Current evidence does not support systematic antibiotherapy prior to joint arthroplasty in patients with asymptomatic bacteriuria-a meta analysis

Antibiotic Prophylaxis for Genitourinary Procedures in Patients with Artificial Joint Replacement and Artificial Heart Valves

Prosthetic joint infection (PJI) and prosthetic valve endocarditis (PVE) are uncommon but serious complications. According to current best practice statements, prior to a genitourinary procedure, patients with prosthetic joints should receive antibiotic prophylaxis if they are within 2 years of arthroplasty, if they are high risk for infection due to their individual comorbidities, or if the procedure poses a high risk for bacteremia. Patients with prosthetic valves should not receive antibiotic prophylaxis for the sole purpose of prevention of endocarditis. Enterococcus species are the uropathogens most often associated with PJI and PVE. Antibiotic selection should take into account local resistance patterns.

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

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.

Clinical Practice Guideline: Total Hip Replacement for Osteoarthritis–Evidence-Based and Patient-Oriented Indications

BACKGROUND

Total Hip Replacement (THR) belongs to the most common inpatient operations in Germany, with over 240 000 procedures performed per year. 90% of the artificial joints are still functional at 15 years, and up to 60% at 20 years after surgery. It is essential that the indications for such procedures should be uniform, appropriate, and patient-oriented.

METHODS

This review is based on publications retrieved by a systematic literature search for national and international guidelines and systematic reviews on the topic of hip osteoarthritis and THR.

RESULTS

THR should be performed solely with radiologically demonstrated advanced osteoarthritis of the hip (Kellgren and Lawrence grade 3 or 4), after at least three months of conservative treatment, and in the presence of high subjective distress due to symptoms arising from the affected hip joint. Contraindications include refractory infection, acute or chronic accompanying illnesses, and BMI ≥ 40 kg/m2. Patients should stop smoking at least one month before surgery. In patients with diabetes mellitus, preoperative glycemic control to an HbA1c value below 8% is advisable. It is recommended that patients should lower their weight below a BMI of 30 kg/m2.

CONCLUSION

The decision to perform THR should be taken together by both the physician and the patient when the expected treatment benefit outweighs the risks. Evidence suggests that a worse preoperative condition is associated with a poorer surgical outcome.

Preoperative bacteriuria positivity on urinalysis increases wound complications in primary total hip arthroplasty regardless of the urine culture result

BACKGROUND

Current evidence does not recommend screening urine culture and curing asymptomatic bacteriuria (ASB) before joint arthroplasty. The bacteriuria count on pre-operative urinalysis is a more common clinical parameter. We aimed to investigate whether the bacteriuria count on preoperative urinalysis can increase postoperative wound complications in primary total hip arthroplasty (THA).

METHODS

We conducted a retrospective study that included patients who underwent primary THA in our institution from 2012 to 2018. We obtained preoperative urinalysis results before THA during the same hospitalization and identified patients with abnormal urinalysis. Receiver operating characteristic (ROC) curves were first generated to evaluate the predicted value of leukocyte esterase (LE), nitrite, bacteriuria, and pyuria in the urinalysis for superficial wound infection. Then, all included patients were divided into two groups according to the preoperative urinalysis: a bacteriuria-positive group and a bacteriuria-negative group. The primary outcome was the superficial wound infection rate within 3 months postoperatively, and the secondary outcomes included wound leakage, prosthetic joint infection (PJI), pulmonary infection, urinary tract infection (UTI), readmission rate within 3 months postoperatively, and length of stay (LOS) during hospitalization. We utilized univariable analyses to compare the outcomes between the two groups. A multivariable logistic regression model was generated to explore the potential association between bacteriuria and the risk of superficial wound infection, wound leakage, and readmission rate controlling for baseline values.

RESULTS

A total of 963 patients were included in the study. One hundred sixty patients had abnormal urinalysis. The AUCs for LE, nitrite, bacteriuria, and pyuria were 0.507 (95% confidence interval (CI), 0.315 to 0.698), 0.551 (0.347 to 0.756), 0.675 (0.467 to 0.882), and 0.529 (0.331 to 0.728), respectively. Bacteriuria was diagnostically superior to LE, nitrite, and pyuria. Among the 963 patients, 95 had a positive bacteriuria on preoperative urinalysis, and only 9 (9.5%) had a positive urine culture. Compared with the bacteriuria-negative group, the bacteriuria-positive group had a higher superficial wound infection rate (4.2% vs. 0.6%, P = 0.008), higher wound leakage rate (11.6% vs. 4.5%, P = 0.007), higher readmission rate (5.3% vs. 1.3%, P = 0.015) within 3 months postoperatively and longer LOS (6.19 ± 2.89 days vs. 5.58 ± 2.14 days, P = 0.011). After adjustment, the bacteriuria-positive group had a significantly increased risk of superficial wound infection (OR = 7.587, 95%CI: 2.002 to 28.755, P = 0.003), wound leakage (OR = 3.044, 95%CI: 1.461 to 6.342, P = 0.003), and readmission (OR = 4.410, 95%CI: 1.485 to 13.097, P = 0.008).

CONCLUSION

Preoperative bacteriuria positivity on urinalysis significantly increased the risk of postoperative wound complications, readmission, and LOS in primary THA regardless of the result of the urine culture. Urinalysis is a fast and cost-acceptable test whose advantages have been underestimated.

LEVEL OF EVIDENCE

Level III, observational study.

Effect of urinary tract infection on the risk of prosthetic joint infection: A systematic review and meta-analysis

PURPOSE

Urinary tract infection (UTI) are very common in the general population, however it is unclear whether UTI is a risk factor of prosthetic joint infection (PJI). Our purposes were: (1) To determine whether UTI is a risk factor of PJI after joint replacement, and (2) to determine whether the microorganisms causing PJI and UTI are the same.

METHODS

PubMed, Web of Science, the Cochrane Library, and EMBASE were searched systematically for studies. The effect sizes of RR were calculated for included studies that reported raw counts with 95% CIs. The aim 1 of the study is a meta-analysis; the aim 2 is a systematic review.

RESULTS

The aim 1 indicated that the risk of PJI was significantly higher in the UTI group than in the control group (RR = 3.17; 95% CI, 2.19-4.59). The aim 2 indicated that the microorganisms of UTI and PJI were the same in the same patient, and these included Enterococcus faecalis, and Pseudomonas, which supports the theory of PJI occurring via the haematogenous route from the genitourinary tract that harbours bacteria in UTI.

CONCLUSION

This study identified UTI as being significantly associated with PJI after joint arthroplasty and PJI occurring via the haematogenous route from the genitourinary tract harbouring bacteria in UTI. Therefore, postponing surgery and even treating patients with known UTI preoperatively are recommended.

Is there scientific evidence to support antibiotic prophylaxis in patients with periodontal disease as a means to decrease the risk of prosthetic joint infections? A systematic review

PURPOSE

To re-assess the scientific literature to ascertain if there is scientific evidence to support antibiotic prophylaxis in patients with periodontal disease as a means to decrease the risk of prosthetic joint infections.

INTRODUCTION

Prosthetic joint infections occur in approximately 0.3-2% of patients and, of these, around 6-13% are thought to be caused by oral bacteria. Antibiotic prophylaxis prior to dental procedures as a means to prevent a prosthetic joint infection has been controversial throughout the years. However, it remains unclear to what extent it has a beneficial effect. We do know that bacteraemia of oral origin is directly proportional to any ongoing inflammation or infection, and that a diseased periodontium may act as an entry for bacteria to spread to distant locations, through the bloodstream, and potentially be the cause of distant site infections.

MATERIALS AND METHODS

Updated literature search using the PubMed (Medline), and the Clarivate Analytics databases, to identify eligible articles since the previous searches up to April 2019 (last 5 years).

RESULTS

No studies that relate periodontal disease to the development of a prosthetic joint infection were found.

CONCLUSION

Currently, there is no evidence to support or exclude the need of antibiotic prophylaxis as a means to decrease the risk of prosthetic joint infections in patients with periodontal disease.

Is Routine Urinary Screening Indicated Prior To Elective Total Joint Arthroplasty? A Systematic Review and Meta-Analysis

BACKGROUND

Prosthetic joint infection (PJI) is a serious complication after total joint arthroplasty, and prevention is of great importance. The genitourinary tract is a potential source of bacterial seeding and one that can be easily managed. Despite little supportive evidence, routine urine screening and subsequent treatment before elective surgery in patients without symptoms has found its way into clinical practice in many countries. This systematic review and meta-analysis aims to ascertain whether asymptomatic bacteriuria (ASB) is a risk factor for PJI and if so, whether preoperative antibiotic treatment is effective in reducing its risk.

METHODS

PubMed, Ovid Medline, and Cochrane databases were searched using a systematic strategy. Selection of papers was exclusive to include only those which offered information about PJI rate specifically in patients with or without asymptomatic abnormal urinalysis or bacteriuria and/or information on whether ASB patients were preoperatively treated with antibiotics or not to be included in the analysis.

RESULTS

Six-hundred sixty-three papers were screened, and 10 papers were ultimately included (28,588 patients). Results show an increased risk of developing PJI among ASB patients (odds ratio = 3.64, 95% confidence interval = 1.40-9.42). However, most PJI microorganisms are unrelated to those previously found in the urine and preoperative antibiotic therapy does not influence PJI risk (odds ratio = 0.98, 95% confidence interval = 0.39-2.44).

CONCLUSION

Routine urinary screening prior to elective total joint arthroplasty and treatment of asymptomatic patients is not recommended.