Jurnal Interna UTI
Jurnal Interna UTI
Jurnal Interna UTI
Page 1 of 8
Research
RESEARCH
Antibiotic prophylaxis for urinary tract infections after
removal of urinary catheter: meta-analysis
OPEN ACCESS
12
Jonas Marschall internist and infectious disease specialist , Christopher R Carpenter internist and
3
4
emergency medicine specialist , Susan Fowler medical librarian , Barbara W Trautner internist and
56
infectious disease specialist , for the CDC Prevention Epicenters Program
Division of Infectious Diseases, Washington University School of Medicine, St Louis, MO 63110, USA; 2Department of Infectious Diseases, Bern
University Hospital and University of Bern, Friedbhlstrasse 51, CH-3010 Bern, Switzerland; 3Emergency Care Research Section, Division of
Emergency Medicine, Washington University School of Medicine, St Louis, MO, USA; 4Bernard Becker Medical Library, Washington University, St
Louis, MO, USA; 5Houston VA Health Services Research and Development Center of Excellence, Michael E DeBakey VA Medical Center, Houston,
TX, USA; 6Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
1
Abstract
Objective To determine whether antibiotic prophylaxis at the time of
removal of a urinary catheter reduces the risk of subsequent symptomatic
urinary tract infection.
Design Systematic review and meta-analysis of studies published before
November 2012 identified through PubMed, Embase, Scopus, and the
Cochrane Library; conference abstracts for 2006-12 were also reviewed.
Inclusion criteria Studies were included if they examined antibiotic
prophylaxis administered to prevent symptomatic urinary tract infection
after removal of a short term (14 days) urinary catheter.
Results Seven controlled studies had symptomatic urinary tract infection
after catheter removal as an endpoint; six were randomized controlled
trials (five published; one in abstract form) and one was a
non-randomized controlled intervention study. Five of these seven studies
were in surgical patients. Studies were heterogeneous in the type and
duration of antimicrobial prophylaxis and the period of observation.
Overall, antibiotic prophylaxis was associated with benefit to the patient,
with an absolute reduction in risk of urinary tract infection of 5.8%
between intervention and control groups. The risk ratio was 0.45 (95%
confidence interval 0.28 to 0.72). The number needed to treat to prevent
one urinary tract infection was 17 (12 to 30).
Conclusions Patients admitted to hospital who undergo short term
urinary catheterization might benefit from antimicrobial prophylaxis when
the catheter is removed as they experience fewer subsequent urinary
tract infections. Potential disadvantages of more widespread antimicrobial
prophylaxis (side effects and cost of antibiotics, development of
antimicrobial resistance) might be mitigated by the identification of which
patients are most likely to benefit from this approach.
Introduction
Urinary catheterization is common in patients in hospital,
particularly for surgical patients in the perioperative period
when physiological mechanisms of bladder emptying are
suspended. Catheterization of the urinary tract, however, is
associated with an increased risk of bacteriuria and symptomatic
urinary tract infection, the risk being associated with the duration
of catheterization.1 National guidelines recommend removal of
urinary catheters once they are no longer needed,2-4 and surgical
experts advocate discontinuation of catheterization as early as
24-48 hours postoperatively.5 Bacteriuria in a patient with a
catheter, however, can persist after the catheter is removed and
can develop into a symptomatic urinary tract infection.
Manipulation of the catheter itself during removal might also
predispose to infection.6 Current definitions from the National
Healthcare Safety Network (NHSN) for catheter associated
urinary tract infection (CAUTI) reflect this by identifying
infections up to 48 hours after catheter removal as catheter
associated (www.cdc.gov/nhsn/pdfs/pscmanual/7psccauticurrent.
pdf).3
Whether administration of prophylactic antibiotics when the
catheter is removed will prevent subsequent symptomatic urinary
tract infection is unclear. Randomized trials have yielded
conflicting results,7 8 and there has been no meta-analysis. Also,
there is considerable heterogeneity in the management of
antimicrobial prophylaxis around removal of a urinary catheter.9
The 2009 Infectious Diseases Society of America (IDSA)
guidelines for the diagnosis, management, and prevention of
catheter associated urinary tract infection determined that there
was insufficient evidence to recommend widespread antibiotic
prophylaxis after catheterization.2 In contrast, in their 2008 best
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Page 2 of 8
RESEARCH
Methods
Results
The two literature searches identified 246 and 221 potentially
relevant abstracts (fig 1). In the primary search, we identified
27 abstracts that led to full article review and two further studies
by reviewing bibliographies or through conference abstracts.
In the secondary search, two reviewers independently
determined that 17 of 221 abstracts required review of the full
manuscript. After review, we excluded studies in which the
patients had suprapubic catheters,17 18 the endpoint was not
symptomatic bacteriuria,19-21 or antibiotic prophylaxis was started
shortly after catheter insertion rather than at the time of
removal.22 23 We also excluded studies that lacked a concurrent
control group.24 Seven studies met eligibility criteria.
This meta-analysis includes five published randomized
controlled trials,7 8 25-27 one unpublished randomized controlled
trial,28 and one non-randomized controlled study29 (table 1).
Three trials indicated that prophylaxis is associated with lower
incidence of urinary tract infection,7 26 29 whereas three published
studies8 25 27 and the single unpublished randomized study28 did
not report any benefit with prophylaxis. The quality of the
included studies was variable: there was a low risk of detection
bias and performance bias and a high risk of selection and
attrition bias in most studies. Specifically, randomization and
adequate allocation were inadequate in all studies except those
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Page 3 of 8
RESEARCH
Discussion
In our meta-analysis of pooled data from seven studies (six of
which were randomized), there were significantly fewer
symptomatic urinary tract infections in patients receiving
prophylaxis during removal of a urinary catheter than in those
not receiving prophylaxis. Our finding in favor of antibiotic
prophylaxis, however, must be tempered by possible publication
bias toward positive studies, the limitations of the included
studies, and practical considerations about encouraging more
widespread antibiotic use.
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RESEARCH
Conclusions
This meta-analysis of available data indicates an overall benefit
of antibiotic prophylaxis at the time of removal of a urinary
catheter to prevent subsequent urinary tract infections. The
number needed to treat indicates that 17 patients would need to
receive prophylaxis to prevent one symptomatic urinary tract
infection. We know little, however, about the potential negative
consequences of implementing antibiotic prophylaxis in this
setting in a wider frame or indeed which types of patients would
be most likely to benefit. Increasing antimicrobial resistance,
healthcare costs for antibiotics, and the potential for side effects
No commercial reuse: See rights and reprints http://www.bmj.com/permissions
3
4
5
Saint S, Lipsky BA. Preventing catheter-related bacteriuria: should we? Can we? How?
Arch Intern Med 1999;159:800-8.
Hooton TM, Bradley SF, Cardenas DD, Colgan R, Geerlings SE, Rice JC, et al. Diagnosis,
prevention, and treatment of catheter-associated urinary tract infection in adults: 2009
International Clinical Practice Guidelines from the Infectious Diseases Society of America.
Clin Infect Dis 2010;50:625-63.
Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA. CDC-HICPAC: Guideline
for prevention of catheter-associated urinary tract infections. Centers for Disease Control
and Prevention, 2009. www.cdc.gov/hicpac/cauti/001_cauti.html.
Lo E, Nicolle L, Classen D, Arias KM, Podgorny K, Anderson DJ, et al. Strategies to
prevent catheter-associated urinary tract infections in acute care hospitals. Infect Control
Hosp Epidemiol 2008;29(suppl 1):S41-50.
Cutter CS, Kelly SR, Marcello PW, Mahoney JE, Nicolle LE, McLeod RS. CAGS and ACS
evidence based reviews in surgery. Is there a role for prophylactic antibiotics in the
prevention of urinary tract infections following Foley catheter removal in patients having
abdominal surgery? Can J Surg 2011;54:206-8.
Warren JW, Damron D, Tenney JH, Hoopes JM, Deforge B, Muncie HL Jr. Fever,
bacteremia, and death as complications of bacteriuria in women with long-term urethral
catheters. J Infect Dis 1987;155:1151-8.
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Banks JA, McGuire BB, Loeb S, Shrestha S, Helfand BT, Catalona WJ. Bacteriuria and
antibiotic resistance in catheter urine specimens following radical prostatectomy. Urol
Oncol 2012, Jan 25 epub ahead of print.
Grabe M, Forsgren A, Hellsten S. A short antibiotic course given in conjunction with and
after catheter removal consecutive to transurethral prostatic resection. Scand J Urol
Nephrol 1984;18:193-9.
Harding GK, Nicolle LE, Ronald AR, Preiksaitis JK, Forward KR, Low DE, et al. How long
should catheter-acquired urinary tract infection in women be treated? A randomized
controlled study. Ann Intern Med 1991;114:713-9.
Wazait HD, Patel HR, van der Meulen JH, Ghei M, Al-Buheissi S, Kelsey M, et al. A pilot
randomized double-blind placebo-controlled trial on the use of antibiotics on urinary
catheter removal to reduce the rate of urinary tract infection: the pitfalls of ciprofloxacin.
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Brandenburg A, Lingsma M, Terpstra S, Vd Mijle H, Ott A. Urinary tract infection after
removal of urinary catheter; no effect of nitrofurantoin profylaxis. J Hosp Infect
2006;64(S1):S108.
Pinochet R, Nogueira L, Cronin AM, Katz D, Rabbani F, Guillonneau B, et al. Role of
short-term antibiotic therapy at the moment of catheter removal after laparoscopic radical
prostatectomy. Urol Int 2010;85:415-20.
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of Foley cathetersis infection the greatest risk? J Urol 2012;187:1662-6.
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pattern of antimicrobial resistance within 42,033 Escherichia coli isolates from nosocomial,
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RESEARCH
Tables
Table 1| Summary of studies on effect of antibiotic prophylaxis for urinary tract infections after removal of urinary catheter included in this
meta-analysis
Median duration of
catheterization (days)
Author
Year
published
Van Hees8
2011
Randomized,
placebo
91 general surgery
5/6
4.5
Pinochet29
2010
Prospective,
comparative
(patients of
surgeon A vs.
surgeon B)
713 radical
prostatectomy
11
Pfefferkorn7
2009
Randomized, no
placebo
205 abdominal
surgery
Brandenburg28
2006
Randomized,
placebo
Wazait27
2004
Randomized,
placebo
Harding26
1991
Grabe25
1984
Design
Control
No of cases*
Antibiotic used
Antibiotics Control
1/36
Observation
period
Ciprofloxacin (n=31) or
TMP/SMX (n=24) x1
dose before removal
1/55
2 weeks
Ciprofloxacin (3 day
course starting day
before removal)
8/261
33/452 6 weeks
6.5
5/103
33
Nitrofurantoin (2 doses,
first before removal)
12/137
18/151 4 weeks
48 on medical and
surgical wards,
excluding
genitourinary surgery
3.8
3.6
Ciprofloxacin (4 doses,
two daily, first before
removal)
2/25
1/23
2 weeks
Randomized, no
placebo
79 women on
medical and surgical
wards with
bacteriuria
2.
0/37
7/42
4 weeks
(prophylaxis) v
2 weeks (no
prophylaxis)
Randomized, no
placebo
96 transurethral
prostatectomy
1.9
1.8
3/47
8/49
1 week
TMP/SMX=trimethoprim/sulfamethoxazole.
*Total was 31/665 (4.7%) in antibiotic group and 90/855 (10.5%) in control group.
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RESEARCH
Table 2| Assessment of quality in studies on effect of antibiotic prophylaxis for urinary tract infections after removal of urinary catheter
Van Hees8
Pinochet29
1/0
0/1
Pfefferkorn7
Brandenburg
Wazait27
Harding26
28
Grabe
25
Rating agreement ()
1.0
1.0
0.7
NA
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RESEARCH
Figures
Fig 1 Selection of studies for meta-analysis of trials investigating antibiotic prophylaxis for urinary tract infections after
removal of urinary catheter
Fig 2: Forest plot of seven included studies with 1520 participants on effect of antibiotic prophylaxis on urinary tract infections
after removal of urinary catheter
Fig 3 Funnel plot of seven included studies with 1520 participants on effect of antibiotic prophylaxis on urinary tract infections
after removal of urinary catheter
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