Screening for asymptomatic bacteriuria before total joint arthroplasty

Mayne, Alistair; Davies, Peter; Simpson, J. M.

doi:10.1136/bmj.i3569

Cited by 10 publications

(6 citation statements)

References 10 publications

(9 reference statements)

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“…However, the association between preoperative asymptomatic bacteriuria (ASB) and periprosthetic joint infection (PJI) is less clear. Therefore, the efficacy of the practice of routine urine cultures has been questioned in recent studies [6,7].…”

Section: Introductionmentioning

confidence: 99%

“…Guidelines concerning the screening of the preoperative urine samples of asymptomatic patients undergoing elective joint replacement surgery are conflicting. The British Orthopaedic Association recommends preoperative urine screening [6], whereas the consensus statement from the International Consensus Meeting on Periprosthetic Joint Infection opposes it [20]. The current Infectious Diseases Society of America guideline gives no recommendations on the matter [16], but lists urine screening before joint replacement surgery as an important topic for future research as does the International Consensus statement [20].…”

Section: Introductionmentioning

confidence: 99%

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The impact of preoperative bacteriuria on the risk of periprosthetic joint infection after primary knee or hip replacement: a retrospective study with a 1-year follow up

Honkanen

Jämsen

Karppelin

et al. 2018

Clinical Microbiology and Infection

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Objectives: Patients who undergo elective joint replacement are traditionally screened and treated for preoperative bacteriuria to prevent periprosthetic joint infection (PJI). More recently, this practice has been questioned. The purpose of this study was to determine whether preoperative bacteriuria is associated with an increased risk of PJI. Methods: Patients who had undergone a primary hip or knee replacement in a tertiary care hospital between September 2002 and December 2013 were identified from the hospital database (23 171 joint replacements, 10 200 hips, and 12 971 knees). The results of urine cultures taken within 90 days before the operation were obtained. Patients with subsequent PJI or superficial wound infection in a 1-year follow-up period were identified based on prospective infection surveillance. The association between bacteriuria and PJI was examined using a multivariable logistic regression model that included information on the operated joint, age, gender and the patients' chronic diseases. Results: The incidence of PJI was 0.68% (n ¼ 158). Preoperative bacteriuria was not associated with an increased risk of PJI either in the univariate (0.51% versus 0.71%, OR 0.72, 95% CI 0.34e1.54) or in the multivariable (OR 0.82, 95% CI 0.38e1.77) analysis. There were no cases where PJI was caused by a pathogen identified in the preoperative urine culture. Results were similar for superficial infections. Conclusions: There was no association between preoperative bacteriuria and postoperative surgical site infection. Based on these results, it seems that the preoperative screening and treatment of asymptomatic bacteriuria is not required.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

The impact of preoperative bacteriuria on the risk of periprosthetic joint infection after primary knee or hip replacement: a retrospective study with a 1-year follow up

Honkanen

Jämsen

Karppelin

et al. 2018

Clinical Microbiology and Infection

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“…Standard utilisation of laminar flow theatres 17 18 19) and surgical helmet systems in arthroplasty procedures has shown a rapid increase 16 20) despite conflicting evidence. Anecdotally, routine preoperative screening and treatment of asymptomatic bacteriuria (ASB) 21 22 23) , perioperative catheterisation 24 25) , and administration of antibiotics on insertion and removal 26 27 28 29) are still performed in some orthopaedic departments despite a lack of scientific evidence and a growing evidence base to support elimination of this practice. Routine screening of a patient’s urine is not recommended by NICE unless “it will influence the decision to operate” 30) .…”

Section: Introductionmentioning

confidence: 99%

Variation of Practice in Prophylactic Protocol to Reduce Prosthetic Joint Infection in Primary Hip and Knee Arthroplasty: A National Survey in the United Kingdom

Morris,

Hoggett,

Rogers

et al. 2023

Hip & Pelvis

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Purpose Prosthetic joint infection (PJI) has an enormous physiological and psychological burden on patients. Surgeons rightly wish to minimise this risk. It has been shown that a standardised, evidence-based approach to perioperative care leads to better patient outcomes. A review of current practice was conducted using a cross-sectional survey among surgeons at multiple centers nationwide. Materials and Methods An 11-question electronic survey was circulated to hip and knee arthroplasty consultants nationally via the BOA (British Orthopaedic Association) e-newsletter. Results The respondents included 56 consultants working across 19 different trusts. Thirty-four (60.7%) screen patients for asymptomatic bacteriuria (ASB) preoperatively, with 19 (55.9%) would treating with antibiotics. Fifty-six (100%) screen for methicillin-resistant Staphylococcus aureus and treat if positive. Only 15 (26.8%) screen for methicillin-sensitive S. aureus (MSSA) or empirically eradicate. Zero (0%) routinely catheterise patients perioperatively. Forty-one (73.2%) would give intramuscular or intravenous gentamicin for a perioperative catheterisation. All surgeons use laminar flow theatres. Twenty-six (46.4%) use only an impervious gown, 6 (10.7%) exhaust pipes, and 24 (42.3%) surgical helmet system. Five different antimicrobial prophylaxis regimens are used 9 (16.1%) cefuroxime, 2 (3.6%) flucloxacillin, 19 (33.9%) flucloxacillin and gentamicin, 10 (17.9%) teicoplanin, 16 (28.6%) teicoplanin and gentamicin. Twenty-two (39.3%) routinely give further doses. Conclusion ASB screening, treatment and intramuscular gentamicin for perioperative catheterisation is routinely practiced despite no supporting evidence base. MSSA screening and treatment is underutilised. Multiple antibiotic regimens exist despite little variation in organisms in PJI. Practice varies between surgeons and centers, we should all be practicing evidence-based medicine.

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“…Mayne et al highlighted the challenges of definitively answering whether screening for and treatment of ASB can positively affect postoperative clinical outcomes. They estimated that “a trial comparing screening and treatment of ASB with no treatment would require at least 50,000 patients in each arm to detect a difference in infection risk of 0.15% and is, therefore, in practice, impossible.…”

Section: Introductionmentioning

confidence: 99%

“…They estimated that “a trial comparing screening and treatment of ASB with no treatment would require at least 50,000 patients in each arm to detect a difference in infection risk of 0.15% and is, therefore, in practice, impossible. Bigger and better observational research is still possible, however, and should be a priority.” (p1) Thus, we sought to use a large, multicenter, national cohort to measure the association between ASB and key postoperative infectious outcomes, including SSI and UTI, and to determine if antimicrobial therapy directed against the colonizing organism was associated with reduced rates of infection after major cardiac, orthopedic, and vascular surgical procedures. A secondary aim was to evaluate if the colonizing organism matched the infecting organism in cases of SSI and UTI.…”

Section: Introductionmentioning

confidence: 99%

Association of Screening and Treatment for Preoperative Asymptomatic Bacteriuria With Postoperative Outcomes Among US Veterans

Salazar

O’Brien²,

Strymish

et al. 2019

JAMA Surg

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IMPORTANCE Limited data suggest that screening for asymptomatic bacteriuria (ASB) prior to nonurologic procedures is not useful. However, high-quality evidence to support consensus recommendations and influence clinical practice is lacking. OBJECTIVE To characterize the association between detection and treatment of preoperative ASB and postoperative outcomes. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study involved patients, predominantly male veterans, who underwent surgical procedures in 109 US facilities within the US Department of Veterans Affairs health care system from October 1, 2008, to September 30, 2013. Participants included patients (n = 68 265) who had cardiac, orthopedic, or vascular surgical procedures. Each received a planned clinician review of complete medical records for antimicrobial prophylaxis as well as 30-day surgical-site infection (SSI) and urinary tract infection (UTI) outcomes, and each had a preoperative urine culture result available within the 30 days prior to the procedure. Data analysis was performed from December 2016 to August 2018. MAIN OUTCOME AND MEASURES The primary outcome was the association between preoperative ASB and postoperative SSI. The secondary outcomes included postoperative UTI and the association between antimicrobial therapy for ASB and postoperative infectious outcomes. RESULTS In total, 68 265 patients (65 664 [96.2%] were men and 2601 [3.8%] were women, with a mean [SD] age of 64.6 [9.2] years) were identified, and 17 611 (25.8%) were eligible for inclusion in the primary analysis. Preoperative urine cultures were performed in 17 749 (26.0%) patients, and the results were positive in 755 (4.3%), of which 617 (81.7%) were classified as ASB. With adjustments for age, American Society of Anesthesiologists class, smoking status, race/ethnicity, sex, and diabetes status, patients with or without ASB had similar odds of SSI (2.4% vs 1.6%; adjusted odds ratio [aOR], 1.58; 95% CI, 0.93-2.70; P = .08). Receipt of antimicrobial therapy with activity against the ASB organism was not associated with a reduced SSI risk (aOR, 1.01; 95% CI, 0.28-3.65; P = .99). Urinary tract infection occurred in 14 (3.3%) of 423 patients with ASB and 196 (1.5%) of 12 913 patients without ASB (aOR, 1.42; 95% CI, 0.80-2.49; P = .22). Treatment or prophylaxis for the ASB organism similarly was not associated with reduced odds of postoperative UTI (aOR 0.68; 95% CI, 0.20-2.30; P = .54). The ASB organisms matched a postoperative wound culture in 2 cases, both Staphylococcus aureus. CONCLUSIONS AND RELEVANCE The findings of this study suggest that receipt of antimicrobial therapy with activity against ASB organisms identified in preoperative urine cultures was not associated with reductions in the risk for postoperative infections, including UTI and SSI; such findings suggest there is evidence for discontinuing the practice of screening and treatment for preoperative ASB.

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Screening for asymptomatic bacteriuria before total joint arthroplasty

Abstract: Time to change orthopaedic practice

Cited by 10 publications

References 10 publications

The impact of preoperative bacteriuria on the risk of periprosthetic joint infection after primary knee or hip replacement: a retrospective study with a 1-year follow up

The impact of preoperative bacteriuria on the risk of periprosthetic joint infection after primary knee or hip replacement: a retrospective study with a 1-year follow up

Variation of Practice in Prophylactic Protocol to Reduce Prosthetic Joint Infection in Primary Hip and Knee Arthroplasty: A National Survey in the United Kingdom

Association of Screening and Treatment for Preoperative Asymptomatic Bacteriuria With Postoperative Outcomes Among US Veterans

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