Systematic Review of UTI Literature

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The rationale for this review is that catheters are known to cause Urinary Tract Infections, especially in cases where they are not handled or inserted correctly. As such, this literature review examines three articles that attempted to prevent CAUTI through interventions-based methods. However, it is important to consider these articles together to consider any patterns that might exist within them, as well as to discover which methods did and did not work in these intervention strategies to achieve a better understanding of CAUTI prevention in the future. As for Participants, Interventions, Comparisons, Outcomes and Study Design (PICOS), the question is this: In patients requiring urinary catheterization in the hospital settings (P), can additional education, perineal care, or insertion techniques (I), when compared to current standards (C), decrease CAUTI rates (O)? The answer to this question is yes, and it will be further discussed later in this literature review.



For the articles included in this literature review, all backgrounds, objectives, methods and results were given at the beginning of the article.

Eligibility Criteria

The eligibility criteria for the Carter et al. (2016) article is as follows:

Types of studies: CAUTI prevention programs were examined by using catheter implementation criteria as well as by tracking the decrease of catheters inserted by emergency department staff. Carter et al. (2016) conducted interviews and focus groups. Focus groups occurred during on-site visits and interviews occurred either via telephone or on-site. These measures were transcribed verbatim after they were audio recorded and analyzed by using NVivo. Carter et al. (2016) did not mention any language, publication status, or publication date impositions. 

Types of Participants: Carter et al. (2016) engaged with six diverse emergency department staffs, including nurses, hospital leaders, and other health care personnel to obtain diverse perspectives and rich data about CAUTI prevention programs.

Types of Intervention: Carter et al. (2016) used lead nurses as the source for creating CAUTI prevention programs by having them reframe catheters as potentially hazardous to patients’ health, empowering clinical nurses to address opportunities to decrease CAUTI, creating an environment for teamwork, and by holding these nurses accountable for actions taken.

Types of Outcome Measures: In the cases where lead nurses implemented the intervention strategies listed above, CAUTI prevention programs were more successful.

The eligibility criteria for the Nogueira et al. (2017) article is as follows:

Types of Studies: Quantitative questionnaires were given to participants after they had signed an informed consent form. Seven of the questions dealt with demographic information, while the other eight questions dealt with the knowledge of the subject matter. Nogueira et al. (2017) did not mention any publication date or status restrictions, but it is important to note that this publication also appears in Portuguese, as the study occurred in Brazil.

Types of Participants: Nogueira et al. (2017) obtained information from a variety of healthcare professionals from ICU settings, which included diversity in terms of age, professional status, as well as how long the person had trained and how much experience they had in ICU settings.

Types of Intervention: Nogueira et al. (2017) engaged in five intervention strategies: engaging in practices associated with CAUTI prevention, the criteria for when a urinary catheter should be utilized, how to properly handle and insert urinary catheters, how to maintain the catheter once it has been inserted, and minimizing catheter usage in general, but especially for patients at a high risk for developing UTIs.

Types of Outcome Measures: Nogueira et al. (2017) wanted to discover if health care personnel knew the correct information and procedures concerning urinary tract information, and found that in terms of the first intervention strategy, only 21.2% understood the issues associated with catheters. As for the second strategy, only 43.9% of participants knew the correct method for inserting a catheter. For the third intervention strategy, only 58.5% got the answer correct. For the fourth, 3.7% of health care personnel got all the answers correct. Finally, as for revising catheter use overall, 58.5% of participants found the correct responses.

The eligibility for Sax et al.’s (2016) article is as follows:

Types of Studies: This study is a follow-up from a study previously performed at the same hospital setting. The researchers wanted to see if the CAUTI prevention programs were still successful after this eight-year period. For the quantitative portion, Sax et al. (2016) examined UTI cases of hospitalized patients and determined the rate of UTI cases per population. For the qualitative portion of the study, Sax et al. (2016) interviewed members of the hospital staff. Sax et al. (2016) did not mention any publication date or status restrictions. There was also no reference to language restrictions. 

Types of Participants: Sax et al. (2016) analyzed 336 patients for the quantitative portion of the study. For the qualitative portion, 15 members of the healthcare staff were interviewed. The majority of these participants were nurses, but a doctor, an anesthesiologist and a medical student were also interviewed.

Types of Interventions: Sax et al. (2016) did not engage with any intervention strategies in this particular study; rather, their objectives were to determine if previously-implemented intervention strategies such as the strategies used for treating Type II Diabetes, were still being utilized and were successful. The previously-mentioned intervention included minimizing catheter usage and being more knowledgeable about this type of intervention.

Types of Outcomes: For quantitative results, Sax et al. (2016) found that CAUTI had decreased in those eight years. In terms of qualitative research, Sax et al. (2016) found several themes within their interviews. The first theme is that the employees, for the most part, did not remember the intervention strategy. The participants could also not remember the proper insertion techniques for catheters, or where to properly place them. Furthermore, there was frequently a delay in removing patient catheters, due to communication issues between departments within the hospital.

Information Sources

Studies for this review were identified by searching the CINAHL database (1995-present). Limits were applied for peer-reviewed articles and ones that appeared in English. 


The following search terms were included to find articles for this literature review: UTI, urinary tract infections cause urinary tract infection prevention, CAUTI prevention, qualitative study CAUTI, quantitative study CAUTI and mixed method research UTI. 

Study Selection

The articles were chosen for their adherence to the search terms, specifically in terms of research methods that were utilized in the studies. Furthermore, the articles were chosen because they were peer-reviewed.

Data Collection Process

Carter et al. (2016) performed focus groups and interviews. Information was audio recorded and transcribed. Nogueira et al. (2017) performed a quantitative, cross-sectional study of a self-administered questionnaire structured, containing 15 questions that elaborated on the objectives of the study. Sax et al. (2016) extracted quantitative information from patient records and qualitative information from interviews with healthcare staff.

Data Items

Information from the articles were extracted based on the intervention strategies that were used in CAUTI prevention programs, as well as the research methods that were utilized in the studies.

Risk of Bias in Individual Studies

Carter et al. (2016) did not mention any protocols that were utilized to minimize impacts of individual bias in this article. As a qualitative study were face-to-face interactions took place, Carter et al. (2016) should have mentioned some actions they took to ensure that bias did not impact their study. Nogueira et al. (2017) performed a quantitative study where all outcomes were determined through SPSS, which makes instances of individual bias much less likely than in other studies. As for Sax et al. (2016), the authors note that selection bias could have played a role in the employees they chose to interview for their study. 

Summary Measures

All three articles mentioned in this review determined that having a leader in charge of catheter usage and implementation, as well as having the staff be knowledgeable about CAUTI prevention programs, leads to an overall decrease in CAUTI.

Synthesis of Results

Even though the methods of the articles included in this literature review varied, results were combined by considering the similarities between the studies (e.g. intervention strategies, backgrounds and objectives of the articles), as well as the information they highlighted (participants’ knowledge of intervention strategies and general catheter experience and/or knowledge).

Risk of Bias across Studies

Generally speaking, the risk of bias across studies could include how individual biases were not considered within the qualitative-based studies.

Additional Analyses

Carter et al. (2016) recommended that further research was conducted with other emergency departments to see if results could be more generalizable. Nogueira, et al. (2017) recommended that further research was done because the professionals from their study had a general unwillingness to cooperate. Finally, Sax et al. (2016) noted that there could be issues with selection bias in their study.


Study Selection

Carter et al. (2016) chose participants that varied in profession. Because this study was qualitative, they did not have to eliminate any participants from their final research sample. Nogueira et al. (2017) wanted to include 100 participants in their study, but because some professionals were unwilling to participate, the final number was only 82. Finally, Sax et al. (2016) chose their interviews via convenience sampling. They also started with 344 patients for the quantitative portion, but eight had to be cut from the final report because their records contained missing information.

Study Characteristics

Methods: Two of the three articles utilized interview data. All articles were published in English.

Participants: All three articles include participants who worked in healthcare settings. The total number of participants is 502.

Interventions: The three articles in this literature review engaged with participant knowledge and catheter-handling procedures to reduce CAUTI.

Results of Individual Studies

Carter et al. (2016) found that lead nurses had the greatest opportunity to create CAUTI prevention in their programs. Nogueira et al. (2017) found that overall, healthcare professionals from their study did not possess the correct knowledge for how to insert urinary catheters. Sax et al. (2016) found that CAUTI had decreased over the eight-year period and that leaders were the best point of contact for understanding and demonstrating catheter usage.

Summary of Evidence

Overall, these articles imply that CAUTI can be prevented if health care employees have proper understanding of how to use catheters as well as minimize their general usage. Specifically, these results will have the greatest impact on stakeholders and healthcare professionals, especially nurses who were the primary population that was studied.


The limitations of these articles are that the study results may not be generalizable to other populations or studies. Furthermore, interviews were done via convenience sampling and many quantitative surveys that were analyzed had missing data, which indicates that these results might not be representative either.


The three articles within this literature review provide some ideas about which intervention strategies might be useful in CAUTI, specifically in terms of increasing healthcare provider knowledge and understanding of catheter usage, as well as minimizing catheter usage overall. Future research should attempt to conduct larger studies with more representative populations, as well as employ a more randomized sampling system.


Carter et al. (2016) received funding from grant R18 from the Agency for Healthcare Research and Quality. Nogueira et al. (2017), as well as Sax et al. (2016) do not discuss the funding they received.


Carter, E.J., Pallin, D.J., Mandel, L., Sinnette, C. & Schuur, J.D. (2016). A qualitative study of factors facilitating clinical nurse engagement in emergency department catheter-associated urinary tract infection prevention. The Journal of Nursing Administration, 46(10), 495-500.

Nogueira, H.K.L, Góes, A.C.F., de Oliveira, D.F., Simõs, N.A., Saba Fernandes, M., & Saba Fernandes, M. (2017). Knowledge of intensive professionals about the bundle for the prevention of urinary tract infection associated with the use of probes. Journal of Nursing, UFPE Online, 11(12), 4817-4825.

Sax, H., Kuster, S.P., Tehrany, Y.A., Ren, R., Uçkay, I., Agostinho, A., Stephan, F., Wachsmuth, M., Walder, B., Hoffmeyer, P., & Pittet, D. (2016). Eight-year sustainability of a successful intervention to prevent urinary tract infection: A mixed-methods study. American Journal of Infection Control, 44, 820-824.