Catheter-Associated Urinary Tract Infections in the Adult Patient Group: A Qualitative Systematic Review on the Adopted Preventative and Interventional Protocols From the Literature

Catheter-associated urinary tract infections (CA-UTIs) are among the most common nosocomial infections acquired by patients in health care settings. A significant risk factor for CA-UTIs is the duration of catheterization. To summarize the current strategies and interventions in reducing urinary tract infections associated with urinary catheters, use and the need for re-catheterization on the rate of CA-UTIs, we performed a systematic review. A rapid evidence analysis was carried out in the Medline (via Ovid) and the Cochrane Library for the periods of January 2005 till April 2021. The main inclusion criterion required to be included in this review was symptomatic CA-UTI in adults as a primary or secondary outcome in all the included studies. Only randomized trials and systematic reviews were included, reviewed, evaluated, and abstracted data from the 1145 articles that met the inclusion criteria. A total of 1145 articles were identified, of which 59 studies that met the inclusion criteria were selected. Studies of relevance to CA-UTIs were based on: duration of catheterization, indication for catheterization, catheter types, UTI prophylaxis, educational proposals and approaches, and mixed policies and interventions. The duration of catheterization is the contributing risk factor for CA-UTI incidence; longer-term catheterization should only be undertaken where needed indications. The indications for catheterization should be based on individual base to base cases. The evidence for systemic prophylaxis instead of when clinically indicated is still equivocal. However, antibiotic-impregnated catheters reduce the risk of symptomatic CA-UTIs and bacteriuria and are more cost-effective than other impregnated catheter types. Antibiotic resistance, potential side effects and increased healthcare costs are potential disadvantages of implementing antibiotic prophylaxis. Multiple interventions and measures such as reducing the number of catheters in place, removing catheters at their earliest, clinically appropriate time, reducing the number of unnecessary catheters inserted, decrease antibiotic administration unless clinically needed, raising more awareness and provide training of nursing personnel on the latest guidelines, can effectively lower the incidence of CA-UTIs.


Introduction And Background
Catheter-associated urinary tract infection (CA-UTI) is defined as a urinary tract infection that occurs with the use of an indwelling urinary catheter. A prevalence survey from 2006 about hospital-acquired infections in acute hospitals in Ireland revealed that UTIs account for 22.5% in a hospital setting, of which 56.2% were catheter-related [1]. A urinary tract infection (UTI) is an infection to the epithelium of the urinary tract in response to the colonization of the pathogen. Urinary tract infections (UTIs) are one of the most common hospital community-acquired infections (HCAI), with up to 70-80% attributable to the presence of indwelling urinary catheters [2]. Between 10% to 25% of hospitalized patients, during their hospitalization, will receive indwelling urinary catheters, of whom 20% develop UTIs [3,4]. The risk of catheter-related infection increases by 5% each subsequent day the catheter remains in situ, with the risk increasing to 35% and 70% after seven and 14 days of indwelling catheterization, respectively. Around 50% of patients with indwelling catheters after 15 days of installation will develop UTIs, and almost 100% of the patients will develop UTI in one month [5]. Results of the 2009 pilot study for the European HCAI (HALT) study in longterm care facilities revealed that urinary tract infections accounted for 30% of the reported HCAIs and that almost half of all systemic antimicrobials were prescribed for an indication related to the urinary tract (48.9%) [6].
In line with the literature findings, it is clear that there is no standardization or even consensus among practitioners and hospitals/institutions regarding the protocols carried out of urinary catheter's insertion and maintenance. Regarding antibiotics prophylaxis, type of catheter to use, dwell time of the catheter, periurethral cleansing with anti-septic or sterile solutions etc., non-standardized practices in managing catheterized patients are noticed. A study by Conway et al. revealed that implementation protocol guidelines for CA-UTI prevention in the ICUs (intensive care units) is inadequate and insufficient, with 42% of ICUs reported having existing evidence-based practices (EBP) and policies for prophylaxis [7]. Therefore, there is a need for competent healthcare workers to set up and adhere to preventive and management protocols to reduce the probability of catheter-related infection. This article aims to provide a general overview of urinary catheterization and its association with UTI and preventative strategies by presenting the available results and recommendations in the literature.

Review
Method databases. Our searches used the following joint search term variations of the following Medical Subject Heading terms, specifically tailored for each database. The search terms-"urinary tract infections," "bacteriuria," "catheter," "indwelling catheter," "urinary catheterization," "asymptomatic bacteriuria," ''intervention studies"-were looked at both as free texts and MesH terms. We also evaluated the reference lists of articles, which provided us with further articles for consideration. Only full-text publications in English were considered. While catheter-associated asymptomatic bacteriuria was mentioned and compared to CA-UTI, it was decided not to be included.

Study Selection
A rapid evidence analysis was carried out in the Medline (via Ovid) and the Cochrane Library for January 2005 to April 2021. The main inclusion criterion required to be included in this review was symptomatic catheter-associated UTI in adults as a primary or secondary outcome in all the included studies. Only randomized trials and systematic reviews were included in this systematic analysis. One thousand one hundred forty-five articles were identified, of which 1086 were excluded, as explained in figure 1. The final review is thus based on 59 articles.

Data Extraction and Quality Assessment
The two authors of this review (HA and MG) independently reviewed and abstracted data from the 1145 articles that met the inclusion criteria. Extracted data included primary study objectives, patient population characteristics, inclusion criteria, terms and definitions used and quality issues. The data from the literature search were evaluated and shortlisted by the first author according to methodological/theoretical rigor and trustworthiness and data relevance on CA-UTI as a primary or secondary outcome.

Study Characteristics for Inclusion
Our database search included publications published in the English language. We did not exclude studies based on the number of residents or patients included (gender, age, catheter type, use of antibiotic), duration of pre and post-intervention periods, study withdrawals, or whether follow-ups were done or not.

Data Source and Searching the Literature
The following data sources were searched: Ovid MEDLINE, Cochrane Library via Wiley and CINAHL. Only systematic search strategies were performed in the process of collecting the data ( Figure 1). The first systematic search was conducted using the previously mentioned data sources to find searches associated with indications and need for catheterization, type of catheterization, duration of catheterization, infection prophylaxis, education programs, and interventions at reducing UTIs. The second systematic search was conducted in the described above data sources Ovid MEDLINE & Cochrane to identify RCT or studies to reduce UTI incidences use of antimicrobial coated catheters in settings such as hospitals, nursing homes, communities and rehabilitation units and spinal cord injury or orthopaedic programs, which do compromise a considerable population with chronic catheter needs.

Study Selection & Data Extraction
A data collection instrument was adapted and used for characterization of the selected studies containing items such as the descriptors used, title, authors, area of work, year of publication, language, design, objectives, method, results, conclusion, recommendations, limitations and level of scientific evidence, among others. The three phases of this systematic review are detailed in figure 1 [8].

Analysis of the Literature Search
The database search yielded 1145 results (Figure 1), of which 59 relevant studies were included in this review ( Table 1). The included studies are grouped thematically: duration of catheterization (n = 9), type of catheterization (n = 13), assessing indication/necessity for catheterization (n = 2), maintenance and care of catheterized patients (n= 5), prophylactic measures (n = 17), preventative and/ or educational initiatives (n = 10), and studies with multiple interventions (n = 3). A total of 23 systematic reviews (including 6 Cochrane reviews) and 36 randomized, controlled trials (RCTs) were identified.  Routine prophylactic antibiotics were not given.

Comparing Intermittent Catheterization & Short-term Indwelling Catheters?
Two RCTs [9,10] and two SR [11,12] were identified in which intermittent (self-) catheterization was compared with the use of temporary indwelling catheters. Including the 182 patients who underwent hip fracture or hip replacement surgery that Hälleberg Nyman et al. included; The absolute risk difference of CA-UTI in the intermittent catheterization group was a low 2.4% with a Confidence interval of 6.9 to 11.6%, a statistically insignificant difference (8 out of 85 patients (9.4%) with CA-UTI in the intermittently catheterized group, compared to 10 out of 85 patients (11.8) with indwelling catheters [10]. When comparing transurethral indwelling with intermittent catheters, Hakvoort et al. reported a (p = 0.03) lower CA-UTI rate with intermittent catheterization (12% rate) compared to an indwelling catheter (33%) left in place for seventy-two hours [9].
Nine RCTs with 1771 patients were included in a meta-analysis by Zhang [11].

Comparing Temporary Transurethral to Suprapubic Catheterization
Two RCTs compared the use of transurethral and suprapubic catheterization in patients who required urological interventions; suprapubic catheterization was comparable to transurethral catheterization with little to no difference in the rate of infection [13,14]. Two SRs [12,15] and one Cochrane review [16] were also identified. When comparing suprapubic to urethral, all revealed that there is no statistically significant difference in the rates of CA-UTI. In a systematic review and meta-analysis (included twelve RCTs) by Healy et al., suprapubic catheterization was associated with a significant reduction in postoperative UTIs (20%; OR: 0.31; 95% CI, 0.185-0.512; p < 0.01) compared to 31% for urethral catheterization in the selected gynecologic patients [15]. Patients are three times more likely to develop a UTI with a transurethral catheter than a suprapubic catheter. Although Healy pointed out the increased noninfectious complication rate that suprapubic catheter was associated with (29% compared to 11%; OR: 4.14; 95% CI, 1.33-12.9; p = 0.01), those were tube malfunction related with no visceral injuries reported among the 1,300 participants [15].
Hunter et al. identified studies comparing suprapubic catheterization to various other methods of chronic bladder emptying, such as intermittent or indwelling urethral catheterization in the adult population [12]. Their review focused on suprapubic catheters, with the available evidence of 14 studies (one prospective non-randomized study and eight retrospective reviews with a comparator, a case-series, and qualitative assessments of quality of life) reported no significant difference between symptomatic CA-UTI outcomes between suprapubic and urethral catheters. However, the evidence is limited by the varied UTI criteria defined in their outcomes. The study revealed that suprapubic catheterization was associated with a lower incidence of urethral complications. However, the incidence of upper and lower urinary tract complications between urethral and suprapubic catheters was similar [12]. Similarly, a Cochrane review by Kidd et al. found an insufficient difference in symptomatic UTI risk between the suprapubic versus indwelling urethral catheters, but the suprapubic catheter group were catheterized for a longer duration than the urethral group (RR: 1.01; [0.61; 1.69]) [16].

Fixation with a Catheter Securing Device (StatLock ®) or Valve
Only one review devoted to reviewing the evidence on the effect of catheter valves compared to free drainage into a bag for patients with indwelling urinary catheter [18]. While two RCT were evaluated by Van den Eijkel et al., results relating to CA-UTI were only reported in a single RCT; 60% of the intervention group with the valve developed CA-UTI, compared to 68% in the control group. The absolute differential in the infection rates of the two groups was statistically insignificant, with a p = 0.286 [17].
An RCT conducted by Darouiche et al. investigated the effect of the StatLock ® system, a fixation device for indwelling catheters was used in adult patients with neurogenic bladder due to spinal cord injury. Out of the 118 patients, among the 60 patients who received StatLock, the rate of CA-UTI was 45% lower, but a statistically insignificant association with increased UTI rates was established (RR: 0.55; [0.25; 1.22]) [18].

Bladder Clamping and Free Urinary Drainage
One RCT [19] and three SRs [20,21,65] evaluated the necessity of bladder clamping before removing a urinary catheter. The RCT by Gong et al. did not report any statistically significant difference between the two groups (CA-UTI in the clamping group was 22.9% vs 20.3% for the controlled group). Wang et al. revealed no statistically significant difference between clamping and free drainage. There was no significant difference between clamping and unclamping groups found across four studies included in their study (OR 0.76, 95% CI (0.33, 1.73)). Gong et al. and Wang et al. concluded no significant difference between the clamping and unclamping groups in the outcomes of UTI and patients bladder function [19,21].
Fernandez et al. [20] delineated and compared three timepoints of catheter management as follows: (Group A) within 24 hours removal after free drainage, (Group B) within 72 hours removal, (Group C) within 24 hours removal in addition to bladder re-education. No significant differences were reported in the rates of CA-UTI in the 24 hours group

Duration of catheterization and minimizing dwell time
The time a catheter is in place for a particular time associated with operative gynaecological interventions was studied in seven RCTs [22][23][24][25][26][27][28]. The catheters in the trials were either immediately removed postoperative or within 24 hours in the following RCTs [22][23][24][25]. While Bray et al. set the catheter removal 48 to 72 hours after as the prerequisite criteria to their intervention, Weemhoff et al. compared catheterization duration of two vs five days and its association with temporary catheter replacements, temporary catheter replacements and fewer urinary tract infections, and shorter hospital stays [27,28]. The seven authors of the selected RCTs concluded that the policy of short term catheterization compared to immediate or long term catheterization was associated with lower symptomatic urinary tract infection rates and less rate of recatheterization. All agreed that short term catheterization is also associated with earlier postoperative ambulation. However, all the studies but Chai et al. did not report lower rates of CA-UTI [24]. Moreover, contrary to the data above by the other authors, Liang [65]. Out of the 11 trials, seven trials with data suggested fewer urinary tract infections when a catheter was removed earlier. Although the studies did not indicate any statistical significance in the confidence interval of CA-UTI incidences, the point estimators conclusively indicated that the shorter duration resulted in the overall better outcome [65].
Fernandez et al. was the one study that purely focused on the duration and set different catheterization durations before the removal of short-term indwelling urethral catheters [30]. Four trials out of the eight showed no significant differences in CA-UTI rates in patient outcome after TURP (RR 0.55, 95% CI 0.30 to 1.03). A statistically significant difference in CA-UTI rate was reported in one RCT that compared catheterization for 1 vs 5 days after rectal resection. The five-day rate was almost as twice as higher as the one-day indwelling catheterization [30]. Similarly, Phipps et al. suggested fewer urinary tract infections occur when a catheter is removed earlier (for example, 1 vs 3 days, RR 0.50, 95% CI 0.29 to 0.87) [65].
It is worth noting that both the Lam et al. and Lusardi et al. reviews evaluated the expected duration of internal bladder catheters for up to 14 days. Whether they including a large number of interventions to be evaluated affected the calculated incidence rate of urinary tract infection in their studies or not remains to be unknown [38,39]. Li et al. suggested that the routine use of indwelling urinary catheters for caesarean delivery is not necessary and is associated with fewer UTIs and no increase in postoperative adverse urinary events (relative risk [RR] of urinary tract infection compared with the use of indwelling urinary catheters, the non-catheterized patients had a significantly lower incidence of UTIs [RR 0.08; with 95% confidence interval 0.01, 0.64 (study design: RCT); the RR in the single NCRT was 0.10 with 95% CI 0.02, 0.57] [37].

Assessing indication/necessity for catheterization
Regarding the incidence of UTIs in another cesarean-related study, Nasr et al. found no statistically significant difference (P<0.001) between the catheterized and non-catheterized patients regarding UTI symptoms. The incidence of UTIs was 5.7% in the catheterized group for the 24 h postoperative and 2.9% for the one week postoperative, vs 0.5% (P<0.001) 24 h postoperative and 0% (P<0.001) one week after the operation in the non-catheterized [36].

Cleansing or Disinfection of the External Urethral Orifice
A network meta-analysis by Ercole et al. summarized data from thirty-three studies with seven different methods of urethral cleaning versus disinfection of the external urethral orifice was included (normal saline vs tap water vs soapy water vs antibacterial vs iodine vs chlorhexidine) [31]. No evidence of heterogeneity (P>0.05) was observed among the studies. The results showed no statistical difference in the incidence of CA-UTIs (P>0.05 for all) when analyzing the different urethral cleaning methods versus disinfection [31].
Cao et al., through twenty-eight RCTs and nine SRs, that they included in their review, presents that the rate of urinary tract infection is not predicated on whether the perineum is cleaned with or without sterile water, or with the use of the povidone-iodine solution or chlorhexidine, or even with the use of clean or sterile technique, no difference in the incidence of CA-UTIs when comparing the different urethral cleaning methods versus disinfection (P > 0.05 for all), this was postulated based upon thirty-three trials including 6390 patients with seven different urethral cleanings versus disinfection methods [32]. Similarly, studies that, prior to intermittent or indwelling catheterization, used anti-septic or non-medicated agents to clean peri-urethral or meatal areas showed no statistical significance in reducing its association with the incidence rate of UTI [33].
It was suggested that cleaning the peri-urethral area before catheter insertion can be undertaken, nonsterile water would be an equally weighted option, and the economical alternative as its effectiveness compared to the sterile water. Anti-septic solutions (chlorhexidine and PVP-I) were as equal. More studies about UTI development and saved expenditure on costs were not looked at and needed to be confirmed [31][32][33].
Even though a consistent level of hygiene was scrutinized with short-term catheter use in their RCT, Fasugba et al. failed to result in a substantial reduction in CA-UTI rates for long-term catheterization [54].

Irrigations and Washouts
The practice of irrigating long-term indwelling urinary catheters has also been assessed by two systematic reviews [34,35], including reports of various solutions and regimens. One of the RCTs in a dedicated RCT conducted by Shepherd et al. [35]. Four trials studied the following: (any washout vs no washout, saline washout versus no washout, citric acid washout versus no washout). The authors were uncertain if comparing washout and no washout had any significant effect on the rate of symptomatic UTI or duration of catheterization in situ. The evidence was not adequate to conclude if washouts were beneficial or harmful due to the poor methodological quality and reporting [35].
Both Systematic reviews have five studies that were labelled to be of poor quality and concluded inconclusive effective at either reducing symptomatic CA-UTIs or duration of first catheter change [34,35].

Antiseptic-coated Compared to Standard Non-septic Catheters
Lam, Pickard, Bonfill, and Jahn, most notably, from the studies we included, compared the effect of antiseptic catheter surfaces vs the non-septic catheters, respectively [38,[40][41][42]. Two Cochrane reviews conducted by Lam [38,42]. Jahn et al. concluded evidence should not be treated as a reliable basis for practical implications due to the small sample of the trials and that very few trials have compared several types of catheters for long-term bladder drainage [42].
While Lam et al. [38] concluded that the antiseptic-coated catheters resulted in no statistically significant reduction in symptomatic CA-UTI and was considerably expensive, Pickard'sPickard's 2012 RCT further stated that silver alloy-impregnated catheters might be less cost-effective than the antibiotic (Nitrofurazone) coated with OR 0.96 (0.78 to 1.19); p=0.69 compared to OR 0.81 (0.65 to 1.01) p=0.031, respectively [40].
There is no unequivocal evidence supporting the use of either anti-septic, or antimicrobial coated catheters is more beneficial than using standard catheters in reducing UTI in patients who require long term catheterization, no sufficient data to decide which type is the go-to for CA-UTI prevention [41,42].
Beattie et al. emphasized that the heterogeneity was too significant for them to calculate an estimate for all studies combined but stated that there was nothing to suggest that one approach was better than the other [43]. The low number of participants, wide confidence intervals and risk of systematic errors and biases in one of the studies means that the methodological quality should be considered to be a low one, and cannot conclude if whether silver-alloy urinary catheters reduce CA-UTI compared with standard silicon or latex urinary catheters [43].
Moreover, in adults requiring short-term urinary urethral and supra-pubic catheterization up to and including 14 days, the patients who received the following systemic antibiotic prophylaxis (cefotaxime, trimethoprim/sulfamethoxazole, ciprofloxacin, or Nitrofurantoin) antibiotic prophylaxis was associated with an absolute reduction in risk of urinary tract infection of 5.8% with a risk ratio of 0. 45 [59]. With use of the random-effects negative binomial regression models, the rates decreased from 6.42 to 3.33 (incidence rate ratio [IRR], 0.46; 95% CI, 0.36-0.58; P < .001) [59]. This was the only intervention that demonstrated a statistically significant reduction in CA-UTI in chronically catheterized patients due to the implemented comprehensive program that limited antimicrobial use, improved hand hygiene, and promote standardized CA-UTI definitions and active drug-resistant organisms surveillance protocol [59].

Miscellaneous & Coupled Interventions
One Cochrane review, following urogenital surgery in adults, examined seven trials that compared the postoperative duration of catheter use; these trials suggested that shorter-term catheterization was associated with fewer UTI incidences and more patients required re-catheterization following a urethral compared to a suprapubic catheter [65]. While Ercole et al. showed that the use of an intermittent catheter with clean technique results in low rates of complications or infections compared to the use of an indwelling catheter, in the same review, postoperative catheter removal up to 24 hours and the use of an antimicrobialimpregnated or hydrophilic-coated catheter resulted in lower urinary tract infection [31].
One RCT conducted by Kringel

Discussion
We included fifty-nine combined studies, including thirty-six RCTs and twenty-three SRs, meant to shed light on more than fifty measures. Ten of these measures were studied. The bulk of the studies was published in the 2010s period. Since we identified numerous studies with different evidence and measures regarding the prevention and management of CA-UTI in different patient groups and settings, the data regarding catheterization, duration, and prophylactic measure are clinically heterogeneous states of the evidence not conclusive. Although several review authors have identified a couple of studies for some interventions, they could not perform meta-analyses due to the highly heterogeneous finding between the included studies. Three contributing factors for the resulted heterogeneity might be as follows:

Study Groups
The patient groups that were compared varied from one study to the other. Patients with different diagnoses, anatomies and health/immunological status may have different preconditions and predispositions to infections, which in turn makes it harder to combine and group studies to obtain enough participants with similar physical and immunological conditions in comparison to be able to report an efficient data for the prevention of catheter-associated urinary tract infections.

Interventions
Different interventions lead to large variations in what was compared. Studies that were conducted before the first half of the first decade in the 2000s were excluded due to the fear that the applicability and practicality of their findings-in particular, relating to the guidelines related to administration of prophylactic antibiotics or types of education programs would not resonate nor translate to the current clinical practices; as the perception about prescribing practices and awareness around resistance may well have over the time. Therefore, to avoid the need to examine the preparations or methods used at the time in the study today or whether there have been other changes over the years, 2005 was agreed on.

Measurement of Outcome Measures
The terms Urinary tract infection, bacteriuria and catheter-associated urinary tract infection were loosely used and varied between the studies. Some studies have not even defined the criteria for their used outcome. Some studies used the terms CA-UTI and catheter-associated asymptomatic bacteriuria or catheterassociated bacteriuria interchangeably. Additionally, terms like Bacteriuria and UTI were differently defined.
All Catheter types are susceptible to biofilm formation and catheter encrustation; hence administering prophylactic antibiotics may delay the pathogenesis of CA-UTIs rather than preventing their occurrence. The use of low-dose, prophylactic antibiotics might aid in creating "persister" cells that are genetically capable of invading the uroepithelium and result in infection and integration with urinary bladder microbiota. Therefore, contributing more to sepsis and infection [68].
The duration of a catheter is generally based on individual cases rather than evidence-based knowledge and therefore varies among clinical practice. In-dwelling catheters have been associated with positive urine cultures, which can subsequently lead to urinary tract infection can which, as a result, increases the duration of hospital stay, costs and risk of morbidity. The risk of developing a CA-UTI is related to catheter dwell time [69,70]. For catheterized patients, the rate of development of catheter-associated bacteriuria is between 3% to 7% per day [71,72]. The likelihood of bacteriuria approaches 100% if a patient has an indwelling urinary catheter for ≥30 days [73,74], which is part of the rationale for why a urine culture alone is not sufficient to diagnose a CA-UTI. While bacteriuria is a risk factor for UTI, the frequency of progression from bacteriuria to CA-UTI is low and treating ASB does not decrease the risk of future CA-UTI. Other risk factors for the development of CA-UTI include urinary tract instrumentation, diabetes mellitus, and malnutrition [75,76]. The two principal factors that lead to CA-UTIs are unnecessary urinary catheter placement and unacceptable delay in removing a catheter when it is no longer needed [77]. Unfortunately, 38% of attending physicians are unaware that their patients have a urinary catheter in place, which might be due to the ambiguity of catheter placement indication in approximately 30% of cases [78].
An analysis by Hutton et al. [79] showed that implementing their multimodal intervention program led to 8.7 fewer CA-UTIs and 2.9 fewer resident hospitalizations per nursing home per year. 120-bed NH would have program costs of $20,279/year. The cost of disease treatment would be reduced by $54,316 per year, resulting in a net cost savings of $34,037. A cost savings of $15,136 in CA-UTI care and $39,180 in-hospital care for CA-UTIs and CA-UTI-associated septicemia, for a total net savings of $34,037 for the healthcare system. As well as 0.2 more QALYs (quality-adjusted life-years) than their control group.
Duszyńska et al. estimated the cost of HAIs in a Polish ICU to range from EUR 10,035 to 22,411 [80]. While in the USA, an estimate of 449,334 healthcare-associated catheter-associated urinary tract infections (CA-UTIs) per year, associated with an additional cost of US$749-10077-9 per admission in 2007 (or an estimated US$3744 when complicated by blood septicemia) [77,81].
An Australian study revealed that staffing costs for infection prevention nurses exceed AUD 100million per year and that 36% of their time is spent on patient monitoring. Another study confirmed that those undertaking active surveillance on patients had never been trained, and skills like reporting data to hospital executives are either not appropriately done [82,83]. This means that much of the CA-UTI data being collected might not be a true reflection of the magnitude of catheter complications and makes it harder to analyze the infection rate in an efficient, productive manner. Saint et al. surveyed 719 acute-care American hospitals for their CA-UTI prevention protocols in 2005; more than 70% of the surveyed hospitals documented their rates of CA-UTI, 44% documented which patient had a urinary catheter inserted, and 26% documented the duration of catheterization. No widely accepted protocol to prevent CA-UTI was reported.
30% of the surveyed hospitals reported the regular use of antimicrobial catheters, 14% reported condom catheters in men, and a mere 9% used catheter reminders or stop-orders [84].

Conclusions
In terms of implications to clinical practice, the results of this review suggest that healthcare workers should think of 2 strategies to reduce rates of CA-UTI: limit catheter use and shorten the duration of catheterization. The literature also supports either daily scheduled reviews or stop orders to safely reduce the duration of inappropriate urinary catheterization in hospitalized patients. Based on the current state of evidence, there are insufficient data to determine whether transurethral or suprapubic routes are most appropriate for catheterization. The reduced morbidity rate of suprapubic catheterization is offset by higher rates of catheter-related complications and doesn't necessarily mean a shorter hospital stay. No good evidence exists to adequately conclude if washouts were beneficial or harmful due to poor methodological quality and the substantial risk of bias of the included studies. No significant difference was found between the clamping and unclamping groups. Given the scant state of evidence, procedures relating to clamping of indwelling urinary catheters should not be favoured over free drainage. No significant differences have been demonstrated among the various methods of cleansing or disinfecting the external urethral orifice. Evidence from studies that, before intermittent or indwelling catheterization, used either anti-septic or nonmedicated agents to clean peri-urethral or meatal area showed no statistical significance in reducing its association with the incidence rate of UTI. Evidence of antiseptically coated catheters, compared to standard uncoated catheters, is equivocal. Antibiotic-impregnated catheters seem to be more documented in the literature and reduce the rate of catheter-associated symptomatic urinary tract infection. The current evidence on phytotherapy using cranberry extracts to prevent UTIs remains debatable, in part due to the trials were small and methodological weaknesses were shown. Therefore, the evidence was not a reliable basis for any clinical conclusions. So, there is no well-justification in recommending it highly.

Conflicts of interest:
In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.