Intermittent catheterization: The devil is in the details
1Christison K, 1Walter M, 2Wyndaele J, 3Kennelly M, 4Kesslerr T, 5Noonan V, 5Fallah N, 1Krassioukov A
1International Collaboration on Repair Discoveries (ICORD), Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada; 2Department of Urology, University of Antwerp, Antwerp, , Belgium; 3Department of Urology, Carolinas Medical Center, Charlotte, NC, USA; 4Neuro-Urology, Spinal Cord Injury Center & Research, Balgrist University Hospital, Zürich, , Switzerland; 5Rick Hansen Institute, Vancouver, BC, Canada
During the last few years, the international community engaged in strong debates on urinary tract infection (UTI) and re-use of catheters during the management of neurogenic lower urinary tract dysfunction among individuals with SCI. The most frequent complication of intermittent catheterization is UTI. In this respect, the Cochrane 2014 systematic review ‘Intermittent Catheterisation for Long-Term Bladder Management’ by Prieto et al. became one of the leading documents that captured the mind and attention of clinicians around the world. However, many clinicians expressed their concern with 2014 Cochrane review’s conclusions.
We conducted a thorough independent appraisal of the data and analyses presented in the 2014 Cochrane review.
We identified four main concerns with the 2014 Cochrane review.
First, data selection, i.e. two of the 31 trials included in the 2014 Cochrane review were only published as conference abstracts and eight of the 31 trials were classified as not providing data to be used in meta-analysis”. However, two of these eight trials did provide data which could have been included.
Second, data extraction, i.e. five types of disagreements were observed: Extracted content 1. was mislabeled or 2. did not match the original trial or 3. was in a method not consistent with convention or 4. was in a form that could not be used in meta-analyses or 5. was not originally extracted, although eligible.
Third, definition of UTI, i.e. although the review was published in 2014 the UTI definition was taken from an outdated 1992 National Institute on Disability and Rehabilitation Research (NIDRR) consensus statement. Yet, at the time of conducting the review the Infectious Diseases Society of America (IDSA) 2009 consensus statement already provided the most up-to-date and comprehensive definition of UTI, which specifically covered catheter-associated UTI.
Fourth, data analysis, i.e. 20 of all 39 analyses from the Cochrane review consisted of only one trial. However, according to the ‘Cochrane Handbook for Systematic Reviews of Interventions Version’ at least two trials are required for meta-analysis.
Furthermore, when we applied the up-to-date (IDSA) definition of symptomatic UTI at least 50% of trials from the 2014 Cochrane had to be excluded due to outdated UTI definitions. In contrast to Prieto et al., we found that there is a trend (albeit small) toward single use of catheter.
Given the presented evidence, we strongly believe that the statement made in the Cochrane review: “…there is still no convincing evidence that the incidence of UTI is affected…” by any of the established intermittent catheterization technique should be corrected. Until evidence can confidently demonstrate that multiple use is as safe as single use of catheters, healthcare providers should advocate a single use of catheters in individuals with SCI, especially considering that catheter cleaning is a major issue since there is no standardized and universally accepted cleaning method which would be the prerequisite for multiple use of catheters.
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