Introduction

Catheter-associated urinary tract infection (CAUTI) is one of the most frequently reported healthcare-associated infections in adult acute-care hospitals [1,2]. Older reviews describe high urinary-infection burdens, but differences in survey year, case mix and event definition prevent using those accounts as a contemporary universal CAUTI ranking [3,4]. The strongest device-burden anchor in the selected evidence is the 2014 U.S. multistate point-prevalence survey across 183 hospitals: device-associated infections — central-line-associated bloodstream infection, CAUTI and ventilator-associated pneumonia combined — accounted for 25.6% of healthcare-associated infections in that survey [5]. This percentage describes the combined device-associated category in a historical U.S. survey, rather than CAUTI alone or present-day Saudi hospitals.

Indwelling urinary catheters breach the natural defence mechanisms of the urinary tract, and biofilm formation on catheter surfaces is a consistent feature of prolonged catheterisation [3]. The inspected SHEA update reports a daily bacteriuria risk of approximately 3–7% while an indwelling urethral catheter remains in place [1]. Bacteriuria is distinct from symptomatic infection, so that cumulative colonization risk must not be presented as an equivalent clinical CAUTI rate. A meta-analysis of multifaceted infection-control interventions estimated a 35–55% preventable proportion across infection categories in the intervention studies, with reductions reported across national income settings, although 143 of 144 included studies were judged at high risk of bias [6].

The clinical salience of CAUTI has been complicated by two parallel controversies. First, surveillance definitions — most notably the National Healthcare Safety Network (NHSN) CAUTI definition updated in 2015 with exclusion of yeast and an increase in the urine-culture bacterial threshold to ≥10⁵ colony-forming units per millilitre (CFU/mL) — can change the events captured by a surveillance programme without any change in clinical disease [1]. Second, asymptomatic bacteriuria (ASB) in most catheterised patients is not an indication for antimicrobial treatment; exceptional populations, including pregnancy and selected endoscopic urologic procedures with mucosal trauma, require separate guideline-based consideration, and reflexive urine-culture ordering can change event ascertainment (numerator) independent of catheter utilisation (denominator) [1,3]. The inspected SHEA update describes an ideal surveillance definition as capturing symptomatic infection that benefits from treatment, while acknowledging substantial limitations in available definitions [1]. Surveillance classification and bedside clinical diagnosis therefore remain related but different tasks. The 2024 International Society for Infectious Diseases (ISID) position paper notes differences in CAUTI rates, costs, length of stay, and mortality between high-income and low-/middle-income countries and supports the relevance of context-specific prevention strategies [7].

This review is a focused critical narrative synthesis of evidence on CAUTI prevention in adult acute-care hospitals. It deliberately does not exhaustively cover the parallel urine-culture stewardship and asymptomatic-bacteriuria-overdiagnosis literature, although stewardship is acknowledged as a supporting context. The aim is to provide a clinically and analytically useful platform for a Saudi research and evaluation agenda, recognising that local case mix, device practices and outcome measurement require appraisal before any inference about transportability.

Review approach

A focused PubMed retrieval on 6 October 2026 combined catheter-associated urinary tract infection or CAUTI with prevention or removal and hospital or acute-care terms in titles/abstracts. The publication-date ceiling was 6 October 2026; animal-only records were excluded. Records were selected for adult hospital prevention, device alternatives, removal safety, harms and outcome measurement, supplemented by reference checking of relevant guidance. The SHEA/IDSA/APIC/AHA/The Joint Commission update was inspected as full-text XML [1]; other selected sources were verified through PubMed metadata and abstracts. The authors report retaining the exact retrieval and source-access records; these records were not supplied for verification.

This is a focused narrative synthesis. No registered protocol, exhaustive screening, dual human extraction, original statistical pooling, formal risk-of-bias scoring or GRADE assessment was performed. Reported effect estimates retain their source authors' certainty and design qualifiers. The tables summarize published evidence and interpretive limits.

Burden, definition tensions, and the meaning of "prevention"

CAUTI prevention cannot be interpreted without attention to the surveillance definition used to identify events. The 2022 SHEA expert guidance update highlights that the clinical diagnosis of CAUTI is often a diagnosis of exclusion, making standardisation difficult, and that the NHSN CAUTI definition, while widely adopted, was revised in 2015 by excluding yeast and raising the urine-culture bacterial threshold to ≥10⁵ CFU/mL to better align with a clinical definition for symptomatic CAUTI [1]. The 2024 ISID position paper notes that implementing evidence-based preventive strategies has the potential to lower CAUTI rates, reduce related costs, and enhance patient outcomes in high- and low-/middle-income countries [7]. The 2025 systematic review of interventions to prevent CAUTI reported that some included interventions achieved reductions in CAUTI rates as high as 94% [8]. A heterogeneous set of bundled and context-specific interventions does not permit attribution of the largest reported reductions to one component. Concurrent changes in catheter utilisation, surveillance definitions and urine-culture ordering practices are possible alternative explanations that should be acknowledged rather than dismissed.

This matters because CAUTI rates are not a pure measure of patient harm. Schreiber and colleagues' meta-analysis of 144 studies found a pooled incidence rate ratio of 0.543 (95% CI 0.445–0.662) for multifaceted interventions to reduce CAUTI, with reductions in infection rates independent of the economic status of the study country; however, the risk of bias was high in 143 of 144 studies (99.3%) [6]. In an Australian six-hospital point-prevalence survey, overall healthcare-associated urinary tract infection and CAUTI prevalence were 1.4% and 0.9% respectively, with one-quarter of patients having a urinary catheter and fewer than half having appropriate documentation, illustrating how surveillance sensitivity and documentation quality shape reported prevalence [9]. In a Chinese case-control study of 7,295 elderly catheterised inpatients, CAUTI occurred in 182 patients (3.4 per 1,000 catheter days); once CAUTI occurred, hospital stay was reported as increased by 18 days, total cost increased by ¥18,000, and all-cause mortality at discharge increased 2.314-fold [10]. These figures are reported associations in a single-centre elderly cohort, vulnerable to confounding by indication and severity, and should be read as associations rather than as attributable-harm estimates.

A practical interpretation is that CAUTI prevention programmes should report catheter utilisation, CAUTI rates, standardised infection ratio (SIR), standardised utilisation ratio (SUR), and ideally urine-culture-ordering practices simultaneously; otherwise, apparent infection-rate declines may in part reflect denominator shifts or diagnostic-stewardship changes rather than prevention alone [1,3]. The SIR is the ratio of observed to predicted surveillance events, and SUR is the ratio of observed to predicted catheter-days; both are surveillance metrics and should not be conflated with patient-level risk.

Device appropriateness — the highest-yield intervention

Duration of catheterisation is the greatest modifiable risk factor for developing a CAUTI, including initial indwelling catheter placement when it may not otherwise be necessary [2]. The 2021 Cochrane review on short-term catheter removal strategies reports that approximately 15–25% of all hospital admissions involve short-term indwelling catheterisation at some point during care, and that shorter durations probably reduce the risk of symptomatic CAUTI (RR 0.52, 95% CI 0.45–0.61; 41 RCTs, 5,759 participants; moderate-certainty evidence), although shorter duration may increase recatheterisation (RR 1.81, 95% CI 1.35–2.41; low-certainty evidence) [11]. A four-year quasi-experimental nurse-led bundle study reported lower SIR and SUR with fewer reinsertions; Table 3 retains its estimates [12]. The 2017 systematic review of nurse-driven protocols (NDPs) found 29 included studies, all described by the review authors as case-control (pre/post) approaches and all reporting reductions in CAUTI clinical predictors — particularly catheter utilisation — although one study showed no change in CAUTI numbers; methodological quality met an average of only 4.9 of 11 quality indicators [13].

The 2022 SHEA update classifies the following as essential practices: appropriate indications for catheter use, aseptic insertion, maintenance of a closed drainage system with the collection bag below the bladder, daily assessment of catheter necessity, and prompt removal when no longer indicated [1]. A 2024 Cureus quality improvement report from Sultan Bin Abdulaziz Humanitarian City, a 511-bed rehabilitation facility in Saudi Arabia, describes a comprehensive interdisciplinary project that decreased the CAUTI rate from 1.28 to 0.42 per 1,000 catheter days; the report emphasises the participation of patients and families in catheter care [14]. This is a single-centre rehabilitation-facility report, and it is included here only to illustrate the kinds of local data that exist — not as a generalisable Saudi acute-care outcome. A 2023 Chinese precision-management study involving over 36,000 catheterised inpatients across hospital units compared an evidence-based precision-management plan to standard care; the intervention group showed a significant decrease in CAUTI incidence (0.48‰ vs 1.12‰; χ² = 20.814, p < 0.001), an SIR decrease (0.55 vs 1.37), a shortened mean catheterisation duration, and improved hand-hygiene compliance [15].

The Boston Medical Center 5-year intensive care unit (ICU) bundle initiative illustrates how layered components can be combined. Five bundles were implemented: (1) insertion and maintenance of Foley catheters; (2) appropriate indications; (3) appropriate CAUTI testing; (4) alternatives to indwelling devices; and (5) sterilisation techniques. CAUTI events decreased from 53 in 2013 to 9 in 2017 (83% reduction), with a 33.8% reduction in Foley utilisation between the fourth quarters of 2015 and 2017 [16]. The investigators noted that the introduction of female external incontinence devices, along with insertion/removal protocols and CAUTI-awareness education, coincided with decreases in CAUTI rates, although concurrent changes and the 2015 surveillance-definition revision prevent isolating the relative contribution of each component [16]. This is consistent with the 2024 review by Scruggs-Wodkowski and colleagues, which emphasises that alternatives to indwelling urinary catheters, including intermittent straight catheterisation and external catheters, should be considered in applicable patients [2].

The IDSA guideline record describes diagnosis, prevention and management of symptomatic and asymptomatic catheter-associated infection; it provides historical context, but its abstract cannot independently verify each detailed preventive recommendation [17]. The inspected SHEA update advises against routine systemic antimicrobial prophylaxis, antimicrobial or antiseptic-impregnated catheters, antimicrobial bladder irrigation for infection prevention, and routine catheter changes to prevent infection [1]. These are recommendations against routine preventive use, rather than merely omissions from the essential-practice list.

Aseptic insertion, closed drainage, and maintenance practices

Aseptic insertion and closed-drainage maintenance are foundational, although the evidence base for many individual maintenance components is modest. The 2022 SHEA update frames essential practices as foundational to all healthcare-associated infection programmes and includes: appropriate urinary catheter indications, aseptic insertion technique, maintenance of a closed drainage system with the collection bag below the level of the bladder, and routine surveillance for CAUTI [1]. In an F1000Research review, Septimus and Moody list the core elements of a CAUTI-prevention bundle as hand hygiene for insertion and catheter or bag manipulation, insertion only for appropriate indications, aseptic insertion technique, removal when no longer needed, and maintenance of a closed system with bag and tubing below the bladder [18].

The 2024 Scruggs-Wodkowski review summarises the position with the statement that if an indwelling urinary catheter is required, aseptic insertion technique and maintenance should be performed, and that through collaborative multidisciplinary intervention efforts CAUTI rates can be successfully reduced [2]. In a 2025 pre/post observational study at a 160-bed Veterans Affairs hospital, implementation of a nurse-driven protocol reduced the CAUTI rate from 0.99 to 0.27 per 1,000 urinary catheter days and the device utilisation ratio from 14% to 12% [19]. The pre/post design and absence of adjustment for surveillance-definition changes temper causal inference; the consistency of direction across studies is reassuring but does not by itself establish a causal estimate.

Bundle-level associations should not be conflated with effects of individual maintenance techniques (e.g., meatal cleaning with chlorhexidine, catheter-securement devices), which have been the subject of inconsistent or negative trial results and which the 2022 SHEA update does not promote as essential practices [1,17].

Table 1 summarizes the preventive decisions and distinguishes guideline categories from implementation examples.

Table 1. Preventive decisions and implementation examples in adult acute-care hospitals.

Source / interpretation note for Table 1. The first column distinguishes essential practices, ways to deliver the essential organization-wide removal program, locally selected implementation aids and recommendations against routine preventive use. Nurse-driven removal, reminders and stop orders belong within the essential removal-program discussion in the inspected SHEA guidance [1]. The table does not assign formal evidence grades to its own synthesis. Evidence-direction entries are reproduced from the cited abstracts/metadata and from full-text inspection of PMC11287483 [1]; effect estimates are reported with their original qualifiers. The "Acute-care applicability" column reflects the conceptual fit of each intervention with adult acute-care hospital workflows, not a claim of local adoption or effect.

Prompt removal with retention safeguards — the central design choice

The 2022 SHEA update places daily assessment of catheter necessity among essential practices [1]. The 2024 review by Scruggs-Wodkowski and colleagues highlights that the greatest modifiable risk factor for developing a CAUTI is duration of catheterisation, including initial indwelling catheter placement when it may not otherwise be necessary, and that alternatives to indwelling urinary catheters, including intermittent straight catheterisation and the use of external catheters, should be considered in applicable patients [2]. The 2023 BMC Infectious Diseases case-control study in elderly catheterised patients identified catheterisation ≥10 days as an independent risk factor for CAUTI, along with hospitalisation ≥14 days, age ≥74 years, male sex, diabetes, malnutrition, and moderate-to-severe dependence in self-care [10].

The 2021 Cochrane review (99 trials, 12,241 participants) provides the most rigorous evidence base for short-term catheter removal strategies. Shorter durations of catheterisation probably reduce symptomatic CAUTI (RR 0.52, 95% CI 0.45–0.61; moderate-certainty evidence) but may increase recatheterisation (RR 1.81, 95% CI 1.35–2.41; low-certainty evidence) [11]. Late-night removal (10 pm–midnight) compared with early-morning removal (6–7 am) may slightly reduce the risk of requiring recatheterisation (low-certainty evidence), with very low-certainty evidence for symptomatic CAUTI that does not establish whether a difference exists [11]. Prophylactic alpha blockers before catheter removal produced very uncertain effects on both recatheterisation and CAUTI [11].

The source review reports differing timing-comparison estimates and apparently inconsistent participant counts. The shorter-versus-longer duration results are separate outcomes.

The principle of "retention safeguards" deserves explicit articulation. Removing a catheter too early can produce urinary retention, bladder over-distension, and ultimately recatheterisation, which is itself a recognised risk factor for CAUTI [11]. The Cochrane review found that 41 trials enrolling 5,759 participants, predominantly from surgical populations contributed to the shorter-versus-longer-duration comparison; the possible benefit–harm trade-off warrants discussion with surgical teams and patients using shared decision-making [11]. The 2022 SHEA update implementation section notes that a key aspect of any intervention to reduce CAUTI is sustainability, citing an 8-year follow-up at a Veterans Affairs system in which catheter prevalence decreased from 13–25% (by unit type) to 7% (all units) after an early-removal intervention, with inappropriate uses remaining low [1]. The same section reports that in two large studies (one VA, one Comprehensive Unit-based Safety Program non-VA), CAUTI rates declined in medical-surgical wards but not in ICUs — a pattern that may in part reflect critical-care culture and practices that consider indwelling urethral catheters a default rather than a relative choice [1].

Nurse-driven removal protocols (NDPs) are described within the essential-practice organization-wide removal program in the 2022 SHEA update [1]. They should use explicit continued-use criteria and exceptions, such as postoperative urology patients or catheters placed after difficult specialist assessment. A shorthand mnemonic cannot replace those criteria. Immobility or a pressure injury alone should not become an automatic indication for catheter retention. A 2025 pre/post observational study at a Veterans Affairs hospital showed a CAUTI rate reduction from 0.99 to 0.27 per 1,000 catheter days and a device-utilisation-ratio reduction from 14% to 12% after implementation of an NDP supported by a utilisation dashboard [19]. A 2022 study on dashboard design for multiple hospital-acquired conditions (HACs) found that clinicians favoured gauge-style dashboards showing competing risks of CAUTI, hospital-acquired pressure injury, and falls, rather than mandatory alerts [21]. This point is directly relevant to hospitals considering EMR-embedded CAUTI prevention, as a competing-risk dashboard can support catheter-removal decisions without imposing rigid mandates.

Table 2 presents selected removal-strategy comparisons with the source review’s certainty judgments and denominators.

Table 2. Strategies for short-term indwelling urinary catheter removal in adults (Cochrane 2021 synthesis [11]).

Source / interpretation note for Table 2. Effect estimates, trial counts, and certainty ratings are reproduced from the 2021 Cochrane review of strategies for the removal of short-term indwelling urethral catheters in adults (search date 17 March 2020) [11]. The review authors' own certainty assessments (low, very low, moderate) are retained. The table summarises existing evidence and does not present an original pooled result. "Shorter vs longer" comparisons predominantly enrolled surgical populations; the review's authors explicitly call for future trials in non-surgical patients. An em dash indicates that the estimate and participant count are not displayed.

External catheters, intermittent catheterisation, and the limits of alternatives

External catheters (e.g., condom catheters for men, female external collection devices) and intermittent catheterisation are widely recommended as alternatives when clinically appropriate, but the evidence supporting their superiority over indwelling catheters in preventing CAUTI is limited. The 2024 review by Scruggs-Wodkowski and colleagues recommends that alternatives to indwelling urinary catheters should be considered in applicable patients, but does not provide effect estimates [2]. The Boston Medical Center initiative observed a control-chart shift in CAUTI rates after introduction of female external incontinence devices, alongside insertion/removal protocols and CAUTI-awareness education, although the relative contribution of each component was not isolated [16]. A 2024 Cureus quality improvement report from a 511-bed Saudi rehabilitation facility describes a comprehensive interdisciplinary project that decreased the CAUTI rate from 1.28 to 0.42 per 1,000 catheter days; the report emphasises the involvement of patients and families in catheter care but does not specifically attribute reductions to external catheter use [14].

Intermittent catheterisation reduces catheter-days compared with continuous indwelling catheterisation, but its effect on CAUTI rates is poorly quantified in randomised trials, and inappropriate technique can introduce its own risks. The 2022 SHEA update includes intermittent catheterisation among the alternatives to consider, but does not provide effect estimates, reflecting the weak underlying evidence base [1]. The 2009 IDSA guidelines note that intermittent catheterisation is preferred to indwelling catheterisation in patients with spinal cord injury and bladder dysfunction requiring catheter-based bladder emptying, but provide no effect estimates for the broader adult acute-care population [17]. The 2024 ISID position paper notes that the review emphasises evidence-based strategies for CAUTI prevention across diverse healthcare environments, but does not provide detailed effect estimates for alternatives to indwelling catheters [7].

External collection devices require attention to fit, skin injury, leakage and the reliability of collected urine volumes. They do not provide the same information about bladder emptying or retention as an indwelling drainage system; monitoring requirements should be defined rather than assuming that no urine-output record is possible [1]. Female external catheters are a relatively recent technology; the 2024 Scruggs-Wodkowski review lists them among alternatives but provides no effect estimates [2]. The Boston Medical Center report reported a control-chart shift after introduction of the PureWick female incontinence device, alongside insertion/removal protocols, education and surveillance changes, without isolating the device's contribution [16]. The overall implication is that alternatives to indwelling catheters should be considered as part of a broader bundle, with their relative contribution to CAUTI reduction remaining uncertain in isolation.

Antimicrobial and biofilm-inhibiting catheters — technology not yet ready for universal adoption

A 2025 systematic review of interventions to prevent CAUTI (12 studies, 9,476 titles screened) reported that antiseptic solutions, specialised catheters (including a "BIP Foley" and silver-alloy-coated types), and educational sessions all significantly reduced CAUTI rates, with a maximal reported reduction of 94% across selected included studies [8]. This is the review abstract’s summary of reported reductions, not an independently verified isolated product effect. The largest reported effects do not establish the isolated benefit of one technology. Plausible alternative explanations include combined bundle effects, concurrent changes in catheter utilisation, and surveillance-definition changes. The 2022 SHEA update does not recommend antimicrobial catheters for routine use, and the 2009 IDSA guidelines note that antimicrobial catheters have not been definitively shown to reduce symptomatic CAUTI in a way that justifies routine adoption [1,17]. A 2024 multicentre double-blind randomised controlled trial of a JUC Spray Dressing pretreatment of catheters in 264 Chinese patients with acute urinary retention (all male according to the report) found that the incidence of CAUTI in the JUC group was significantly lower than in the placebo group (p < 0.01), with no biofilm formation on day 5 in the JUC group versus visible biofilm in the placebo group [22]. The source paper describes this as the first report of biofilm inhibition on indwelling catheters in CAUTI patients, but the single-product focus, clinical and culture assessments through day 7, with biofilm observations reported at day 5, and the lack of integration with a broader removal strategy limit generalisability. The ISID position-paper abstract emphasizes evidence-based prevention across diverse healthcare environments, but does not independently verify a product-specific recommendation [7]. The recommendation against routine antimicrobial-impregnated catheters in this review is supported by inspected SHEA guidance [1].

The 2025 systematic review's headline figure of "reductions as high as 94%" warrants particular caution, as it may reflect combined bundle effects rather than the effect of any single technology; the review's authors themselves note that future research should continue exploring diverse, context-specific interventions to address barriers to CAUTI prevention [8]. The 2022 SHEA update's classification of antimicrobial catheters as not an essential practice reflects this uncertainty [1]. For hospitals considering new catheter technologies, the defensible position is that adoption should occur within a research or evaluation framework, not as a blanket replacement for fundamental bundle components.

The broader spectrum of catheter harms

A distinctive feature of the 2022 SHEA update is its explicit attention to catheter-associated harms beyond CAUTI, including non-CAUTI bacteriuria, candiduria, trauma, patient discomfort, and the contribution of catheter use to immobility, delirium, and longer hospital stay [1]. The 2024 review by Scruggs-Wodkowski and colleagues notes that the greatest modifiable risk factor for developing a CAUTI is duration of catheterisation, including initial indwelling catheter placement when it may not otherwise be necessary, and that alternatives should be considered in applicable patients [2]. The 2024 ISID position paper highlights differences in CAUTI rates, healthcare costs, extended hospital stays, and mortality between high-income and low-/middle-income countries, underscoring that the clinical and economic burden of catheter-associated harm extends well beyond the CAUTI event itself [7].

Non-infectious harms include urethral trauma, stricture formation, and catheter-related bladder discomfort, which can trigger inappropriate urine-culture ordering and antimicrobial prescribing. The 2022 SHEA update recommends that hospitals track catheter utilisation, SIR, and ideally urine-culture-ordering practices simultaneously, as competing priorities such as fall prevention and pressure-injury prevention can lead to inappropriate catheter retention [1,21]. A dashboard-design study found clinician preference for gauges showing competing risks of infection, pressure injury and falls; preference testing did not establish clinical effectiveness [21]. The elderly inpatient cohort described earlier reinforces the need to monitor patient harms alongside surveillance events, while its observational design precludes attributing those harms to CAUTI alone [10].

A 2022 cross-sectional study of 301 nurses at a Malaysian tertiary teaching hospital found that nurses' knowledge and attitude regarding CAUTI prevention were generally good, but attitude explained a higher variance in perceived practice than knowledge did [23]. The self-reported design does not establish observed catheter-care behavior or patient effects. The association is consistent with, rather than proof of, the 2022 SHEA update's emphasis on socioadaptive components of implementation, including psychological safety and stakeholder engagement, rather than relying solely on technical fixes [1].

Implementation, socioadaptive components, and sustainability

The 2022 SHEA update dedicates substantial space to implementation strategies, emphasising that preventing CAUTI requires a focus on both technical and socioadaptive (or behavioural) components [1]. The 4-Es model (Engage, Educate, Execute, Evaluate), originally developed for CLABSI reduction, is recommended for CAUTI [1]. A 2013 Michigan study cited in the SHEA update found that hospitals participating in collaboratives aimed at reducing healthcare-associated infections and using bladder scanners, stop orders, reminders, or nurse-initiated catheter removal achieved approximately 25% reduction in CAUTI rates compared with other hospitals [1]. A 7-VA-hospital study cited in the same document showed a significant reduction in CAUTI rates on medical-surgical wards (from 2.4 to 0.8 per 1,000 catheter days; p = 0.001) but no significant change in ICU rates [1]. A Comprehensive Unit-based Safety Program (CUSP) intervention in more than 900 non-VA hospital units reduced CAUTI rates on medical-surgical wards (from 2.40 to 2.05 per 1,000 catheter days) but again not in ICUs [1]. The same document notes that the CUSP model was used in ICUs with elevated baseline rates; this negative experience revealed a need to develop a new model for such settings [1].

A 2021 Brazilian quasi-experimental study of five public ICUs implementing BTS-IHI Improvement Model interventions over 18 months reported a mean monthly CAUTI incidence-density reduction of 0.351 (p = 0.009), with a 45% final decrease, while VAP incidence-density also decreased significantly and CLABSI did not [24]. Length of stay and mortality did not change significantly [24]. The 2024 ISID position paper notes that implementing evidence-based preventive strategies has the potential to lower CAUTI rates, reduce related costs, and enhance patient outcomes in high- and low-/middle-income countries [7]. A 2021 surgical unit study attributed sustainability to daily communication via a hospital-wide multidisciplinary safety huddle [20].

The 2022 SHEA update cites an 8-year follow-up at a VA system in which catheter prevalence decreased from 13–25% (by unit type) to 7% (all units) after an early-removal intervention, with inappropriate uses remaining low [1]. The SHEA update describes a 4-year Duke University Hospital initiative reporting sustained reductions in urine-culture utilisation, catheter utilisation and CAUTI; that underlying initiative is cited here through the inspected guidance [1]. These findings underscore that sustainability requires ongoing attention rather than one-time intervention.

Table 3 contrasts selected reported program outcomes and separates setting and design from effect attribution.

Table 3. Selected hospital CAUTI prevention initiative outcomes, including one rehabilitation-facility report.

Source / interpretation note for Table 3. Most entries are pre/post or quasi-experimental initiatives; the Michigan comparison uses survey and surveillance comparisons rather than a conventional before-and-after design. These designs are vulnerable to confounding, ascertainment differences and secular trends, although the contribution of any particular bias was not established for each listed report. The Sultan Bin Abdulaziz Humanitarian City entry is a single-centre rehabilitation-facility report and is not a national estimate. The table summarises reported outcomes and does not present an original pooled result. The Michigan, 7-VA, and CUSP non-VA entries are cited via the SHEA 2022 update [1].

Applicability to Saudi Arabia and feasible research priorities

This review does not establish the presence or absence of a national Saudi surveillance system, IPC-standard alignment or published local evaluations. Its selected bibliography includes the 2024 Cureus quality improvement study from Sultan Bin Abdulaziz Humanitarian City, a 511-bed rehabilitation facility, which describes an interdisciplinary CAUTI-prevention project that decreased the CAUTI rate from 1.28 to 0.42 per 1,000 catheter days [14]. This is a single-centre rehabilitation-facility report and should not be read as a generalisable Saudi acute-care estimate. The 2024 ISID position paper highlights differences in CAUTI rates, healthcare costs, extended hospital stays, and mortality between high-income and low-/middle-income countries, which is directly relevant to designing a Saudi research programme [7]. The boundaries of the present review's selected evidence must be acknowledged: any Saudi applicability statements below are framed as proposed research and evaluation priorities, not as claims of existing local adoption or effects.

Against this context, the following proposed priorities warrant local feasibility assessment:

1. Standardised local epidemiology. A multicentre point-prevalence survey of healthcare-associated infections in Saudi adult acute-care hospitals could be paired with longitudinal surveillance of CAUTI events, catheter-days, patient-days and urine-culture ordering. Incidence rates and device utilisation require the longitudinal denominators; any SIR or SUR requires an appropriate, validated prediction baseline for the local setting. The 2014 U.S. multistate survey [5] and the 2014 Australian six-hospital survey [9] provide methodological templates.

2. Bundle component evaluation. A pragmatic cluster-randomised or stepped-wedge study comparing a core bundle (appropriate indications, aseptic insertion, closed drainage, daily review, nurse-driven removal) to a core bundle plus a context-specific component (e.g., EMR-embedded reminder, competing-risk dashboard, or external catheter protocol) would generate context-specific evidence. The 2021 Cochrane review's call for trials in non-surgical patients is directly relevant [11].

3. External catheter and intermittent catheterisation outcomes. A prospective cohort or registry study of external catheters (including female external collection devices) and intermittent catheterisation in appropriate adult populations, with explicit CAUTI, non-infectious-harm, and patient-reported-outcome endpoints, would address a major evidence gap highlighted by the 2024 Scruggs-Wodkowski review [2].

4. Catheter removal timing in non-surgical populations. The 2021 Cochrane review explicitly notes that most evidence on shorter versus longer catheterisation comes from surgical populations and calls for future trials in non-surgical patients [11]. Multicentre Saudi evidence on medical, geriatric, and obstetric populations would address this gap.

5. Competing-risk dashboard integration. The 2022 dashboard-design study found that clinicians favoured gauge-style visual designs and did not want mandatory alerts [21]. A multicentre study of an EMR-integrated competing-risk dashboard (CAUTI, pressure injury, falls) in medical and geriatric populations would address a directly actionable implementation question.

6. Surveillance definition standardisation. A cross-sectional study comparing CAUTI identification under NHSN 2015 criteria versus pre-2015 criteria in the same Saudi hospitals would quantify the contribution of definition changes to reported CAUTI-rate trends, addressing the 2022 SHEA update's explicit concern that apparent infection-rate declines may reflect denominator shifts [1].

7. Knowledge–attitude–practice (KAP) assessment. A national KAP survey of nurses, physicians, and IPC staff regarding CAUTI indications, alternatives, and prevention practices would extend the 2022 Malaysian cross-sectional study [23] to a Saudi context and inform targeted education.

These priorities are framed as research and evaluation, not as implementation claims.

Evidence tensions, contradictions, and limitations

Several tensions warrant explicit acknowledgment. First, the literature consistently reports large CAUTI-rate reductions following multifaceted bundles, but the risk of bias in 143 of 144 studies in the Schreiber meta-analysis was high, and pre/post designs are particularly vulnerable to surveillance-definition and urine-culture-ordering changes [1,6]. Second, the 2021 Cochrane review found moderate-certainty evidence that shorter catheterisation reduces symptomatic CAUTI but low-certainty evidence that it may increase recatheterisation; the possible trade-off should be communicated without overstating the certainty of the recatheterisation finding [11]. Third, the 2025 systematic review's report of reductions "as high as 94%" with antiseptic solutions and specialised catheters may in part reflect combined bundle effects rather than the effect of any single technology [8]; the 2022 SHEA update does not recommend antimicrobial catheters as an essential practice [1].

Fourth, the apparent differential effectiveness of CAUTI prevention between medical-surgical wards and ICUs — where two large U.S. studies (VA and CUSP non-VA) failed to reduce ICU rates — suggests that critical-care culture and practices are a distinct target requiring different implementation strategies, although the absence of ICU effect in those studies does not by itself establish causation [1]. Fifth, the external catheter evidence base remains thin; the Boston Medical Center initiative observed a control-chart shift after female external device introduction, but its contribution was not isolated from concurrent bundle components or surveillance changes [16]. Sixth, the 2024 multicentre RCT of JUC Spray Dressing, while promising, is a single-product study with clinical assessments through day 7 and a day-5 biofilm observation and does not address integration with a broader removal strategy [22].

The limitations of this review are also explicit. The literature search was a relevance-oriented PubMed retrieval, not a systematic review; no protocol registration, dual human extraction, formal risk-of-bias scoring, or GRADE appraisal was undertaken. The 24 references cited are a curated subset, and the exclusion of additional databases (Embase, CINAHL, Cochrane) means that some relevant studies may have been missed. Most cited primary studies and several cited reviews were not directly inspected in full text; effect estimates from systematic reviews are reported with their authors' original qualifiers. The lack of a nationally representative Saudi surveillance analysis in the selected bibliography means that all Saudi-applicability statements are framed as research priorities, not as claims of local adoption or outcome improvement. The 2022 SHEA update is expert guidance based on evidence through 2021, not a new randomised trial [1], and its recommendations should be interpreted accordingly. The 2024 ISID position paper is a consensus statement, and its recommendations reflect expert panel judgement rather than primary evidence [7]. Bibliographic records are public; cited full texts are accessible under source-specific access terms, and not all sources are open access.

Catheter device-life-cycle map

Figure 2 illustrates a catheter device-life-cycle map as a qualitative care and evaluation sequence.

Figure 2. A source-based device-life-cycle map for adult hospital CAUTI prevention. Reminder systems and nurse-driven removal deliver the essential removal program rather than a separately proven technological effect. Shorter catheter duration trades lower symptomatic infection risk against possible recatheterization. The map is a qualitative synthesis; arrows show a care/evaluation sequence, not measured benefits, causal effect sizes or guaranteed local outcomes.

Source and interpretation note for Figure 2. Qualitative synthesis only. No measured effects, patient counts, scores or locally observed benefits. Sources [1,11]; Tables 1–3 and the inspected SHEA essential-practice removal program.

Conclusion

The inspected guidance supports appropriate indications, aseptic insertion, closed drainage, daily necessity assessment and timely removal, including nurse-driven protocols and reminders [1]. Removal timing requires retention safeguards; the Cochrane evidence favors shorter duration for infection prevention while identifying a possible increase in recatheterisation [11]. Alternatives and technology choices remain population- and product-specific.

Bundle studies frequently report improved surveillance outcomes, but infection rates, SIR and utilisation are different measures. Concurrent surveillance or urine-culture changes, heterogeneous components and observational designs limit attribution [1,6,12,15]. Technical practices should be evaluated with socioadaptive supports and patient harms [1,21].

Saudi research can appraise local denominators, alternatives, removal safety and bundle implementation without inferring national efficacy from one rehabilitation-facility report. This focused narrative supplies no new pooled estimate, guideline or local patient dataset; selective full-text coverage and source design limitations remain explicit.

Declarations

Ethics and consent. This focused narrative review synthesizes published material and reports no new recruitment, intervention or patient-level data collection. An institutional determination has not been reported; no ethics approval, exemption or consent waiver is claimed.

Data availability. The cited PubMed metadata and abstracts are public. Full-text accessibility and reuse rights depend on each source. The authors report retaining focused search receipts and source-verification records. No new patient dataset was created.

References

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