Urinary catheterisation is a common procedure, with approximately 15 to 25% of all people admitted to the hospital receiving short-term indwelling urethral catheterisation (IUC) at some point during their care (1). However, the use of urinary catheters is associated with an increased risk of developing symptomatic urinary tract infection. Catheter associated urinary tract infection (CAUTI) is one of the most common hospital-acquired infections (2). It is estimated that around 20% of hospital-acquired bacteraemias arise from the urinary tract and are associated with a mortality of around 10% (3). Our aim was to assess the effectiveness of strategies for removing short-term indwelling catheters (14 days or less) in adults.

We searched the Cochrane Incontinence Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov, WHO ICTRP, and hand searching of journals and conference proceedings (searched 17 March 2020), and reference lists of relevant articles. We included all randomised controlled trials (RCTs) and quasi-RCTs which evaluated the effectiveness of practices undertaken for the removal of short-term IUCs in adults for any reason in any setting. Two review authors independently performed abstract and full-text screening of all relevant articles. At least two review authors independently performed risk of bias assessment, data abstraction and GRADE certainty assessment.

We included 99 randomised and quasi-randomised controlled trials involving 12,241 participants. Most trials were also deemed to be at low risk of attrition and reporting bias. None of the trials reported on quality of life. The majority of participants across the trials underwent some form of surgical procedure.

Thirteen trials involving 1506 participants compared the removal of short-term IUC at one time of day (early morning removal group between 6 to 7 AM) versus another (late- night removal group between 10 PM to midnight). Removal of short-term IUC late at night may slightly reduce the risk of requiring recatheterisation compared with early morning removal (RR 0.71, 95% CI 0.53 to 0.96; 10 studies; 1920 participants; low-certainty evidence). We are uncertain if there is any difference between early morning removal and late- night removal in the risk of developing symptomatic CAUTI (RR 1.00, 95% CI 0.61 to 1.63; 1 study; 41 participants; very low-certainty evidence). We are uncertain whether the time of day makes a difference to the risk of dysuria (RR 2.20; 95% CI 0.70 to 6.86; 1 study; 170 participants; low-certainty evidence).

Sixty-eight trials involving 9247 participants compared shorter durations of IUC versus longer durations of IUC. Shorter durations of catheterisation may increase the risk of requiring recatheterisation compared with longer durations (RR 1.81, 95% CI 1.35 to 2.41; 44 studies; 5870 participants; low-certainty evidence), but probably reduce the risk of symptomatic CAUTI (RR 0.52, 95% CI 0.45 to 0.61; 41 studies, 5759 participants; moderate-certainty evidence) and may reduce the risk of dysuria (RR 0.35, 95% CI 0.16 to 0.79; 6 studies; 1178 participants; low-certainty evidence).

Seven trials involving 714 participants compared clamping policies of short-term IUC versus free drainage. There may be little to no difference between clamping and free drainage in terms of the risk of requiring recatheterisation (RR 0.82, 95% CI 0.55 to 1.21; 5 studies; 569 participants; low-certainty evidence). We are uncertain if there is any difference in the risk of symptomatic CAUTI (RR 0.99, 95% CI 0.60 to 1.63; 2 studies; 267 participants; very low-certainty evidence) or dysuria (RR 0.84, 95% CI 0.46 to 1.54; 1 study; 79 participants; very low-certainty evidence).

Three trials involving 402 participants compared the use of prophylactic alpha blockers versus no intervention or placebo. We are uncertain if the use of prophylactic alpha blockers before short-term IUC removal has any effect on the risk of requiring recatheterisation (RR 1.18, 95% CI 0.58 to 2.42; 2 studies, 184 participants; very low-certainty evidence), or risk of symptomatic CAUTI (RR 0.20, 95% CI 0.01 to 4.06; 1 study; 94 participants; very low-certainty evidence). None of the included trials investigating prophylactic alpha blockers reported the number of participants with dysuria.

There is some evidence to suggest the removal of IUC late at night rather than early in the morning may reduce the number of people requiring recatheterisation. It appears that the removal of short-term IUC after shorter durations probably reduces the risk of symptomatic CAUTI and may reduce the risk of dysuria. However, it may lead to more people requiring recatheterisation. The other evidence relating to the risk of symptomatic CAUTI and dysuria is too uncertain to draw any conclusions. The comprehensive search strategy, along with the increased efforts made to obtain unpublished data, means that we can be confident that the evidence presented in this review is as complete as possible.

This systematic review and meta-analysis highlighted the need for a standardised set of core outcomes which should be measured and reported by all future trials comparing strategies for the removal of short-term urinary catheters. The adoption of a clearly defined core outcome set such as The Core Outcome Measures in Effectiveness Trials (COMET) for research relating to short-term catheterisation would assist trialists in identifying and investigating clinically important questions.  This would allow systematic reviewers more scope for the meaningful synthesis of the evidence and lead to more robust clinical recommendations made by guideline panels and decision-makers. Future trials should also look to study the effects of short-term IUC removal on non-surgical patients.

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Bonkat G , Pickard R , Bartoletti R , Bruyère F , Geerlings S , Wagenlehner F , Wullt B , Pradere B , Veeratterapillay R . EAU Guidelines on Urological Infections 2020. EAU Guidelines Office (available at: https://uroweb.org/guideline/urological-infections/#1) 2020.