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KSR Number: KSRA100830

The effect of bladder catheterization on the incidence of urinary tract infection in laboring women with epidural analgesia: a meta-analysis of randomized controlled trials

Risk of Bias Assessment

Overall summary: Low risk of bias in the review

Bottom Line

Current evidence suggests there is no difference in the incidence of postpartum urinary tract infection, postpartum urinary retention or postpartum haemorrhage for intermittent catheterisation versus continuous catheterisation in labouring women undergoing epidural analgesia. However, one potential methodological weaknesses was the study restriction based on publication status (conference abstracts were excluded), meaning relevant studies may have been missed. More high-quality randomised trials are required to provide further evidence to support the findings of this review.

Risk of Bias Assessment

Overall summary Low risk of bias in the review

Low

Studies were restricted based on publication status (conference abstracts were excluded).

A. Did the interpretation of findings address all of the concerns identified in Domains 1 to 4? Probably yes
B. Was the relevance of identified studies to the review's research question appropriately considered? Probably yes
C. Did the reviewers avoid emphasizing results on the basis of their statistical significance? Probably yes
Risk of bias in the review Low

Details of Review

Number of studies 6
Number of participants 850
Last search date January 2019
Review type Intervention
Objective To compare the effect of intermittent catheterisation with that of continuous catheterisation on the incidence of post-partum urinary tract infection, urinary retention and haemorrhage in labouring women with epidural analgesia.
Population Healthy labouring women who requested epidural anaesthesia during labour.
Interventions Intermittent catheterisation, also known as in-out catheterisation (defined as emptying the bladder via the urethra using a catheter that is removed after the procedure, mostly at regular intervals).
Comparator Continuous catheterisation (defined by the passage of a catheter into the urinary bladder via the urethra using an inflatable balloon or other means to retain it in position).
Outcome Postpartum urinary tract infection, urinary retention and haemorrhage.
Study design Randomised controlled trials.

Results

Pooled analysis reported no difference in the incidence of any type of postpartum urinary tract infection (UTI) (risk ratio [RR] 1.25, 95% confidence interval [CI] 0.91 to 1.71; 5 trials, n=712 participants), symptomatic UTI (RR 1.16, 95% CI 0.81 to 1.65; 3 trials, n=516 participants) or asymptomatic bacteriuria (RR 1.67, 95% CI 0.84 to 3.30; 2 trials, n=196 participants) for women undergoing intermittent catheterisation compared to continuous catheterisation.

Pooled analysis reported no difference in the incidence of postpartum urinary retention (RR 0.76, 95% CI 0.21 to 2.77; 2 trials, n=393 participants) for women undergoing intermittent catheterisation compared to continuous catheterisation.

Similarly, a single study reported no difference in the incidence of postpartum haemorrhage for women undergoing intermittent catheterisation compared to continuous catheterisation (RR 1.72, 95% CI 0.60 to 4.95; 1 trial, n=184 participants).

Full Risk of Bias Assessment

The research objective was clearly stated and appropriate inclusion criteria were defined. No restrictions were applied in eligibility criteria based on study characteristics. Studies were restricted based on publication status (conference abstracts were excluded).

1.1 Did the review adhere to pre-defined objectives and eligibility criteria? Probably yes
1.2 Were the eligibility criteria appropriate for the review question? Probably yes
1.3 Were eligibility criteria unambiguous? Probably yes
1.4 Were all restrictions in eligibility criteria based on study characteristics appropriate (e.g. date, sample size, study quality, outcomes measured)? Probably yes
1.5 Were any restrictions in eligibility criteria based on sources of information appropriate (e.g. publication status or format, language, availability of data)? Probably no
Concerns regarding specification of study eligibility criteria High

PubMed, EMBASE and Cochrane Library were searched to identify relevant studies. The reference lists of included studies were searched to identify additional articles. The search strategy was reported in full for each resource and appeared appropriate. The searches were not restricted based on date, publication format or language. Two reviewers independently judged the study eligibility, and disagreements were resolved by discussion.

2.1 Did the search include an appropriate range of databases/electronic sources for published and unpublished reports? Probably yes
2.2 Were methods additional to database searching used to identify relevant reports? Probably yes
2.3 Were the terms and structure of the search strategy likely to retrieve as many eligible studies as possible? Probably yes
2.4 Were restrictions based on date, publication format, or language appropriate? Probably yes
2.5 Were efforts made to minimise error in selection of studies? Probably yes
Concerns regarding methods used to identify and/or select studies Low

The data extraction was performed by two researchers independently and disagreements were resolved by discussion. Sufficient study characteristics appear to have been extracted to allow interpretation of results. Relevant study results appear to have been extracted. Study quality was assessed using the Cochrane tool for risk of bias assessment in randomised controlled trials. Two authors were independently involved in the risk of bias assessment, and any disagreements was resolved by discussion.

3.1 Were efforts made to minimise error in data collection? Probably yes
3.2 Were sufficient study characteristics considered for both review authors and readers to be able to interpret the results? Probably yes
3.3 Were all relevant study results collected for use in the synthesis? Probably yes
3.4 Was risk of bias (or methodological quality) formally assessed using appropriate criteria? Probably yes
3.5 Were efforts made to minimise error in risk of bias assessment? Probably yes
Concerns regarding methods used to collect data and appraise studies Low

The synthesis appeared to include all relevant studies. The pre-defined analysis methods appear to have been performed and reported appropriately. The method of analysis was explained and appeared appropriate. Heterogeneity was assessed and found to be low for all outcomes. Sensitivity analysis was performed to check the robustness of study results. Bias in primary studies was addressed while interpreting the findings.

4.1 Did the synthesis include all studies that it should? Probably yes
4.2 Were all pre-defined analyses reported or departures explained? Probably yes
4.3 Was the synthesis appropriate given the degree of similarity in the research questions, study designs and outcomes across included studies? Probably yes
4.4 Was between-study variation minimal or addressed in the synthesis? Probably yes
4.5 Were the findings robust, e.g. as demonstrated through funnel plot or sensitivity analyses? Probably yes
4.6 Were biases in primary studies minimal or addressed in the synthesis? Probably yes
Concerns regarding synthesis and findings Low

Abstract

INTRODUCTION AND HYPOTHESIS: There is conflicting evidence on whether intermittent catheterization (IC) is less associated with urinary tract infection (UTI) and more likely to prevent urinary retention than continuous catheterization (CC). We aimed to compare the effect of IC with that of CC on the incidence of postpartum UTI, urinary retention and hemorrhage in laboring women with epidural analgesia. METHODS: Electronic searches were performed in PubMed, EMBASE and Cochrane Library from their inception to October 2018. We selected RCTs comparing IC with CC in laboring women with epidural analgesia. A meta-analysis was performed using the RevMan software, and a random-effects model was used to pool the effect size. The Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence. RESULTS: Six RCTs (N = 850) were included in this review. The meta-analyses indicated that there was no significant difference between the IC and CC group in the incidence of postpartum UTI (RR = 1.25, 95% CI: 0.91 to 1.71, P = 0.16), postpartum urinary retention (RR = 0.76, 95% CI: 0.21 to 2.77, P = 0.68) and postpartum hemorrhage (RR = 1.72, 95% CI: 0.60 to 4.95, P = 0.31). GRADE assessment results showed that the quality of evidence was low. CONCLUSIONS: Based on the available evidence, there is no measurable difference in rates of UTI between CC and IC, not that neither stragety decreases UTI, since the included trials do not address this.