g., juice, capsules/tablets, extracts) has been assessed in recent systematic reviews and meta-analysis58, 59, 69 evaluating a total of 14 heterogeneous studies in multiple settings (outpatient, hospital, LTC, spinal cord injury). Both recent meta-analyses58, 59 demonstrated similar non-significant pooled risk ratios for symptomatic UTIs, though one meta-analysis found a significant protection for subgroups such as women with recurrent UTIs 59 that was seen in the other meta-analysis.58 Of note, individual studies in the LTC setting have reported mixed results on bacteriuria outcomes70–72 and UTIs.73–75 Cranberry studies in spinal cord injury patients76, 77 did not reduce either bacteriuria or UTI outcomes. A very recent abstract78 regarding an double-blind placebo-controlled RCT published regarding effectiveness of twice daily cranberry capsules in LTC suggested reduced rates of clinical defined UTIs with treatment effect of 0.79 (95%CI 0.60–1.03) among patients at high risk for UTI (long-term catheterization, diabetes, >=1 UTI in prior year) and 0.83 (95%CI 0.60–1.16) among patients at low risk for UTI, but not likely to be cost-effective.79 In contrast, another very recently published double-blinded placebo-controlled RCT regarding the effectiveness of 2 oral cranberry capsules once daily resulted in no significant difference in the presence of bacteriuria plus pyruria over 1 year among older women residing in nursing homes.80
Vitamin/mineral supplement as UTI prophylaxis	Was not effective in RCT81 for prevention of symptomatic UTIs per 1,000 resident-days in LTC setting.
Treatment of atrophic vaginitis as UTI prophylaxis	Treatment of atrophic vaginitis with topical vaginal estrogens in post-menopausal women with recurrent UTIs (in outpatient setting) has been supported by RCTs (single blind82 and double-blind52 and by a respective chart review of a case-series83 of female LTC nursing home residents with recurrent UTI.
Interventions to improve management of urinary incontinence	Studied as educational strategies21, 23, 25, 29, 30, 38, 39 and protocols regarding incontinence care for staff and residents/family, in addition to interventions of incontinence specialists23, 39 providing individualized treatment plans to LTC residents, which can include a variety of interventions such as pelvic floor exercises, medical treatment for specific types of incontinence including avoidance of exacerbating medication and treatment of atrophic vaginitis.
Implementation of effective infection control program	Infection control program implementation often includes several interventions including hand hygiene programs, and surveillance of nosocomial infections including UTI with the potential as feedback20 to motivate reductions in unnecessary catheter use and improved catheter care. Such interventions have been studied in the LTC setting in studies20, 21 including other specific interventions targeting CAUTs (including infection control “walk rounds” for CAUTI detection, fed back daily to nurses).20
INTERVENTIONS TO REDUCE UNNECESSARY INDWELLING URINARY CATHETER PLACEMENT: Disrupting Lifecycle stages 1 & 4 of the Urinary Catheter
Education regarding the hazards of urinary catheters	Educational interventions aiming to improve staff knowledge of CAUTI and urinary catheter risks are common components in multi-intervention studies implemented in both the acute and LTC settings. Of note, in the LTC setting, educational strategies studied have included modules specific for all healthcare workers (unlicensed and licensed) who care for catheters with separate modules for nurses who insert catheters, with multiple formats including on-line,84, 85 small-group teaching sessions and case reviews, and education of patients/residents13, 25, 29 and families.13, 29
Education and/or policies regarding appropriate indications for indwelling catheters	Education and policies regarding appropriate (and inappropriate) indications for indwelling catheters have been common in the acute care setting,11 often as part of a bundle of CAUTI preventive strategies, implementing the HICPAC list86 of appropriate indications. These lists have also been implemented in the LTC setting13, 39 with either modifications of lists from acute care or LTC.87
Requiring physician order with appropriate indication before placing indwelling catheters	Requiring physician orders for catheter placement has been studied in both acute care11 and long-term care settings.13, 84
Requiring documentation of staff who insert the catheters with reason for catheter placement	Requiring nurses to document insertion with indication has been an intervention employed specifically in the emergency setting84 where catheters were placed without electronic orders and in settings where nurses are empowered to remove catheters by criteria.
Education and supplies for alternatives to indwelling catheters such as external catheters, ISCs, and noncatheter strategies for managing incontinence	Facilitating use of alternatives to indwelling catheters is recommended86 and supported by either lower UTI or other complication rates in patients treated with external catheters36 intermittent catheters and noncatheter88 strategies compared to indwelling Foley catheters.
Urinary retention protocols for ISC and/or bladder scanner use before indwelling catheters requested	Bladder scanners have been used in acute care (post-procedure and floor settings) and in the rehabilitation setting37, 38 to confirm sufficient urinary retention prior to catheterization, to reduce the number of catheterizations.
INTERVENTIONS TO IMPROVE CATHETER INSERTION TECHNIQUE: Disrupting Lifecycle stage 1 of the Urinary Catheter
Education for aseptic insertion of indwelling catheters	Though not confirmed as effective by limited evidence;89 aseptic (as opposed to clean non-sterile) insertion of indwelling catheters is the accepted and recommended86, 90 practice in all settings. Nurse education regarding urinary catheter avoidance, maintenance, insertion, and removal that included one-on-one teaching is preferred, and resulted in higher adherence to CAUTI prevention bundle elements over on-line education alone.91
Hands-on training/competency assessments regarding aseptic indwelling catheter insertion	Catheter placement by “only properly trained persons” using aseptic technique is recommended.86 The use of competency assessments in LTC has been studied12, 13, 85 in CAUTI bundles, though the individual impact of competency training interventions cannot be assessed from available studies. The CDC evidence-based guideline86 recommends that healthcare personnel and others who care for catheters be given periodic in-service training regarding techniques and procedures for catheter insertion, maintenance and removal.
Options regarding intermittent catheterization	Clean versus sterile, and single-use versus multi-use intermittent catheterization has also been studied including several studies in the LTC and rehabilitation settings,92–95 with a systematic review60 indicating no evidence that UTI rates are impacted by these options, in agreement with evidence-based guidelines86, 90 indicating that clean (non-sterile) ISC is acceptable for patients requiring chronic ISC, with guidelines still recommending aseptic insertion for indwelling catheters, though the limited evidence89 regarding this is not convincing.
Standardizing catheter placement supplies/kit	Catheter kit standardization (aiming to standardize catheter placement by making the necessary supplies readily available) is occurring in some acute care settings similar to prior “kit” interventions for prevention of blood stream infections. Some LTC setting studies13 mention interventions regarding selection of catheter products but have not been specific regarding use of a catheter “kit” as opposed to individual catheter products.
IMPROVING CHOICES REGARDING CATHETER TYPES: Disrupting lifecycle stage 1 of the urinary catheter
Type of catheterization	Comparing different types of catheterization (indwelling catheters vs. ISCs vs. external catheters) has also been the subject of systematic reviews. One62 systematic review had zero studies meeting the inclusion criteria. Another66 systematic review focused on suprapubic catheters, with the available evidence of 14 studies (no RCTs, 1 prospective non-randomized study with a comparator, 8 retrospective reviews with comparators, a case-series, and qualitative/descriptive assessments of quality of life) reports no evidence of differences between symptomatic UTI outcomes between suprapubic and urethral catheters, though the evidence is limited by varied UTI definitions applied for outcomes. However, a Cochrane systematic review96 comparing short-term (<14 days) of indwelling urethral UCs to suprapubic UCs found that groups with indwelling UCs had more cases of bacteriuria (RR 2.6, 95% CI 2.12, 3.18) and significantly more patient discomfort (RR 2.98; 95% CI 2.31, 3.85). Evidence-based guidelines86 recommend ISC use is preferable to indwelling suprapubic or urethral catheters for bladder emptying dysfunction, based on decreased rates of symptomatic UTIs and unspecified UTIs in select patient populations. Despite some evidence of lower CAUTI rates for external catheters and ISC compared to indwelling catheters, no catheter remains preferred because of increased rates97, 98 of symptomatic UTI even with non-indwelling catheters by observational studies.
Catheter coating/materials	Different options in catheter coatings (such as hydrophilic-coated, anti-septic or antibiotic impregnated) and materials (latex, PVC, silicone) have been studied. Prior systematic reviews suggesting either insufficient evidence for recommendation99 or no evidence UTI rates are impacted by these options; the CDC86 targeted systematic review suggesting antimicrobial/aseptic catheters may be useful if CAUTI rates are not decreasing with other strategies. A more recent RCT in the acute care setting demonstrated no benefit of antimicrobial catheters.100 Although prior evidence-based guidelines were mixed86, 90 regarding routine use of hydrophilic catheters for ISC, a 2013 systematic review and meta-analysis61 of hydrophilic catheters in the spinal cord injury population indicate these may be preferable (compared to standard non-hydrophilic catheters) for intermittent straight catheterization, with a significantly lower incidence of symptomatic or treated UTIs (OR 0.36; 95% CI 24%–54%, p<0.001).
Catheter tip options	Different options in catheter tip configurations for catheters used for intermittent catheterization (such as straight, coude, olive tip, or introducer-tip) are discussed in narrative reviews citing potential benefits for certain patient populations (such as using coude catheters for men with enlarged prostates). These types of recommendations may be valid clinically, and are choices sometimes recommended by urologists in cases of difficult placement.56 There is simply insufficient evidence to recommend specific catheter tips as a general CAUTI bundle component for the average patient.
Catheter size	The smallest bore catheter possible with consistent good drainage is recommended to avoid black neck and urethral mucosa trauma.54, 86
Catheter length	Narrative reviews suggest than the optimal catheter length varies by gender54 (45cm males, 25mc females) to avoid kinking. Specific recommendations regarding catheter length have not been provided by recent evidence-based reviews though keeping the catheter free from kinking to maintain unobstructed urine flow is recommended.86, 90
“Closed” drainage systems	Evidence-based guidelines86, 90 recommend the use of closed catheter drainage systems to reduce CAUTI in patients with indwelling catheters. Closed drainage systems for intermittent straight catheters also exist but with limited evidence56 regarding benefit.
Catheter securing devices	Proper securing indwelling catheters after insertion is recommended to decrease movement and urethral trauma, and has been studied as part of a bundle85 in the rehabilitation setting. The use of a specific device (StatLock) was studied in the spinal cord injury acute care setting with a marked reduction (without meeting statistical significance) in symptomatic CAUTI rates;32 the implications of this study have been mixed with some interpreting as evidence for supporting use of this type of catheter securing device, and other86 reviews interpreting as not evidence for using these devices given no significant difference in CAUTI or meatal erosion.
MAINTENANCE/CARE OF PATIENTS WITH CATHETERS: Disrupting Lifecycle stage 2 of the Urinary Catheter
Handwashing, gloving before and after catheter/bag care	Hand hygiene is recommended86 immediately before and after insertion or any manipulation of the urinary catheter or site. Gloves should be worn during any manipulation of catheterized patients or when providing intimate care. Gown use should be considered during catheter insertions, manipulation and when providing assistance during activities of daily living. These strategies are useful irrespective of a resident’s colonization status with multi-drug resistant organisms.
Keeping drainage bag below bladder	Keeping the collecting bag below the level of the bladder at all times without placement of the bag on the floor is recommended by evidence-based guidelines.86
Routine perineal cleaning strategies with antiseptics	Evidence-based guidelines86, 90, 101 recommend against cleaning the periurethral area with antiseptics to prevent CAUTI while the catheter is in place. Routine hygiene (cleansing of the meatal surface during daily bathing) is appropriate.90
Irrigations, washouts and instillations	The practice of irrigating or washing out long-term indwelling urinary catheters has also been assessed by systematic reviews65, 102 including reviews of various solutions (e.g., saline, acidic solutions, antiseptic and antibiotic solutions) have summarized 5 studies in multiple settings that were noted to be of poor quality and also did not appear to support these interventions were effective at either reductions of symptomatic CAUTIs or time to requiring first catheter change. Our own systematic search strategy identified several studies involving these interventions that either had previously been evaluated for the previously published systematic reviews (as included103, 104 or excluded105 studies). Washout and irrigation strategies have also been assessed at length by a recent CDC targeted systematic review,86 with agreement that bladder irrigation and catheter drainage bag instillations are not recommended given no differences in symptomatic UTI and mixed results in bacteriuria outcomes.
Catheter replacement issues	Catheter replacement at routine, fixed intervals is not recommended by evidence-based guidelines86 and did not decrease UTIs in the study reviewed in detail in this systematic review (Priefer et al).35 A recent integrative review on catheter change intervals concluded there was insufficient evidence to support or refute the common practice of routine catheter changes but is a pre-emptive strategy employed in those who encrust and develop recurrent blockage.106
Avoid equipment sharing between catheterized patients	This has been recommended in narrative reviews45, 107 and is reasonable and recommended by the CDC guideline86 with regard to not sharing catheter-care supplies (such as devices used to empty catheter bags).
Spatial separation of catheterized patients	Spatial separation has been recommended by a case-control study108 but further research is needed to assess the benefit of spatial separation of catheterized patients.86
Prophylaxis with systematic antimicrobials	The use of antimicrobial prophylaxis for chronically catheterized patients studied in several studies109–112 yielded by our search strategy has also been reviewed in a recent systematic review68 (of 8 studies, including indwelling catheters and ISCs) and systematic review and meta-analysis67 (of 15 studies involving ISCs) systematic reviews67, 68 and meta-analyses67 with no benefit seen in patients with either chronic catheters or ISCs (with increased resistance67 suggested in ISC patients), in agreement with a recent CDC86 targeted systematic review. Our search did reveal one very recent study64 supporting the use of antimicrobial prophylaxis when short-term catheters are removed in the acute care setting; however, other studies indicate that prophylactic antimicrobials are not routinely indicated for changes of chronic catheters due to little morbidity45, 113, 114 reported with chronic catheter changes.
Other systemic chemoprophylaxis	The evidence for methenamine for preventing CAUTI is limited for use in both short-term catheterizations (studied only for post-operative gynecologic surgery) and long-term catheterizations, and not recommended for routine use for patients with long-term intermittent or long-term indwelling urethral or suprapubic catheterization according to evidence-based guidelines.86, 90
Bacterial interference interventions	Novel interventions are being studied115 regarding the feasibility and potential benefit of “bacterial interference” interventions involving urinary colonization with benign bacteria, with the goal to reduce symptomatic infections by pathologic bacteria.
PROMPTING REMOVAL OF UNNECESSARY CATHETERS: Disrupting Lifecycle stage 3 of the Urinary Catheter
Trial removal of indwelling catheters present at admission to long-term care setting	This practice has been studied as a bundle component21, 25, 39 in LTC settings, and functions as a type of stop-order by prompting a trial removal of all indwelling catheters upon admission to the LTC setting. This type of intervention may function similarly to stop-orders studied in the acute care setting. Studies reporting this type of intervention are advised to assess and report potential adverse events to patients, similar to acute care interventions using reminders and stop-orders.11
Urinary catheter reminders, reminding staff that patient/resident has a catheter to consider removing	The use of reminders and/or stop-orders has been demonstrated by a recent systematic review and meta-analysis11 focused on the acute care setting to reduce CAUTIs per 1,000 catheter-days by more than 50%; these studies often included reminders/stop-orders as part of a CAUTI prevention bundle. Reminder types included use of daily checklists, electronic reminders, and the use of catheter patrols. Similar interventions have also been implemented in a few LTC studies including the use of catheter audit tools,39 daily assessment for continued catheter need,13 electronic removal reminder systems14 with some studies reporting decreased infections or catheter use though most studies were underpowered to detect statistical significance of these interventions in the LTC setting.
Urinary catheter stop-orders, requiring removal of catheter unless specific clinical criteria are met

ISC: intermittent straight catheterization; LTC: long-term care

DISCUSSION

We performed a broad systematic review of strategies to decrease UTI, CAUTI, and urinary catheter use that are anticipated to be helpful in the nursing home setting. While many studies reported decreased UTI, CAUTI, or urinary catheter use measures, few demonstrated statistically significant reductions perhaps because many were underpowered to assess statistical significance. Pooled analyses were not feasible to provide the expected impact of these interventions in the nursing home setting.

This review confirms that bundles of interventions for prevention of CAUTI have been implemented with some evidence of success in nursing home settings, with several components in common with those implemented in the acute care setting, such as hand hygiene and strategies to reduce and improve catheter use.⁴¹ Some studies focused on issues more common in nursing homes such as chronic catheterization and incontinence. A nursing home CAUTI bundle should be designed with the resources and challenges present in the nursing home environment in mind, and with recognition that although the number of patients with catheters is less than in acute care, there will be more individual patients with chronic catheterization needs and incontinence.

Although catheter utilization in nursing homes is low, further reductions in catheter days and CAUTIs can be achieved. Catheter removal reminders and stop-orders have demonstrated a greater than 50% reduction in CAUTIs in acute care settings;¹¹ an example of a stop-order intervention in nursing homes is trial removal of indwelling catheters present at facility admission without clear urologic need present at the time of admission.²⁵ Nursing home interventions to avoid catheter placement should include incontinence programs, discussion of alternatives to indwelling urinary catheters with patients, families and frontline personnel, and urinary retention protocols. Programs to reduce CAUTI should include education to improve aseptic insertion, and to maintain awareness and proper care of catheters in place by regular assessment of catheter necessity, securement, hand hygiene, and pre-emptive barrier precautions for catheterized patients. Interventions that focus on improving appropriate use of urine tests and antibiotics to treat UTIs can also significantly impact the rates of symptomatic CAUTIs reported, with the potential to decrease unnecessary antibiotic use.^{20, 21}

The main limitation of this review is that many studies provided limited information about their intervention and on how outcomes were defined. The strength of this review is the detailed and broad search strategy applied with generous inclusion of interventions and outcomes to highlight the available evidence and details of interventions that have been studied and implemented.

CONCLUSIONS

This review synthesizes the current state of evidence and proposes strategies to reduce UTIs in nursing homes. Interventions that motivate catheter avoidance and catheter removal to prevent CAUTI in acute care¹¹ and nursing home settings are supported by the strongest available evidence, although the strength of available evidence is currently less in the nursing home setting. Although the evidence is not as robust, interventions such as incontinence care planning and hydration programs can reduce UTI in this population and is important for overall wellbeing.