What is the role of catheter antibiotic prophylaxis for patients undergoing joint arthroplasty?

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.

Routine Use of Bladder Scans After Primary Total Joint Arthroplasty is Not Necessary: Results of a Protocol Change

BACKGROUND

Postoperative urinary retention is a common concern after total joint arthroplasty (TJA) and can cause discomfort, incontinence and, if left untreated, myogenic changes to the bladder. However, overdiagnosis of postoperative urinary retention by bladder scans may lead to unnecessary interventions and delayed discharges. The purpose of this study was to compare the safety of two bladder management protocols following TJA.

METHODS

From January 3, 2022 to April 29, 2022, 519 consecutive patients operated on by thirteen surgeons underwent routine postoperative bladder scanning (standard protocol). From February 28, 2022 to April 29, 2022, a new protocol was introduced by three surgeons in 209 consecutive patients using a specific algorithm (selective protocol) so that only symptomatic patients had bladder scans. The primary outcome of interest was catheterization rate. Chi-square and Students t-tests were used for analyses. There were 37.7% of patients in the selective group who received scans.

RESULTS

Times to catheterization, readmissions, emergency department visits, and straight catheterization rates (15.0 versus 14.8% P = .999) were similar. More scans in the selective group resulted in intervention (39.2 versus 15.0%, P < .001). Prevoid volumes were higher in the selective protocol (608 versus 448 mL, P < .001). Postvoid volumes were similar (233 versus 223 mL, P = .497). There was one readmission for a urinary tract infection in the standard group and no urinary-related readmissions in the selective group.

CONCLUSION

The selective protocol had a higher rate of same day discharge, fewer bladder scans, and did not lead to increased rates of urinary-related complications. These findings suggest that selective bladder scanning for symptomatic patients can be safely instituted for TJA patients.

Antibiotic prophylaxis for urinary catheter manipulation following arthroplasty: a systematic review

BACKGROUND

Urinary catheter use in the peri- and post-operative phase following arthroplasty may be associated with urinary tract infection (UTI) and deep prosthetic joint infection (PJI). These can be catastrophic complications in joint arthroplasty. We performed a systematic review of the evidence on use of antibiotics for urinary catheter insertion and removal following arthroplasty.

METHODS

Electronic databases were searched using the Healthcare Databases Advanced Search interface. Grey literature was searched. From 219 citations, six studies were deemed eligible for review. Due to study heterogeneity, a narrative approach was adopted. Methodological quality of each study was assessed using the Critical Appraisal Skills Programme appraisal tool.

RESULTS

A total of 4696 hip and knee arthroplasties were performed on 4578 participants across all studies. Of these, 1475 (31%) were on men and 3189 (68%) on women. The mean age of study participants was 69 years. Three thousand four hundred and eighty-nine cases (74.3%) were related to hip arthroplasty and 629 (13.4%) to knee arthroplasty. Five hundred and seventy-eight (12.3%) were either hip or knee arthroplasty. Forty-five PJIs were reported across all studies (0.96%). Two studies found either no PJI or no statistical difference in the rate of PJI when no antibiotic prophylaxis was used for catheter manipulation. Another study found no statistical difference in PJI rates between patients with or without preoperative bacteriuria. Where studies report potential haematogenous spread from UTIs, this association can only be assumed. Increased duration of urinary catheterization is positively associated with UTI.

CONCLUSION

It remains difficult to justify the use of prophylactic antibiotics for catheter manipulation in well patients. Their use is not recommended for this indication.

Controversies in Perioperative Antimicrobial Prophylaxis

Although clinical guidelines for antibiotic prophylaxis across a wide array of surgical procedures have been proposed by multidisciplinary groups of physicians and pharmacists, clinicians often deviate from recommendations. This is particularly true when recommendations are based on weak data or expert opinion. The goal of this review is to highlight certain common but controversial topics in perioperative prophylaxis and to focus on the data that does exist for the recommendations being made.