Comparison of Urinary Tract Infection Rates Associated with Transurethral Catheterization, Suprapubic Tube and Clean Intermittent Catheterization in the Postoperative Setting: A Network Meta-Analysis

An international prospective study of INICC analyzing the incidence and risk factors for catheter-associated urinary tract infections in 235 ICUs across 8 Asian Countries

BACKGROUND

Identify urinary catheter (UC)-associated urinary tract infections (CAUTI) incidence and risk factors (RF) in 235 ICUs in 8 Asian countries: India, Malaysia, Mongolia, Nepal, Pakistan, the Philippines, Thailand, and Vietnam.

METHODS

From January 1, 2014, to February 12, 2022, we conducted a prospective cohort study. To estimate CAUTI incidence, the number of UC days was the denominator, and CAUTI was the numerator. To estimate CAUTI RFs, we analyzed 11 variables using multiple logistic regression.

RESULTS

84,920 patients hospitalized for 499,272 patient days acquired 869 CAUTIs. The pooled CAUTI rate per 1,000 UC-days was 3.08; for those using suprapubic-catheters (4.11); indwelling-catheters (2.65); trauma-ICU (10.55), neurologic-ICU (7.17), neurosurgical-ICU (5.28); in lower-middle-income countries (3.05); in upper-middle-income countries (1.71); at public-hospitals (5.98), at private-hospitals (3.09), at teaching-hospitals (2.04). The following variables were identified as CAUTI RFs: Age (adjusted odds ratio [aOR] = 1.01; 95% CI = 1.01-1.02; P < .0001); female sex (aOR = 1.39; 95% CI = 1.21-1.59; P < .0001); using suprapubic-catheter (aOR = 4.72; 95% CI = 1.69-13.21; P < .0001); length of stay before CAUTI acquisition (aOR = 1.04; 95% CI = 1.04-1.05; P < .0001); UC and device utilization-ratio (aOR = 1.07; 95% CI = 1.01-1.13; P = .02); hospitalized at trauma-ICU (aOR = 14.12; 95% CI = 4.68-42.67; P < .0001), neurologic-ICU (aOR = 14.13; 95% CI = 6.63-30.11; P < .0001), neurosurgical-ICU (aOR = 13.79; 95% CI = 6.88-27.64; P < .0001); public-facilities (aOR = 3.23; 95% CI = 2.34-4.46; P < .0001).

DISCUSSION

CAUTI rate and risk are higher for older patients, women, hospitalized at trauma-ICU, neurologic-ICU, neurosurgical-ICU, and public facilities. All of them are unlikely to change.

CONCLUSIONS

It is suggested to focus on reducing the length of stay and the Urinary catheter device utilization ratio, avoiding suprapubic catheters, and implementing evidence-based CAUTI prevention recommendations.

Catheterization Before Transperineal Ultrasound-guided Prostate Biopsy and the Risk of Urethrorrhagia

OBJECTIVE

To investigate the efficacy of catheterization before transperineal ultrasound-guided prostate biopsy in reducing risk of urethrorrhagia. Currently, transperineal ultrasound-guided prostate biopsy (TPPB) is one of the most commonly used measures to help diagnose prostate cancer. However, whether the retention of catheterization before transperineal ultrasound-guided prostate biopsy is associated with the reduced risk of urethrorrhagia remains uncertain.

METHODS

A cohort study was conducted in our hospital from January 2021 to September 2021. This study included 93 patients who participated in transperineal ultrasound-guided prostate biopsy. We compared the risk of urethrorrhagia in patients who underwent indwelling catheterization before biopsy and those who did that after biopsy, and performed an unadjusted analysis. We also analyzed the use of related confounding factors to limit the cohort of men, and applied propensity-score adjustment to control potential confounders. Analyses that restricted the cohort men with the related confounding factors and that used propensity-score adjustment to control for potential confounders.

RESULTS

A total of 93 men were recruited in the cohort study, and the numbers of patients in group 1 and group 2 were 64 and 29, respectively. There were 34 patients (53.1%) of urethrorrhagia in group 1, and 22 patients (75.8%) of urethrorrhagia in group 2. This was a significant difference between the 2 groups (P = .008). After adjusting for correlative factors, the preoperative catheterization is still a protective factor for postoperative urethrorrhagia through multivariate multiple piecewise linear regression analysis.

CONCLUSION

The result of this cohort study suggested that preoperative catheterization can significantly reduce the risk of urethrorrhagia.

Urinary Outcomes After Magnetic Resonance Imaging-Guided Whole-Gland Transurethral Ultrasound Ablation for Prostate Cancer: Comparison of Suprapubic Tube to Indwelling Urethral Catheter

Background: MRI-guided transurethral ultrasound ablation (TULSA) is under investigation for whole-gland ablation of low- and intermediate-risk prostate cancer. The ideal method for post-TULSA bladder drainage through postoperative suprapubic tube (SPT) vs indwelling urethral catheter (UC) has not been established. The objective of this study was to evaluate urinary outcomes after whole-gland TULSA, comparing postoperative SPT with UC. Materials and Methods: Two-institution retrospective analysis of whole-gland TULSA for men with grade group 1 and 2 prostate cancer. One institution placed SPT at the time of TULSA with clamp trials (day 10) and removal once voiding. The second placed UC until void trial (day 7). Outcomes included the International Prostate Symptom Score (IPSS), urinary bother score, catheter reinsertion, stricture, clean intermittent catheterization (CIC), and incontinence. Results: Forty-five patients (median age 67) were analyzed. The UC cohort (N = 26) was older (p = 0.007) than the SPT cohort (N = 19) but with similar baseline prostate volumes, IPSS, and urinary bother scores. Patients receiving UC had fewer days with catheter (p = 0.013). Although UC patients suffered more lower urinary tract symptoms at 1-month post-TULSA, there was no significant difference between IPSS scores at baseline and 6 months after surgery regardless of urinary management strategy, although the UC group noted significantly decreased urinary bother. Rates of infection were similar between groups. Six strictures were observed overall, with more in the SPT group, although the difference was not significant (4/19 [21.1%] SPT; 2/26 [7.7%] UC). At 6 months, incontinence rates were low and similar between groups (2/19 [10.5%] SPT; 4/26 [15.4%] UC) and only one patient (UC) required CIC. Conclusions: Our overall findings suggest that SPT and UC are both acceptable options for postoperative bladder drainage after whole-gland TULSA, with statistically similar rates of urinary complications but a slightly different side effect profile.

Catheter-Associated Urinary Tract Infection in Neurological Intensive Care Units: A Narrative Review

Catheter-associated urinary tract infection (CAUTI) is among the most common types of healthcare-associated infection (HAI), which is associated with poor outcomes and prolonged hospitalization in critically ill patients. Previous studies have mentioned that patients admitted to neurological ICUs are at higher risk of CAUTI compared to patients in other ICU settings. This review paper aims to review studies published during the last decade that evaluated the incidence, risk factors, causative pathogens, and preventive strategies and treatment in neuro-critically ill patients.

Early warning model construction and validation for urinary tract infection in patients with neurogenic lower urinary tract dysfunction (NLUTD): a retrospective study

Background

This study was performed to construct and validate an early risk warning model of urinary tract infection in patients with neurogenic lower urinary tract dysfunction (NLUTD).

Methods

Eligible patients with NLUTD admitted to Shenzhen Longcheng hospital from January 2017 to June 2021 were recruited for model construction, internal validation and external validation. The first time point of data collection was within half a month of patients first diagnosed with NLUTD. The second time point was at the 6-month follow-up. The early warning model was constructed by logistic regression. The model prediction effects were validated using the area under the Receiver Operating Characteristic curve, the Boostrap experiment and the calibration plot of the combined data. The model was externally validated using sensitivity, specificity and accuracy.

Results

Six predictors were identified in the model, namely patients ≥65 years old (OR = 2.478, 95%CI [1.215- 5.050]), female (OR = 2.552, 95%CI [1.286-5.065]), diabetes (OR = 2.364, 95%CI) [1.182-4.731]), combined with urinary calculi (OR = 2.948, 95%CI [1.387-6.265]), indwelling catheterization (OR = 1.988, 95%CI [1.003 -3.940]) and bladder behavior training intervention time ≥2 weeks (OR = 2.489, 95%CI [1.233-5.022]); and the early warning model formula was Y = 0.907 ×  age+ 0.937 × sex + 0.860 × diabetes +1.081 × combined with urinary calculi+ 0.687 × indwelling catheterization+ 0.912 × bladder behavior training intervention time-2.570. The results show that the area under the ROC curve is 0.832, which is close to that of 1,000 Bootstrap internal validation (0.828). The calibration plot shows that the early warning model has good discrimination ability and consistency. The external validation shows the sensitivity is 62.5%, the specificity is 100%, and the accuracy is 90%.

Conclusion

The early warning model for urinary tract infection in patients with NLUTD is suitable for clinical practice, which can provide targeted guidance for the evaluation of urinary tract infection in patients with NLUTD.

Increased Complications in Octogenarians Undergoing Same-Day Discharge following Total Knee Arthroplasty: A Matched Cohort Analysis

Same-day discharge pathways in total knee arthroplasty (TKA) are gaining popularity as a means to increase patient satisfaction and reduce overall costs, but these pathways have not been thoroughly evaluated in potentially at-risk populations, such as in patients ≥80 years old. The purpose of this study was to compare 90-day complications and mortality following same-day discharge after primary TKA in patients ≥80 years old and those <80 years old. Patients who underwent unilateral primary TKA, were discharged on postoperative day 0, and had a minimum 90-day follow-up were identified in a national insurance claims database (PearlDiver Technologies) using Current Procedural Terminology code 27447. These patients were stratified into two cohorts based upon age: (1) nonoctogenarians (<80 years old) and (2) octogenarians (≥80 years old). These cohorts were propensity matched based upon sex, Charlson comorbidity index, and obesity status. Univariate analysis was performed to determine differences in 90-day complications and mortality between the two cohorts. In total, 1,111 patients were included in each cohort. Both cohorts were successfully matched, with no observed differences in matched parameters for demographics or comorbidities. There was no significant difference in 90-day mortality between the two cohorts (p = 0.896). However, octogenarians were at significantly increased risk of postoperative atrial fibrillation (20.8 vs. 10.4%; p < 0.001), nonatrial fibrillation arrhythmias (8.4 vs. 5.6%; p = 0.009), pneumonia (4.5 vs. 2.2%; p = 0.002), stroke (3.1 vs. 1.7%; p = 0.037), heart failure (10.5 vs. 7.5%; p = 0.012), and urinary tract infection (UTI; 14.3 vs. 9.4%; p < 0.001) compared with the nonoctogenarian cohort. Relative to matched controls, octogenarians were at significantly increased risk of numerous 90-day medical complications following same-day primary TKA, including cardiopulmonary complications, stroke, and UTI. Clinicians should be cognizant of these complications and counsel patients appropriately when electing to perform same-day TKA in the octogenarian population.

Best nonsurgical managements of acute urinary retention: what's new?

PURPOSE OF REVIEW

To provide a comprehensive review of the nonsurgical management of acute urinary retention (AUR).

RECENT FINDINGS

A recent meta-analysis confirmed that α-blockers are associated with higher rates of successful trial without catheter (TWOC) compared with placebo, while combination therapies do not significantly reduce the rate of recatheterization. Compared with standard TWOC, bladder perfusion with physiological serum prior to catheter removal is a simple and cost-effective method to increase TWOC success rates (odds ratio 2.41, 95% confidence interval 1.53-3.8), and to reduce time-to-discharge (-89.68 min, 95% confidence interval -160.55, -18.88). Clean intermittent catheterization (CIC) is increasingly used for urinary retention in patients with benign prostatic hyperplasia as existing data suggest that it may decrease the risk of urinary tract infections, accelerate spontaneous voiding recovery and might be more cost-effective compared with indwelling urethral catheterization. Ongoing trials are examining whether office-placed prostate stent may be a promising solution in patients with AUR.

SUMMARY

The recent development of alternative approaches to traditional TWOC may lead to new therapies for treating patients with AUR. Further studies are needed as the level of evidence from published studies remains low.

Enhanced recovery after surgery: operation-related factors

Background: The enhanced recovery after surgery (ERAS) program, which has been recently introduced in the field of perioperative care, represents a multimodal strategy to attenuate the loss, and improve the restoration, of functional capacity after surgery. This program aims to reduce morbidity and enhance recovery by reducing surgical stress, optimizing pain control, and facilitating early resumption of an oral diet and early mobilization. Considering this perspective, protocols for enhanced recovery should include comprehensive and evidence-based guidelines for best perioperative care. Appropriate protocol implementation may reduce complication rates and enhance functional recovery and thereby reduce the duration of hospitalization.Current Concepts: In major abdominal surgeries, the recommended ERAS protocols involve common items such as preoperative counseling, preoperative optimization, prehabilitation, preoperative nutrition, fasting and carbohydrate loading, bowel preparation, thromboprophylaxis, antimicrobial prophylaxis, surgical access, drainage, nasogastric intubation, urinary drainage, early mobilization and prevention of postoperative ileus, postoperative glycemic control, and postoperative nutritional care. These items have been briefly reviewed with the relevant evidence.Discussion and Conclusion: ERAS is a comprehensive and evidence-based guideline for optimal perioperative care. Although a number of ERAS items still require high-level evidence through well-designed randomized controlled trials, the ERAS guidelines can serve as adequate recommendations for our practice. Thus, these items can be introduced and adopted with evidence. In addition, it is important to remove items that are not supported by evidence from routine procedures.

Guidelines for Infection Control in the Urological Field, including Urinary Tract Management (revised second edition)

The Committee for the Development of Guidelines for Infection Control in the Urological Field, including Urinary Tract Management of the Japanese Urological Association, together with its systematic review team and external reviewers, have prepared a set of practice guidelines, an abridged version of which is published herein. These guidelines cover the following topics: (i) foundations of infection control, standard precautions, route-specific precautions, and occupational infection control (including vaccines); (ii) the relationship between urologists and infection control; (iii) infection control in urological wards and outpatient clinics; (iv) response to hepatitis B virus reactivation; (v) infection control in urological procedures and examinations; (vi) prevention of infections occurring in conjunction with medical procedures and examinations; (vii) responses to urinary tract tuberculosis and bacillus Calmette-Guérin; (viii) aseptic handling, cleaning, disinfection, and sterilization of urinary tract endoscopes (principles of endoscope manipulation, endoscope lumen cleaning, and disinfection); (ix) infection control in the operating room (principles of hand washing, preoperative rubbing methods, etc.); (x) prevention of needlestick and blood/bodily fluid exposure and response to accidental exposure; (xi) urinary catheter-associated urinary tract infection and purple urinary bag syndrome; and (xii) urinary catheter-associated urinary tract infections in conjunction with home care. In addressing these topics, the relevant medical literature was searched to the extent possible, and content was prepared for the purpose of providing useful information for clinical practice.

A Nurse-Driven Protocol for Foley Catheter Utilization Decreases the Incidence of Traumatic Foley Catheterization

Background: Traumatic urethral catheterization is a common reason for urologic consultation in hospitalized patients. The purpose of this study was to determine if a protocol designed to decrease Foley catheter use was effective and if implementation of the protocol decreased the incidence of Foley catheter-associated trauma. Methods: In an effort to decrease catheter use, our institution adopted a nurse-driven Foley catheter protocol in May 2015 that allowed nurses to remove Foley catheters that did not meet criteria. We conducted a retrospective medical records review of patients who had Foley catheter-associated trauma occurring between February 2013 and March 2018 and compiled data concerning Foley catheter use. Using t test statistical analysis, we compared rates of Foley catheter use and Foley catheter-associated trauma before and after protocol implementation. Results: During the 62-month study period, we documented 83 cases of Foley catheter-associated trauma. Prior to protocol implementation, our institution had mean of 2,903 patient-catheterization days per month. Following protocol implementation, the mean decreased to 2,604 patient-catheterization days per month (P<0.01). Prior to protocol implementation, the mean incidence of Foley catheter-associated trauma was 1.81 traumas per month. Following protocol implementation, the mean incidence decreased to 0.97 trauma per month (P<0.05). Conclusion: Implementation of the protocol was successful in decreasing Foley catheter use as well as Foley catheter-associated trauma.

Identifying the Relation between Catheter-Associated Urinary Tract Infections and the National Distribution of Urologists and Urology Residencies

Background: Catheter-associated urinary tract infections (CAUTIs) are associated with urinary catheterization. Up to 25% of hospitalized patients may be catheterized during their stay. Urethral catheters are necessary as part of many urologic procedures, but the removal of unnecessary catheters has become more important to reduce infections, healthcare costs, and patient morbidity. Methods: Open access data from the U.S. Centers for Disease Control and Prevention (CDC), United States Census, and the American Urological Association (AUA) Census was obtained, and a linear correlation used to determine relations. Results: A correlation between the number of urologists per hospital and CAUTIs per hospital was found in both the wards and intensive care units (ICU; p < 0.01). A similar relation was found between the number of urology residencies per hospital and CAUTIs per hospital in the wards (p < 0.01), but this was not significant in the ICU (p = 0.15). The number of urology residencies per state was correlated with the number of urologists per state (p < 0.01). No correlation between state population density and hospital number of CAUTIs, urologists, and urology residencies was found. Conclusions: Increased number of urologic procedures and the need for catheterizations likely drives the correlation with urologists and CAUTIs. Despite this, no urologists are on the CDC committee that created CAUTI guidelines. Urologists should be considered for hospital and national committees particularly because they often care for these patients in the outpatient setting.

Urine drainage management in colorectal surgery

INTRODUCTION

Enhanced recovery programs (ERP) is aimed at reducing a patient's surgical stress response, specifically by reducing the duration of catheterization. In cases of colorectal surgery, there is pronounced heterogeneity in urinary catheterization, which is largely explained by fear of acute urinary retention (AUR).

OBJECTIVE

The objective of the work is to report on the current literature on postoperative urinary catheterization following colorectal surgery, particularly with regard to the risk of AUR, and thereby contribute to the standardization of perioperative practices.

RESULTS

In colon surgery without preoperative urinary disorders, catheterization must not exceed 24h. In rectal surgery, catheter removal starting on postoperative D2 seems reasonable in the absence of AUR risk factor (RF). Male sex, past history of lower urinary tract obstruction, abdomino-perineal amputation (APA) and low rectal anastomosis are AUR risk factors that must be taken into account when deciding to withdraw the urinary catheter. While the role of a suprapubic catheter is not clearly defined, it may be of use following APA. The epidural catheter is another AUR risk factor, but it seems possible to withdraw the urinary catheter on postoperative D1, before the epidural catheter, provided that the other risk factors have been taken into full account. Lastly, up until now no satisfactorily conducted study has assessed the prophylactic value of systematic perioperative alpha-blocker treatment in colorectal surgery.

A Comparison of Two Methods of Catheter Management After Pelvic Reconstructive Surgery: A Randomized Controlled Trial

OBJECTIVE

To compare effects on activity between two catheter management systems after failed voiding trial after pelvic reconstructive surgery.

METHODS

Women with a failed postoperative voiding trial after reconstructive pelvic surgeries were randomized to plug-unplug or continuous drainage catheters. The primary outcome was a mean activity assessment scale score. Secondary outcomes included urinary tract infection (UTI), time to passing outpatient voiding trial, and patient satisfaction. Enrollees who passed the voiding trial were assigned to a "Reference" arm. Ninety participants (30 per arm) provided more than 80% power to detect an effect size of 0.33 in the primary outcome, using a two-sided alpha of 0.05.

RESULTS

Sixty-three patients were randomized (32 plug-unplug, 31 continuous drainage). The first 30 participants discharged without a catheter comprised the reference arm. There was no difference in postoperative activity assessment scale scores (total: plug-unplug 70.3, continuous drainage 67.7, reference arm 79.4; P=.090) between arms. Women in the continuous drainage arm noted more difficulty compared with the plug-unplug arm when managing the catheter "during the day" (P=.043) and "all the time" (P=.049) and felt the catheter impeded activities (P=.012) and wearing clothes (P=.005). The catheter arms had significantly higher rates of culture-positive UTI compared with the reference arm (58.7% vs 6.7%, P<.001). However, rate of UTI did not differ between catheter arms (plug-unplug, 68.8% vs continuous drainage, 48.4%, P=.625). The majority of patients passed their outpatient voiding trials at the initial postoperative visit (plug-unplug 71.9%, continuous drainage 58.1%, P=.250). There was no difference in patient satisfaction, with the majority reporting they were "very satisfied" (plug-unplug 78.1%, continuous drainage 80.0%, reference 66.7%, P=.202).

CONCLUSION

Postoperative activity does not differ in patients discharged with plug-unplug or continuous drainage catheters, but those with plug-unplug perceive easier management and ability to complete activities of daily living. The plug-unplug method is an acceptable alternative to traditional catheterization after pelvic reconstructive surgery.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT03071211.

Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations: 2018

BACKGROUND

This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol.

METHODS

A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.

RESULTS

All recommendations on ERAS® protocol items are based on best available evidence; good-quality trials; meta-analyses of good-quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly.

CONCLUSIONS

The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS® Society in this comprehensive consensus review.

Postoperative Catheter Management After Pelvic Reconstructive Surgery: A Survey of Practice Strategies

OBJECTIVE

The aim of this study was to evaluate practice preferences in catheter management after a failed inpatient voiding trial after pelvic reconstructive surgery.

METHODS

This is a cross-sectional study of postoperative catheter management after pelvic reconstructive surgery after failed voiding trial. Physicians practicing at ACGME-accredited residencies and fellowships in Obstetrics and Gynecology (Ob/Gyn), Urology, and Female Pelvic Medicine and Reconstructive Surgery (FPMRS) within the United States completed a Web-based questionnaire in March 2017. Respondents were asked about voiding trial protocols, definitions of abnormal postvoid residual (PVR), type of catheterization used after failed voiding trials, and antibiotic use. Primary outcome was type of catheterization after failure of an inpatient voiding trial. Data were analyzed using χ statistical tests.

RESULTS

One hundred five respondents had a mean age of 36.5 years (range, 36 years). A total of 45.9% of participants practiced in FPMRS, 36.5% in Ob/Gyn, and 17.6% in Urology. Catheters were discontinued most frequently by postoperative day 1 after all procedures. Distribution of catheterization by specialty differed. Clean-intermittent straight catheterization had the greatest prevalence in all specialties and was the highest, by percentage, in Urology (33% Ob/Gyn, 40.6% FPMRS, and 69% Urology); P = 0.026. Type of catheterization differed significantly between Ob/Gyn and FPMRS respondents (P = 0.045). A total of 77.7% measured PVR by ultrasound and 22.3% performed catheterization. This distribution was similar across the specialties (70% Ob/Gyn, 79% FPMRS, and 100% Urology; P = 0.092). Abnormal PVR was defined most frequently as 150 mL or greater (30.5%). A minority of respondents routinely administer antibiotics during catheterization (17.1%). Duration and time until repeat voiding trial varied from 1 day to 2 weeks.

CONCLUSIONS

Practice variability in catheterization after pelvic reconstructive and incontinence surgery is high. Distribution of catheterization type by specialty varies significantly, with clean-intermittent straight catheterization most prevalent. Future studies are necessary to establish a consensus on optimal catheterization management technique for patients with acute postoperative voiding dysfunction.