Risk of Surgical Site Infection in Patients with Asymptomatic Bacteriuria or Abnormal Urinalysis before Joint Arthroplasty: Systematic Review and Meta-Analysis

Is asymptomatic bacteriuria a noticeable risk factor for periprosthetic joint infection following total joint arthroplasty? A systematic review and meta-analysis

INTRODUCTION

Total joint arthroplasty (TJA) is a common procedure that improves the quality of life for severe arthritis patients. The rising demand for TJA places enormous financial strain on the world's healthcare systems, which is exacerbated by postoperative readmissions for complications such as periprosthetic joint infections (PJIs). We conducted a systematic review and meta-analysis to determine if asymptomatic bacteriuria (ASB) increases infection risk.

METHODS

We conducted searches in three databases: PubMed, Scopus, and Web of Science. Screening steps have been carried out according to PRISMA guidelines. The study focused on patients who had undergone TJA and exhibited ASB. Two reviewers independently screened, assessed quality, and extracted data. Meta-analysis used Mantel-Haenszel method.

RESULTS

Following full-text screening, 12 studies were deemed eligible for inclusion in the systematic review, encompassing a total of 42,592 patients. A heightened occurrence of PJI was observed among TJA patients with ASB in comparison to controls (OR [95%CI] = 3.47 [1.42-8.44]). However, microorganisms responsible for the PJIs differed from those identified in the urine cultures of ASB. Additionally, analyses indicate that preoperative antibiotic treatment for ASB does not significantly affect the subsequent risk of PJI (OR [95% CI] = 1.00 [0.42-2.39]). Unlike surgical site infection (SSI), which did not show a difference in the rate of occurrence between the two groups, TJA patients with ASB were more likely to experience superficial wound infection (OR [95%CI] = 3.81 [2.02-7.21]).

CONCLUSION

This review and meta-analysis confirm that ASB correlate with heightened risks of PJI and superficial infection in TJA patients. However, no relationship was found between ASB and PJI microorganisms which raise doubts about the role of ASB microorganisms as the direct cause of infection following TJA.

Is there variation in utilization of preoperative tests among patients undergoing total hip and knee replacement in the US, and does it affect outcomes? A population-based analysis

Study objective

To describe recent practice patterns of preoperative tests and to examine their association with 90-day all-cause readmissions and length of stay.

Design

Retrospective cohort study using the New York Statewide Planning and Research Cooperative System (SPARCS).

Setting

SPARCS from March 1, 2016, to July 1, 2017.

Participants

Adults undergoing Total Hip Replacement (THR) or Total Knee Replacement (TKR) had a preoperative screening outpatient visit within two months before their surgery.

Interventions

Electrocardiogram (EKG), chest X-ray, and seven preoperative laboratory tests (RBCs antibody screen, Prothrombin time (PT) and Thromboplastin time, Metabolic Panel, Complete Blood Count (CBC), Methicillin Resistance Staphylococcus Aureus (MRSA) Nasal DNA probe, Urinalysis, Urine culture) were identified.

Primary and secondary outcome measures

Regression analyses were utilized to determine the association between each preoperative test and two postoperative outcomes (90-day all-cause readmission and length of stay). Regression models adjusted for hospital-level random effects, patient demographics, insurance, hospital TKR, THR surgical volume, and comorbidities. Sensitivity analysis was conducted using the subset of patients with no comorbidities.

Results

Fifty-five thousand ninety-nine patients (60% Female, mean age 66.1+/− 9.8 SD) were included. The most common tests were metabolic panel (74.5%), CBC (66.8%), and RBC antibody screen (58.8%). The least common tests were MRSA Nasal DNA probe (13.0%), EKG (11.7%), urine culture (10.7%), and chest X-ray (7.9%). Carrying out MRSA testing, urine culture, and EKG was associated with a lower likelihood of 90-day all-cause readmissions. The length of hospital stay was not associated with carrying out any preoperative tests. Results were similar in the subset with no comorbidities.

Conclusions

Wide variation exists in preoperative tests before THR and TKR. We identified three preoperative tests that may play a role in reducing readmissions. Further investigation is needed to evaluate these findings using more granular clinical data.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05945-y.

The Timing of Preoperative Urinary Tract Infection Influences the Risk of Prosthetic Joint Infection Following Primary Total Hip and Knee Arthroplasty

BACKGROUND

The importance of preoperative urinary tract infection (UTI) in total hip and knee arthroplasty (THA and TKA) is controversial. The purpose of this study was to investigate the timing of preoperative UTI diagnosis and association with prosthetic joint infection (PJI) and determine if antibiotics impact this risk.

METHODS

A national database was used to analyze patients undergoing THA and TKA diagnosed with a preoperative UTI. Timing of diagnosis was categorized by 1-week intervals prior to surgery. Matched cohorts without UTI were collected, and PJI rates within 2 years of surgery were compared. Patients who received antibiotic prescriptions were identified and compared to no prescription.

RESULTS

Preoperative UTI within 1 week of TKA was associated with higher rates of PJI (odds ratio [OR] 1.34, 95% confidence interval [CI] 1.26-1.43, P < .001). Preoperative UTI within 1 week of THA (OR 1.56, 95% CI 1.44-1.68, P < .001) and between 1-2 weeks prior to THA (OR 1.12, 95% CI 1.02-1.22, P = .022) was associated with significantly higher rates of PJI. UTI diagnosis at any other time interval did not reach statistical significance. Antibiotic prescription was not associated with lower rates of PJI.

CONCLUSION

Patients with preoperative UTI within 1 week of TKA or within 2 weeks of THA have an increased risk of postoperative PJI. Antibiotics do not appear to mitigate risk.

LEVEL OF EVIDENCE

Level III; Retrospective, database comparison.

Risk factors associated with surgical site infections following joint replacement surgery: a narrative review

Background

Surgical site infection following joint replacement surgery is still a significant complication, resulting in repeated surgery, prolonged antibiotic therapy, extended postoperative hospital stay, periprosthetic joint infection, and increased morbidity and mortality. This review discusses the risk factors associated with surgical site infection.

Related risk factors

The patient-related factors include sex, age, body mass index (BMI), obesity, nutritional status, comorbidities, primary diagnosis, living habits, and scores of the American Society of Anesthesiologists physical status classification system, etc. Surgery-related factors involve preoperative skin preparation, prolonged duration of surgery, one-stage bilateral joint replacement surgery, blood loss, glove changes, anti-microbial prophylaxis, topical anti-bacterial preparations, wound management, postoperative hematoma, etc. Those risk factors are detailed in the review.

Conclusion

Preventive measures must be taken from multiple perspectives to reduce the incidence of surgical site infection after joint replacement surgery.

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 optimization to prevent periprosthetic joint infection in at-risk patients

Periprosthetic joint infection (PJI) remains an important complication with devastating consequences after total joint arthroplasties. With the increasing number of arthroplasties worldwide, the number of PJI will increase correspondingly with a significant economic burden to our healthcare system. It is likely impossible to completely eradicate PJI; hence, assessment and optimization of its risk factors to preventing such a disastrous complication will be the key. There are many strategies to prevent PJI in the preoperative, intraoperative, or postoperative phases. The preoperative assessment provides a unique opportunity to screen and diagnose underlying comorbidities and optimize modifiable risk factors before elective surgeries. In this review, we will focus on current literature in preoperative assessment of various modifiable risk factors and share the experience and practical approach in our institution in preoperative optimization to reduce PJI in total joint arthroplasties.

Systematic review and meta-analysis of asymptomatic bacteriuria after renal transplantation: incidence, risk of complications, and treatment outcomes

BACKGROUND

Routine treatment for asymptomatic bacteriuria (ASB) after renal transplantation (RT) represents nowadays a controversial topic, being unknown its impact on the overall prognosis of the transplanted patient.

METHODS

Studies published during 1970-2019 that evaluated the benefit of treating ASB after RT regarding the risk of renal complications were included. The primary outcome was to assess whether the treatment is associated with a lower risk of symptomatic urinary tract infection (UTI) or an improved renal function at the end of the follow-up period. The secondary outcome was the risk of acute graft rejection (AGR). A meta-analysis with a random-effect model was performed. Heterogeneity was assessed with the I² measure.

RESULTS

Fifteen studies were included. The incidence of ASB in the first month and the first year after RT was 22% and 30%, respectively. ASB was not correlated to AGR (OR 1.18; 95% CI, 0.78-1.79). Eight studies compared the outcomes of ASB treatment, finding no benefit of treating regarding the risk of symptomatic UTI (OR 1.08; 95% CI, 0.63-1.84; I²  = 35%) or the change in renal function (mean difference in serum creatinine concentration-0.03 mg/dL,95% CI-0.15-0.10; I²  = 53%).

CONCLUSIONS

Asymptomatic bacteriuria represents a frequent finding after RT, highlighting the need for appropriate management of this condition. Considering that its treatment did not decrease the risk of the studied complications, antibiotic therapy should start to be questioned, as it has been related to higher rates of antimicrobial resistance and high economic costs.