Elimination of Routine Urinalysis before Elective Orthopaedic Surgery Reduces Antibiotic Utilization without Impacting Catheter-associated Urinary Tract Infection or Surgical Site Infection Rates

Abstract

Purpose Routine preoperative urinalysis has been the standard of care for the orthopedic population for decades, regardless of symptoms. Studies have demonstrated antibiotic overuse and low concordance between bacteria cultured from the surgical wound and the urine. Testing and treatment of asymptomatic urinary tract colonization before total joint arthroplasty (TJA) is unnecessary and increases patient risk. We investigated reducing antibiotic use by (1) modifying testing algorithms to target patients at risk, (2) modifying reflex to culture criteria, and (3) providing treatment guidelines. Materials and Methods A pre-post study was conducted to determine identify the impact of eliminating universal urinalysis prior to TJA on surgical site infection (SSI) and catheter-associated urinary tract infection (CAUTI) rates and number of antibiotic prescriptions. Patients who underwent primary hip or knee TJA or spinal fusions from February 2016 to March 2018 were included. Patient data was collected for pre- and post-practice change period (February 2016-October 2016 and August 2017-March 2018). Patient demographics, urinalysis results, cultures, and prescriptions were analyzed retrospectively from every tenth chart in the pre-period and prospectively on all patients in the post-period. Results A total of 4,663 patients were studied. There was a 96% decrease in urinalyses performed ( P <0.0001), and a 93% reduction rate in antibiotic utilization ( P <0.001). No significant difference in SSI and CAUTI rates was observed ( P >0.05). Conclusion The elimination of routine urinalysis before orthopedic surgery resulted in a reduction in antibiotic utilization with no significant change in the SSI or CAUTI rates. Cost savings resulted from reduced antibiotic usage.

Leveraging diagnostic stewardship within antimicrobial stewardship programmes

“…Reliance on a sole diagnostic test, whether culture or non-culture based, leads to false-positive results, excessive antimicrobial exposure and associated downstream negative consequences, such as adverse drug events, CDI and selective pressure leading to development of resistance. 8 …”

“…Reliance on a sole diagnostic test, whether culture or non-culture based, leads to false-positive results, excessive antimicrobial exposure and associated downstream negative consequences, such as adverse drug events, CDI and selective pressure leading to development of resistance. 8 Perhaps the most common cases of overdiagnosis and overtreatment occur in the setting of ASB. As defined in the 2019 Infectious Diseases Society of America guidelines, ASB is the presence of one or more bacteria in the urine in the absence of signs and symptoms of infection that are attributable or referable to the urinary tract.…”