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ORIGINAL ARTICLE: EPIDEMIOLOGY,
CLINICAL PRACTICE AND HEALTH
Urinary tract infection in patients with hip fracture: An
underestimated event?
Christopher Bliemel, Benjamin Buecking, Juliana Hack, Rene Aigner, Daphne-Asimenia Eschbach,
Steffen Ruchholtz and Ludwig Oberkircher
1
Center for Orthopedics and Trauma Surgery, University Hospital Marburg, Marburg, Germany
Aim: Urinary tract infections (UTI) represent a common perioperative complication among elderly patients with hip
fracture. To determine the impact of UTI on the perioperative course of elderly patients with hip fractures, a prospective
study was carried out.
Methods: A total of 402 surgically-treated geriatric hip fracture patients were consecutively enrolled at a level 1 trauma
center. On admission, all patients received an indwelling urinary catheter. Clinically symptomatic patients were screened
more closely for UTI. Patients diagnosed with UTI were compared with asymptomatic patients. Outcomes in both patient
groups were measured using in-hospital mortality, overall length of hospital stay, wound infection, functional results and
mobility at discharge. Multivariate regression analysis was carried out to control for influencing factors.
Results: A total of 97 patients (24%) sustained a UTI during in-hospital treatment. UTI were independently associated
with inferior functional outcomes as assessed by the Barthel Index (β=0.091; P= 0.031), Timed Up and Go test
(β=0.364;P= 0.001) and Tinetti test (β=0.169; P= 0.001) at discharge. Additionally, length of hospital stay was
significantly longer for patients with a UTI diagnosis (β=0.123;P= 0.029) after controlling for all other variables. No
differences were observed in the rate of wound infection (odds ratio 1.185; P= 0.898) or in-hospital mortality (P<0.997).
Conclusions: Patients with UTI seem to be at risk of inferior functional outcomes. In addition to an early
detection of symptomatic UTI and a targeted antibiotic therapy, perioperative care should focus on preserving
functional ability to protect these patients from further loss of independence and prolonged clinical courses.
Geriatr Gerontol Int 2017; ••:••–••.
Keywords: hip fracture, length of hospital stay, mobility, mortality, urinary tract infection.
Introduction
Elderly patients who have sustained a hip fracture
represent a highly vulnerable population, with
complication rates ranging from 7% to 40% during
inpatient treatment.
1,2
To prevent these patients from
acquiring secondary damages, such as pressure sores or
pulmonary infection, immediate full weight-bearing
mobilization is targeted. Nevertheless, mobilization often
remains difficult, because of these patients’pre-existing
comorbidities and unsteadiness of gait.
3
The perioperative
use of indwelling urinary catheters has become routine
practice inorthopedic and trauma surgery wards to enable
improved care of these immobile patients.
4
Nevertheless,
the benefits of indwelling catheters in the postoperative
period are reduced by the substantial risk of urinary tract
infection (UTI) accrued in direct relationship to the
duration of catheterization. Specifically, the rate of UTI is
estimated to increase 3–10% each day that the catheter is
left beyond the first 48 h of catheterization.
5,6
Although UTI represent one of the most common
postoperative complications in many fields of surgery, less
attention is paid to this complication compared with, for
instance, postoperative wound infections, pneumonia,
bleeding, ileus or delirium.
7–9
Hence, little is known about
the impact of UTI on the perioperative course of patients
with hip fractures. Following this, UTI might be an
underestimated event. Nevertheless, a better
understanding of its influence on the perioperative course
of this vulnerable patient population is urgently required,
especially in terms of its effect on associated wound
infections, and overall morbidity and mortality. This
knowledge would help optimize the care of affected
Accepted for publication 8 March 2017.
Correspondence: Dr Christopher Bliemel MD, Center for
Orthopaedics and Trauma Surgery, University Hospital Marburg,
Baldingerstrasse, 35043 Marburg, Germany. Email: bliemel@med.
uni-marburg.de
© 2017 Japan Geriatrics Society doi: 10.1111/ggi.13077 | 1
Geriatr Gerontol Int 2017
bs_bs_banner
patients, and would provide important prognostic
information for both clinicians and patients.
To determine the effect of UTI on the perioperative
course of elderly patients with hip fractures, we carried
out a study including more than 400 patients. We
hypothesized that the occurrence of UTI would be
associated with higher rates of wound infection, and
higher morbidity and mortality.
Methods
The present prospective, observational cohort study
included 402 consecutive patients aged ≥60 years with
hip fractures who were admitted to a single level 1 trauma
center. Patients were only included in this study if they had
not sustained a hip fracture as a result of polytrauma
(Injury Severity Score ≥16) or a malignancy-related
fracture. The recruitment period ranged from 1 April
2009 to 30 September 2011. The local ethics committee
approved this study (AZ 175/08). All patients or their legal
representatives provided written informed consent for
participation. Trained study staff (physicians and study
nurses) recorded the patients’sociodemographic data
(e.g.age, sex and pre-fracture residential status), type of
fracture, American Society of Anesthesiologists (ASA)
score, pre-fracture Charlson Comorbidity Index (CCI),
pre-fracture Barthel Index (BI) and Mini-Mental State
Examination (MMSE) score at hospital admission.
Additionally, pre-existing comorbidities were
documented.
Indwelling urinary catheter management and detection
of UTI
All patients received an indwelling urinary catheter at the
time of hospital admission to receive better care during
the perioperative phase. Indwelling urinary catheters were
removed whenthe patients were mobile enough to use the
toilet again, at least with the support of the nursing staff.
Patients presenting with clinical signs of UTI, such as
characteristic odor, pain or burning while urinating, but
also with more diffuse symptoms, such as increased
inflammation values and a lack of well-being including
fatigue, fever and weakness, were screened more closely
by analyzing a urinary specimen for urinary status and/or
using a Uricult dip-slide system (Orion Diagnostica Oy,
Espoo, Finland). A urinary specimen for urinary status
analysis was regarded as positive if there was proof of
leucocytes and nitrite. A urine culture was regarded as
positive in the Uricult dip-slide system if bacteriuria was
greater than 10
5
CFU/mL, respectively.
Treatment of U T I
In the case of pathogen detection, antibiotic therapy was
commenced as soon as possible. In accordance with
national guidelines, oral antibiotic therapy was
preferred.
10
When selecting a suitable antibiotic, several
criteria were taken into account, such as,.patient’s
individual risk including known allergic reactions against
certain antibiotics, the spectrum of pathogens and its
antibiotic sensitivity, the individual effectivity of the
antimicrobial substance, eventual adverse drug effects,
and possible effects on the individual resistance situation
of a patient (collateral damage).
Surgical procedure
Surgical fixation was carried out within the first 48 h after
the fracture, using a prosthetic replacement for
intracapsular fractures or internal fixation for
extracapsular fractures. To account for possible
postoperative wound infections, patients received
intraoperative single-shot antibiotic prophylaxis.
According to standard operating procedures, a second-
generation cephalosporin (cefuroxime) was administered.
In the case of known allergic reactions to cefuroxime,
clindamycin –a lincosamide antibiotic –was administered.
Outcome parameters
The frequency of UTI, in-hospital mortality rate and the
occurrence of wound infection were documented. A
wound infection was diagnosed in the synopsis of clinical,
laboratory and sonographic examinations with an
additional exclusion of other infectious foci at the same
time. As clinical signs of wound infection, redness,
swelling, hyperthermia, local pain and persistent wound
secretion were assessed. As systemic markers of
inflammation, which can also indicate a wound infection,
increased leukocyte values as well as increased values of
C-reactive protein were considered, especially if these
parameters did not gradually decline over the
postoperative period and other infectious foci could be
excluded. If the above mentioned values suggested a
wound infection, in addition a sonographic examination
of the hip was carried out to detect an existing
seroma/hematoma as further proof of a wound infection.
Patients’functional results were monitored using the BI
at discharge. Mobility at discharge was assessed using the
Timed Up and Go test (TUG) and Tinetti test (TT).
Furthermore, the patients’overall length of hospital stay
was documented.
Statistical analysis
Data were collected using a FileMaker database
(FileMaker, Santa Clara, CA, USA). Double entry with a
plausibility check was carried out to ensure data quality.
IBM SPSS 22 (IBM, Armonk, NY, USA) was used for the
data analysis. The data are presented as the means,
medians, standard deviations and ranges. Continuous
variables, such as age, ASA score, CCI and BI, were
examined using the Mann–Whitney test according to the
CBliemelet al.
© 2017 Japan Geriatrics Society2|
results of the Shapiro–Wilk test for normal distribution.
Fisher’s exact test was carried out to compare categorical
variables, such as sex distribution, mortality rate,
pre-existing comorbidities and the occurrence of wound
infections, between the patient groups. To determine the
distribution of the different fracture types, χ
2
-tests were
carried out. Significance was defined as P<0.05 for all
tests.
Finally, multivariate linear regression analysis with
backward selection was carried out to assess the influence
of UTI on functional outcome parameters (BI, TUG, TT),
wound infection and in-hospital mortality. This analysis
included the following covariates that are known to
influence patient outcomes after hip fracture: age, sex,
pre-fracture BI and CCI, ASA score, hemoglobin value at
admission, time between admission and surgery, duration
of surgery, type of surgical treatment (internal fixation vs
prosthesis), pre-existing dementia, and depression.
Results
Overall, 402 hip fracture patients were included in the
present study. A total of 97 patients (24%) sustained a
UTI during in-hospital treatment. The baseline
characteristics of all patients are shown in Table 1.
Compared with male patients, significantly more female
patients were affected by a UTI (13% vs 28%; P=0.001).
No significant differences occurred in age (P=0.120),
fracture localization (P= 0.599), ASA score (P=0.500),
pre-fracture BI (P= 0.052), pre-fracture CCI (P=0.897),
MMSE score (P= 0.057) or pre-fracture residential status
(P= 0.210; Table 1). Of the pre-existing comorbidities on
admission to the hospital, significantly higher rates of
UTI were observed in patients with a diagnosis of
Parkinson’s disease (P = 0.025). Cardiovascular disease
(P= 0.873), diabetes mellitus (P= 0.145) and dementia
(P =0.387)showednosignificant correlations with the
occurrence of UTI in hip fracture patients (Table 2).
In 90 patients (93%), a urinary status analysis was
carried out, and in 62 patients (64%), the Uricult dip-slide
system was used for further pathogen detection. The
specific urinary analysis for pathogenic germs showed that
the bacterial spectrum was predominantly Gram-negative
(72%), with 21% Gram-positive bacteria and urinary yeast
infection in approximately 6% (Fig. 1).
The bivariate statistical analysis showed significantly
worse functional outcomes in patients with a diagnosis
of UTI, as shown by the results of the BI (P<0.003), the
TUG (P<0.002) test and the TT (P<0.001) at discharge
(Table 3). Furthermore, the mean length of hospital stay of
patients with a diagnosis of UTI was significantly longer
than that of patients without a diagnosis of UTI (15 ± 6
vs 12 ± 6 days; P<0.018). Regarding the rate of
perioperative wound infection, no significant differences
were observed (P= 1.000; Table 3).
None of the patients diagnosed with UTI died
during inpatient treatment, whereas in the group of
patients without a UTI diagnosis, 25 patients died
Ta b l e 1 Baseline data for patients included in the study
Whole study population
(n=402)
Patients with UTI
(n=97)
Patients without UTI
(n=305)
P-value
Age, years (mean ± SD) 81 ± 8 82 ± 8 81 ± 8 P=0.120*
Sex
Male 109 (27%) 14 (13%) 95 (87%)
Female 293 (73%) 83 (28%) 210 (72%) P=0.001**
Fracture location
Femoral neck 195 (49%) 46 (24%) 149 (76%)
Trochanteric 186 (46%) 44 (24%) 142 (76%)
Subtrochanteric 21 (5%) 7 (33%) 14 (67%) P=0.599***
ASA score (mean ± SD) 2.9 ± 0.6 2.9 ± 0.5 2.9 ± 0.6 P=0.500*
Pre-fracture BI
(mean ± SD)
80 ± 25 76 ± 24 81 ± 25 P=0.052*
Pre-fracture CCI
(mean ± SD)
2.4 ± 2.3 2.1 ± 1.7 2.5 ± 2.5 P=0.897*
MMSE score (mean ± SD) 20 ± 9.1 19 ± 10 21 ± 9 P=0.057*
Pre-fracture residential status
Community-
dwelling
336 (84%) 77 (23%) 259 (77%)
Living in a nursing
home
66 (16%) 20 (33%) 46 (67%) P=0.210**
*Mann–Whitney test; **Fisher’sexacttest;***χ2-test. ASA, American Society of Anesthesiologists; BI, Barthel Index; CCI, Charlson
Comorbidity Index; SD, standard deviation; UTI, urinary tract infection.
Urinary tract infection in patients with hip fracture
© 2017 Japan Geriatrics Society | 3
during their hospital stay. Reasons for death were
related to the cardiovascular system in 10 patients and
to insufficiency of the kidneys in five patients, with all
of them suffering from acute renal failure. In four
patients, death was due to insufficiency of the
respiratory tract, twice each due to liver failure, sepsis
and multiorgan failure. This difference in in-hospital
mortality rate between groups was statistically significant
in the univariate analysis (P<0.001; Table 3).
To further analyze the effects of UTI on functional
outcomes, length of hospital stay, complication and
mortality rate, a multivariate regression analysis
adjusting for the aforementioned influencing factors
was carried out. Additionally, in the multivariate
regression analysis, significant differences were observed
in BI at discharge (R
2
=0.541, β=0.091, P<0.031),
TUG at discharge (R
2
=0.446, β=0.364,P<0.001),
TT at discharge (R
2
=0.405, β=0.169, P<0.001)
Ta b l e 2 Association of pre-existing comorbidities with urinary tract infection in patients with hip fractures
Patients with UTI Patients without UTI P-value
Cardiovascular disease 81 (24%) 258 (76%) P=0.873*
Dementia 36 (27%) 97 (73%) P=0.387*
Diabetes mellitus 31 (30%) 74 (71%) P=0.145*
Parkinson’s disease 9 (47%) 10 (53%) P=0.025*
*Fisher’s exact test. UTI, urinary tract infection.
Figure 1 Spectrum of pathogens detected in
patients diagnosed with urinary tract infection.
Gram-positive germs are marked with dots,
Gram-negative germs are marked with lines
and fungal infection agents are marked with
small boxes.
Ta b l e 3 Functional outcome parameters, length of hospital stay, and complication and mortality rate
Patients with UTI Patients without UTI P-value
Barthel Index at discharge (mean ± SD) 41 ± 25 51 ± 29 P<0.003*
TUG at discharge, s (mean ± SD) 75 ± 79 32 ± 24 P<0.002*
TT at discharge (mean ± SD) 7 ± 6 10 ± 9 P<0.001*
Length of hospital stay (mean ± SD) 15 ± 6 13 ± 6 P<0.018*
Rate of wound infection 6 1 P=1.000*
In-hospital mortality rate 0 25 P<0.001*
*Multiple regression analysis. SD, standard deviation; UTI, urinary tract infection.
CBliemelet al.
© 2017 Japan Geriatrics Society4|
and length of hospital stay (R
2
=0.121, β= 0.123,
P<0.029). However, no differences were observed in
the multivariate regression analysis for the in-hospital
mortality rate (R
2
=0.289, OR not available, P=0.997)
or the rate of wound infection (R
2
=0.388, OR 1.185,
P= 0.898; Table 4).
Discussion
The aim of the current study was to analyze the impact of
UTI on the rate of complications and early functional
outcomes at the end of in-hospital treatment among
geriatric patients with hip fractures. UTI was associated
with an increased length of hospital stay and an increased
risk of inferior functional outcomes, as shown by the
reduced BI, TUG and TT values at discharge. UTI was
not associated with an increased rate of wound infection
or an increased in-hospital mortality rate.
UTI represent one of the most common bacterial
infections in elderly patients with hip fractures.
11
Causes
for UTI in hip fracture patients are manifold, including
postoperative urinary retention
12
or neurogenic bladder
dysfunction. As Schumm and Lam could show, even the
use of indwelling urinary catheters leads to UTI in a
considerable number of cases.
13
In terms of its clinical
appearance, UTI can be divided into symptomatic UTI
and asymptomatic bacteriuria. In accordance with current
literature on hip surgery,
14
asymptomatic colonization of
the lower urinary tract was not determined among patients
included into the present study. Nevertheless, patients
with clinical symptoms were more closely screened. With
UTI occurring in almost one-quarter of all patients, it
was the most common complication in our observational
study. UTI were diagnosed predominantly in female
patients, with Escherichia coli being the most common
pathogen. These results are in line with several pre-
existing studies reporting on UTI in hip fracture
patients.
15–17
Although Hälleberg Nyman et al. showed that diabetes
was a risk factor for UTI, the results of the present study
failed to support this finding. These conflicting results
might be related to the much smaller percentage of
patients diagnosed with diabetes in the population studied
by Hälleberg Nyman et al. (9/86 patients, 11%) compared
with our own study (105/402 patients, 26%). Despite this
difference in diabetes, the present results are consistent
with the findings of Hälleberg Nyman et al.,who
determined that pre-existing coronary disease was not
associated with UTI.
16
Having carried out a randomized
controlled trial, Stenvall et al. could show that hip fracture
patients with an additional diagnosis of dementia benefit
from a multidisciplinary geriatric assessment as
determined by a significantly reduced number of UTI.
18
Even though there was no multidisciplinary treatment in
the present study, no differences were observed in the rate
of UTI between hip fracture patients with and without a
diagnosis of dementia. Patients with lower urinary tract
dysfunction, such as neurogenic bladder dysfunction, are
more likely to develop asymptomatic pyuria, bacteriuria
and symptomatic UTI. In this context Zarowitz et al. could
show among more than 175 000 nursing facility residents
that an overactive bladder, which is a quite common
comorbidity (1%) amongst elderly patients, and
additionally presents with similar symptoms to those of
UTI, was significantly associated with hip fractures.
19
Among the comorbidities assessed in the present study,
neurogenic bladder dysfunction was not explicitly
recorded during the hospital stay. However, Parkinson’s
disease was recorded, which itself is a common cause for
the development of an acquired neurogenic bladder
dysfunction. Furthermore Parkinson’s disease was the
only pre-existing condition that was significantly
associated with UTI in the present patient population.
Similar results have been published by Weber et al.,who
reported elevated rates of UTI after total hip arthroplasty
in Parkinson’s disease patients.
20
These increased rates of
UTI after hip fracture might be explained by Parkinson’s
disease-related bladder dysfunction as a result of
postmicturitional residual urine.
21
The delayed
mobilization of these patients might have additional
negative effects on independent urine control and toilet
use, potentially prolonging the use of urinary catheters.
Ta b l e 4 Multivariate analysis of outcome parameters.
R
2
BβCI of B P-value
Barthel Index at discharge 0.541 –5.758 –0.091 –10.979 to 0.538 P=0.031*
TUG at discharge 0.446 33.413 0.364 20.863 to 45.964 P=0.001*
TT at discharge 0.405 –3.387 –0.169 –5.283 to 1.491 P=0.001*
Length of hospital stay 0.121 1.705 0.123 0.172 to 3.283 P=0.029*
Rate of wound infection 0.388 0.169 OR 1.185 0.089 to 1.5678 P=0.898*
In-hospital mortality rate 0.289 –18.074 OR NA NA P<0.997*
The matched variables of influence were patient age, sex, pre-fracture Barthel Index and Charlson Comorbidity Index, American Society
of Anesthesiologists score, hemoglobin value at admission, time between admission and surgery, duration of surgery, type of surgical
treatment (internal fixation vs prosthesis), pre-existing dementia, and depression.*Multiple regression analysis. β,standardizedregression
coefficient; B, unstandardized regression coefficient; CI, confidence interval; NA, not available; R
2
, adjusted R
2
; TT, Tinetti test; TUG,
Timed Up and Go test.
Urinary tract infection in patients with hip fracture
© 2017 Japan Geriatrics Society | 5
Furthermore, the results of the present study showed that
UTI was independently associated with inferior mobility
outcomes, not only for patients with Parkinson’s disease,
but also in general for patients sustaining a hip fracture.
This decrease in mobility was indicated by reduced values
for TUG and TTat discharge, as well as in activities of daily
living, represented by lower values of BI at discharge. The
inferior mobility results remained evident after adjusting
for common risk factors, such as hemoglobin value at
admission,
22
time between admission and surgery,
23
duration of surgery,
24
type of surgical treatment,
25
pre-existing dementia,
26
and depression.
27
In addition to the reduced mobility, UTI also had a
significant impact on patients’length of hospital stay, with
affected patients having a later discharge. In this context,
shorter length of hospital stay for non-UTI patients might
have been influenced by the fact that in this group, 25
patients have died during their treatment in the acute care
hospital. Regarding this question, the present data showed
that even if those 25 patients were excluded from the
analysis, the remaining 280 non-UTI patients also had
significantly shorter length of hospital stays as compared
with the 97 UTI patients (13.5 vs 14.8 days; P=0.038).
Similar results have been published by Hedström et al.,
who found additionally increased ASA scores in UTI
patients. Therefore, they concluded that the prolonged
hospital stay of these patients was more due to their
underlying disease than to the UTI for which they were
treated.
15
In the present study, patients with and without
UTI had similar ASA scores, and the increased length of
hospital stay could therefore be attributed to the UTI.
Kamel et al. supported these findings in their publication
on an observational study that was retrospectively carried
out at a university hospital. In their study with 138
patients, participants with a UTI diagnosis had a
significantly longer mean length of hospital stay than the
unaffected patients.
28
Interestingly, according to the results of the present
study, UTI diagnosis did not affect the rate of perioperative
wound infection nor the rate of in-hospital mortality.
Contrary to these findings, a descriptive case series of 84
postmenopausal women carried out by Ashraf and Umer
reported a high occurrence of wound infection in hip
fracture patients with a UTI.
29
These different findings
could certainly be related to the nearly 10-fold higher rate
of wound infection in their study (16.7%) compared with
the present study (1.7%). This tremendously high rate of
wound infection can be assumed to be related to the fact
that Ashraf and Umer carried out their study in a
developing country with estimated reduced hygienic
standards. Other studies reporting on postoperative
infections in hip fracture patients failed to show an
association between wound infection and UTI, and
therefore support the findings of the present study.
30,31
After analyzing the comorbidities, complications and
causes of death among 199 people with fractured neck of
femur in a prospectively enrolled study, Berggren et al.
failed to show that UTI was associated with an increased
mortality rate.
32
Furthermore, Ishidou et al. were unable
to find a relationship between UTI and mortality in a
prospectively conducted multicenter study that included
387 patients.
33
Therefore, the current literature supports
the present findings in terms of the lack of evidence for a
relationship between UTI and in-hospital mortality in
hip fracture patients.
Despite the thorough study design, the results should
be interpreted within the context of certain limitations.
First, the results are from an observational study, and thus
conclusions cannot be drawn in terms of causality, and the
relationships described can only be interpreted as
associations. The present study examined and followed
402 prospectively enrolled patients with hip fractures,
making it a large study compared with other single-center
studies reporting on this topic.
16,34
Second, patients were
only screened for UTI if they presented with typical
clinical signs. However, there is a lack of association
between bacteriuria and UTI symptoms, and therefore
some patients with UTI might have been undetected.
35
Nevertheless, the value of implementing general urinary
screening of patients is questionable, as according to a
recent Cochrane review, treating asymptomatic bacteriuria
in elderly patients provides no clinical benefit, but does
result in significantly more adverse events.
36
Acknowledgements
The authors acknowledge Lutz Waschnick, Natalie
Schubert, Anna Waldermann, Kristin Horstmann, Anne
Hemesath and Anke Thomas for their contributions to
the acquisition of data.
Disclosure statement
The authors declare no conflict of interest.
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