Systematic review of interventions to reduce urinary tract infection in nursing home residents

Data Extraction and Quality Assessment

Relevant data regarding study design, participants, inclusion/exclusion criteria, outcomes, and quality criteria were abstracted independently by 2 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 nonrandomized 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 about interventions and outcomes reported, outcome data could not be combined into summary measures for meta-analysis to give overall estimates of treatment effects.

Systematic Search Results and Study Selection

As detailed in the study flow diagram (Figure), 5794 total records were retrieved by systematic search 1 (4697 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 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 nonrandomized interventions, and 1 nonrandomized intervention with concurrent controls. Twelve studies included participants with or without catheters (ie, not limited to catheterized patients only) in nursing homes.^15,20-31 Seven^32-38 studies included catheterized patients only 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 Supplemental Table 1.

As detailed in Table 1 and Supplemental 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,³⁵and 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 The outcome definitions of UTI and CAUTI varied widely. Only 2 studies^22,39 reported UTI outcomes using definitions specific for nursing home settings such as McGeer’s criteria⁴⁰ a detailed review and comparison of published CAUTI definitions used clinically and for surveillance in nursing homes is provided in Supplemental Table 3. Two studies reported symptomatic CAUTIs per 1000 catheter-days.^32,34 Another study²² reported symptomatic CAUTIs per 1000 resident-days. Three reported symptomatic CAUTIs as counts.^35,38 Saint et al³⁶ reported CAUTIs as part of a combined outcome (ie, bacteriuria, CAUTI, or death).

The 19 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); 9 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 that 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 multidrug resistant organism surveillance.³⁴