Antibiotic prophylaxis for urinary tract infections after removal of urinary catheter: meta-analysis OPEN ACCESS

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 andmeta-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. National guidelines recommend removal of urinary catheters once they are no longer needed, and surgical experts advocate discontinuation of catheterization as early as 24-48 hours postoperatively. 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. 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). Whether administration of prophylactic antibiotics when the catheter is removedwill prevent subsequent symptomatic urinary tract infection is unclear. Randomized trials have yielded conflicting results, 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. 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. In contrast, in their 2008 best Correspondence to: J Marschall [email protected] No commercial reuse: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe BMJ 2013;346:f3147 doi: 10.1136/bmj.f3147 (Published 11 June 2013) Page 1 of 8