2009 CAUTI guidelines - Centers for Disease Control and Prevention

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Figure 2: Results of the Study Selection Process8065 potentially relevantstudies identified7005 studies excluded basedon title and abstract1060 studies retrieved forpreliminary evaluation811 studies excluded because:Not in English (n=5); not primary analyticresearch, systematic review or metaanalysis(n=386); not relevant to any keyquestion (n=364); present in includedsystematic reviews (n=50); other (n=6)249 studies included fordata extraction28
Data Extraction and SynthesisData on the study author, year, design, objective, population, setting, sample size, power,follow-up, and definitions and results of clinically relevant outcomes were extracted intoevidence tables (Appendix 2). Three evidence tables were developed, each of whichrepresented one of our key questions. Studies were extracted into the most relevant evidencetable. Then, studies were organized by the common themes that emerged within each evidencetable. Data were extracted by one author (R.K.A.) and cross-checked by another (C.V.G.).Disagreements were resolved by the remaining authors. Data and analyses were extracted asoriginally presented in the included studies. Meta-analyses were performed only where their usewas deemed critical to a recommendation, and only in circumstances where multiple studieswith sufficiently homogenous populations, interventions, and outcomes could be analyzed.Systematic reviews were included in our review. To avoid duplication of data, we excludedprimary studies if they were also included in a systematic review captured by our search. Theonly exception to this was if the primary study also addressed a relevant question that wasoutside the scope of the included systematic review. Before exclusion, data from the primarystudies that we originally captured were abstracted into the evidence tables and reviewed. Wealso excluded systematic reviews that analyzed primary studies that were fully captured in amore recent systematic review. The only exception to this was if the older systematic reviewalso addressed a relevant question that was outside the scope of the newer systematic review.To ensure that all relevant studies were captured in the search, the bibliography was vetted by apanel of clinical experts.Grading of EvidenceFirst, the quality of each study was assessed using scales adapted from existing methodologychecklists, and scores were recorded in the evidence tables. Appendix 3 includes the sets ofquestions we used to assess the quality of each of the major study designs. Next, the quality ofthe evidence base was assessed using methods adapted from the GRADE Working Group. 32Briefly, GRADE tables were developed for each of the interventions or questions addressedwithin the evidence tables. Included in the GRADE tables were the intervention of interest, anyoutcomes listed in the evidence tables that were judged to be clinically important, the quantityand type of evidence for each outcome, the relevant findings, and the GRADE of evidence foreach outcome, as well as an overall GRADE of the evidence base for the given intervention orquestion. The initial GRADE of evidence for each outcome was deemed high if the evidencebase included a randomized controlled trial (RCT) or a systematic review of RCTs, low if theevidence base included only observational studies, or very low if the evidence base consistedonly of uncontrolled studies. The initial GRADE could then be modified by eight criteria. 34Criteria which could decrease the GRADE of an evidence base included quality, consistency,directness, precision, and publication bias. Criteria that could increase the GRADE included alarge magnitude of effect, a dose-response gradient, or inclusion of unmeasured confoundersthat would increase the magnitude of effect (Table 3). GRADE definitions are as follows:1. High - further research is very unlikely to change confidence in the estimate of effect2. Moderate - further research is likely to affect confidence in the estimate of effect andmay change the estimate3. Low - further research is very likely to affect confidence in the estimate of effect and islikely to change the estimate4. Very low - any estimate of effect is very uncertain29
Page 4 and 5: AcknowledgementHICPAC thanks the fo
Page 6 and 7: AbbreviationsADLAPACHE IIASAASBBUNC
Page 8 and 9: I. Executive SummaryThis guideline
Page 10 and 11: II. Summary of RecommendationsTable
Page 12 and 13: II. Proper Techniques for Urinary C
Page 14 and 15: 1. If obstruction is anticipated, c
Page 16 and 17: a. Procedure-specific guidelines fo
Page 18 and 19: III. Implementation and AuditPriori
Page 20 and 21: IV. Recommendations for Further Res
Page 22 and 23: V. BackgroundUrinary tract infectio
Page 24 and 25: acteriuria inevitably occurs over t
Page 26 and 27: VII. MethodsThis guideline was base
Page 30 and 31: After determining the GRADE of the
Page 32 and 33: Category I recommendations are defi
Page 34 and 35: VIII. Evidence ReviewQ1. Who should
Page 36 and 37: Evidence Review Table 1B. What are
Page 38 and 39: Very low-quality evidence suggested
Page 40 and 41: Q2B.2. Hydrophilic catheters vs. st
Page 42 and 43: For all comparisons, we considered
Page 44 and 45: a. Clamping vs. free drainage prior
Page 46 and 47: studies. 3,25,260-276 The findings
Page 48 and 49: 2D.5. Maintain unobstructed urine f
Page 50 and 51: 15. Jain P, Parada JP, David A, Smi
Page 52 and 53: 44. Chaudhuri P, Vengadasalam D. Ur
Page 54 and 55: 71. Kelleher RE, Meeropol E, Parks
Page 56 and 57: 101. Hirsh DD, Fainstein V, Musher
Page 58 and 59: 132. Van Nagell, JR, Penny RM, Rodd
Page 60 and 61: 163. Lai KK, Fontecchio SA, Lai KK,
Page 62 and 63: 193. Waites KB, Canupp KC, Armstron
Page 64 and 65: 222. Cohen A. A microbiological com
Page 66 and 67: 253. Chavigny KH. The use of polymi

2009 CAUTI guidelines - Centers for Disease Control and Prevention

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