Does Treatment of Preoperative Asymptomatic Bacteriuria Reduce the Rate of Postoperative Prosthetic Joint or Surgical Site Infection in Elective Joint Arthroplasty? A Systematic Review

Abstract

Introduction: Inconsistent guidelines for management of preoperative asymptomatic bacteriuria (ASB) prior to elective joint arthroplasty leads to practice variance, surgical delays and antimicrobial overuse. This systematic review examined whether: 1) preoperative ASB in patients awaiting elective arthroplasty was associated with increased rates of postoperative prosthetic joint (PJI) and surgical site infection (SSI) 2) treatment of ASB modifies these rates. Methods: A textual narrative synthesis was performed of randomised control, quasiexperimental and observational studies (identified through MEDLINE, EMBASE, HMIC and grey literature resources), which included patients with ASB and an outcome measure of rate of PJI/SSI. Significant study heterogeneity precluded meta-analysis. Results: Eleven studies (comprising a total of 31857 patients) were included: one randomised control, three quasiexperimental, and seven observational studies. Ten studies involved a control group to address whether ASB was associated with PJI/SSI. Eight out of these ten studies found no association between ASB and PJI/SSI; two studies found an association. Only four out of 239 cases across all studies grew identical pathogens in wound and urine cultures. One study only included patients with ASB and focused on whether treatment of ASB reduced PJI incidence. Two of the former ten studies also explored this. No studies reported that treatment of ASB reduced rates of PJI/SSI. Conclusions: Treatment of ASB prior to joint arthroplasty does not reduce rates of PJI/SSI. Within the current climate of antibiotic stewardship and financial healthcare pressures, this review suggests that preoperative urine cultures should not be routinely sent in asymptomatic patients prior to elective joint arthroplasty.

Full text

32 International Journal of Orthopedics and Rehabilitation, 2018, 5, 32-42
E-ISSN: 2313-0954/18 © 2018 Sav vy Science Pu blisher
Does Treatment of Preoperative Asymptomatic Bacteriuria Reduce
the Rate of Postoperative Prosthetic Joint or Surgical Site Infection
in Elective Joint Arthroplasty? A Systematic Review
Krishanthi Sathanandan1,*, Judith Partridge2, Carolyn Hemsley3, Zameer Shah4 and
Jugdeep Dhesi5
1Pro-active care of Older People undergoing Surgery (POPS), Department of Age and Health, Guy’s and St
Thomas’ NHS Foundation Trust, London, UK
2Pro-active care of Older People undergoing Surgery (POPS), Department of Age and Health, Guy’s and St
Thomas’ NHS Foundation Trust, London, UK
3Department of Infectious Diseases, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
4Department of Orthopaedics, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
5Pro-active care of Older People undergoing Surgery (POPS), Department of Age and Health, Guy’s and St
Thomas’ NHS Foundation Trust, London, UK
Abstract: Introduction: Inconsistent guidelines for management of preoperative asymptomatic bacteriuria (ASB) prior to
elective joint arthroplasty leads to practice variance, surgical delays and antimicrobial overuse. This systematic review
examined whether: 1) preoperative ASB in patients await ing elective arthroplasty was associated with increased rates of
postoperative prosthetic joint (PJI) and surgical site infection (SSI) 2) treatment of ASB modifies these rates.
Methods : A textual narrative synthesis was performed of randomised control, quasiexperimental and observational
studies (identified through MEDLINE, EMBASE, HMIC and grey literature resources), which included patients with ASB
and an outcome measure of rate of PJI/SSI. Significant study heterogeneity precluded meta-analysis.
Results: Eleven studies (comprising a total of 31857 patients) were included: one randomised control, three
quasiexperimental, and seven observational studies. Ten studies involved a control group to address whether ASB was
associated with PJI/SSI. Eight out of these ten studies found no association between ASB and PJI/SSI; two studies
found an association. Only four out of 239 cases across all studies grew identical pathogens in wound and urine
cultures. One study only included patients with ASB and focused on whether treatment of ASB reduced PJI incidence.
Two of the former ten studies also explored this. No studies reported that tr eatment of ASB reduced rates of PJI/SSI.
Conclusions: Treatment of ASB prior to joint arthroplasty does not reduce rates of PJI/SSI. Within the current climate of
antibiotic stew ardship and financial healthcare pressures, this review suggests that preoperative urine cultures should
not be routinely sent in asymptomatic patients prior to electiv e joint arthroplasty.
Keywords: Asymptomatic bacteriuria, Elective joint arthroplasty, Prosthetic joint infection.
INTRODUCTION
International rates of joint arthroplasty are
increasing [1] with approximately 160,000 total hip and
knee replacement procedures performed annually
within the UK [2]. Prosthetic joint infection (PJI)
following joint arthroplasty is a significant complication
with a fivefold increase in mortality at one year, and is
the primary cause of 90 day re-admission following
total knee arthroplasty [3]. Established risk factors for
PJI include active septicaemia, morbid obesity and
poorly controlled diabetes mellitus. Whilst implantation
of prostheses in the context of urinary tract sepsis is
*Address correspondence to this author at the Pro-active care of Older People
undergoing Surgery (POPS), Department of Age and Health, Guy’s and St
Thomas’ NHS Foundation Trust, London, UK;
Tel: 02071882092;
E-mail: krishanthi.sathanandan@nhs.net
contraindicated, the association between PJI and
asymptomatic bacteriuria (ASB) is less clear [4].
ASB is defined as the presence of bacteria in the
urine of an individual without symptoms or signs of
urinary tract infection (UTI) [5]. It is frequent in the older
population with a reported prevalence in patients
awaiting joint arthroplasty of up to 28% [6]. In older
community dwelling and care home residents treatment
of ASB confer no long term benefit in improving chronic
urinary symptoms, delirium, morbidity or mortality
[6-13]. In fact treatment can lead to adverse
antimicrobial side effects and re-infection with resistant
organisms [7].
Various methods are used to diagnose ASB or UTI.
“Urine dipstick” continues to be frequently used,
despite its low positive predictive value for diagnosis of

Asymptomatic Bacteriuria Reduce the Rate of Postoperative Prosthetic International Journal of Orthopedics and Rehabilitation, 2018 Vol. 5 33
bacteriuria or UTI [7]. Additionally urine culture in
asymptomatic patients awaiting elective arthroplasty is
frequently undertaken in preoperative clinics in the UK
[14].
An online and postal survey of members of the
British Association for Knee Surgery reported that two
thirds of specialist knee surgeons would treat ASB prior
to total knee arthroplasty, but 70% of respondents
could not cite evidence for this decision [15].
Furthermore professional guidance on the
management of ASB prior to joint arthroplasty is
inconsistent [4, 16-18], leading to inconsistent clinical
practice, delays in surgery, antimicrobial overuse and
resistance, and subsequent healthcare costs [19].
This systematic review aims to examine whether
treatment of preoperative ASB in patients awaiting
elective joint arthroplasty reduces the risk of PJI and
surgical site infection (SSI). The following questions will
be considered:
1) Is preoperative ASB in patients awaiting elective
hip and knee arthroplasty associated with
increased rates of PJI/SSI?
2) If an association is found, does treatment of ASB
modify rates of PJI/SSI.
METHODS
This systematic review was conducted according to
the protocol registered with PROSPERO
(42017059681). Methodological standards outlined in
Centre for Reviews and Dissemination’s Guidance for
Undertaking Reviews in Health Care were followed
[20].
Identif ication of Studies/Data Sources
MEDLINE, EMBASE and Health Management
Information Consortium (HMIC) electronic databases
via the Ovid Interface were searched using a
prespecified search strategy [see Appendix 1].
Unpublished studies were sought by inputting MeSH
terms of “joint surgery” or “arthroplasty” in combination
with “bacteriuria” into grey literature and clinical trial
databases (Web of Science, Open Grey, Grey
Literature Report and ClinicalTrials.gov). Additional
eligible studies were retrieved by hand searching
bibliographies of relevant articles. The search was
limited to English language articles but no date
restriction was applied. The last electronic search was
performed on January 25, 2017.
Study Selection !
Article abstracts, and subsequently their full text,
were independently assessed for eligibility by two
researchers (KS and JP). Discrepancies were resolved
through a third reviewer (JD). Duplicate publications
were identified through comparison of authors, study
setting and methodology; the article reporting the most
study data was included. !
The criteria for inclusion were: 1) randomised
controlled, quasi-experimental and prospective or
retrospective observational studies; 2) adults (over
18years) undergoing elective hip or knee arthroplasty
with preoperative ASB (including if a subset of total
study population) 3) primary or secondary outcome
measure was rate of PJI or SSI. !
Review and opinion articles, case reports and
foreign language papers were excluded. Studies
addressing only emergency arthroplasties,
symptomatic UTI or postoperative ASB were also
excluded. Absence of recognised definitions for ASB or
PJI/SSI was accounted for in qualitative assessments
rather than precluding inclusion. !
Data Extraction
A single reviewer (KS) extracted data from eligible
full text articles, using a customised form [see
Appendix 2] to collate information on study
characteristics, outcome measures and information for
qualitative assessment.
Data Synthesis
Significant study heterogeneity precluded meta-
analysis. Therefore a textual narrative synthesis was
conducted according to established methodological
standards [20], structured around study design,
population characteristics and reported outcomes. This
was complemented with tabular summaries of results.
Quality Assessment
Full text articles were evaluated for quality in
domains of selection, performance, detection and
attrition, based on the Cochrane Collaboration Risk of
Bias Tool [21]. Studies were considered at low risk of
bias if all quality components were adequate, moderate
risk if one or more component was unclear, and high
risk if one or more component was inadequate.
Additionally a quality score was calculated based on a
validated checklist for health care intervention studies
[22].

34 International Journal of Orthopedics and Rehabilitation, 2018 Vol. 5 Sathanandan et al.
RESULTS
Search Results
One hundred and one articles were identified from
the electronic and hand search (Figure 1). No records
were identified from grey literature sources. Following
application of exclusion criteria 33 full text articles were
obtained for detailed evaluation. Following examination
of full text, 22 articles did not fulfil inclusion criteria.
Ultimately 11 articles were included in this systematic
review. One of these articles [23] was included
following consensus meeting with the third reviewer
(JD).
Study Characteristics
One randomised control trial [24], three
quasiexperimental trials [25-27], three prospective
observational [28-30] and four retrospective
observational studies [23, 31-33] were included. Apart
from one multicentre trial, [24] the study settings were
single centre urban institutions.
Study populations included patients undergoing
both hip and knee arthroplasty, with the exception of
four studies (three only knee [27,29,32]; one only hip
[24]). Orthopaedic procedures were a subgroup of the
total study population in one study [23].
Ten studies included a control group, comparing
rates of PJI/SSI in patients with and without ASB. One
study only included patients with ASB, focusing on
whether antibiotic treatment of ASB reduced the
incidence of PJI [27]. Three studies reported on rates
of SSI only [23, 28,29], six studies reported on rates of
PJI only [24-27, 30, 31], and two studies reported on
both [31, 33]. PJI and SSI was a secondary outcome in
four studies [23, 26, 30, 33], and a primary outcome in
the remaining seven. Three studies explored whether
preoperative treatment of ASB modified rates of PJI
[24-25, 27].
The number of participants in each trial ranged from
128 to 19735, with the mean age of study subjects
ranging from 53-84 years. Study characteristics are
summarised in Table 1.
Figure 1: Flow diagram of included and excluded trials.
*Further exclusion at full text screening required due to insufficient information in abstract.

Asymptomatic Bacteriuria Reduce the Rate of Postoperative Prosthetic International Journal of Orthopedics and Rehabilitation, 2018 Vol. 5 35
Table 1: Summary of Included Studies
Author/
Year
Setting
Study
Design
Study
Period
Populatio-
n (n)/ Mean
age
Exposure/
Bacteriuria
% (n)
Intervention
if Present
(n)
Comparator
(n)
Reported
Outcome
Author
Conclusion
Risk of Bias
Quality
Score
Randomised Control Studies
Cordero-
Ampuero
et al.;
2013
Spain;
single
centre
Prospe
ctive
random
ised
Apr 2009-
Nov 2010;
FU for 12
months at
external
offices
(interview,
bloods, X-
rays)
471
undergoing
THA (228)
& HA (243)
Age 84yrs
ASB (105
CFU per
mL) / urine
taken 12hrs
before
surgery/ 9.8
(46)
7 days
antibiotics for
ASB &
standard
surgical
antibiotic
prophylaxis
(26 –all with
ASB)
Standard
surgical
antibiotic
prophylaxis
only
(425 - 20
with ASB)
Prevalence of
PJI
12 cases in
non-ASB
group; 1 in
treated ASB
group; 0 in
untreated
ASB group
No
association
between
ASB & PJI;
preoperative
treatment of
ASB does
not modify
risk
Overall: high
Selection high
Performance
low
Detection low
Attrition low
Score: 22/32
Quasiexperimental Studies
Sousa
et al.;
2014
Portug
al,
Spain
and
UK;
multi
centre
Prospe
ctive
non
random
ised
Jan 2010-
Dec 2011;
FU for 12
months
(methods
not
reported)
2497
undergoing
THA (1248)
or TKA
(1247)
Age 68yrs
ASB (105
CFU per
mL) /
unclear
urine
sampling
time/ 12.1
(303)
8 days
antibiotics for
ASB 1 week
before
surgery, &
standard
surgical
antibiotic
prophylaxis
(154)
Standard
surgical
antibiotic
prophylaxis
only (2342 -
149 with
ASB)
Rate of PJI
(43 cases):
1.3% in non-
ASB group
infection rate
3.9% in
treated ASB;
4.7% in non-
treated ASB
Association
present
between
ASB & PJI;
preoperative
treatment of
ASB does
not modify
risk
Overall: high
Selection high
Performance
unclear
Detection
unclear
Attrition
unclear
Score: 15/32
Martinez-
Velez
et al.;
2016
Spain;
single
centre
Prospe
ctive
non
random
ised
Apr 2009-
Nov 2010;
FU for 60
months at
external
offices
(interview,
bloods, X-
rays)
215 TKA –
analysis of
11 with
ASB;
Age 73.4yrs
ASB (105
CFU per
mL) / urine
taken 12hrs
before
surgery/ 5.1
(11)
7 days
antibiotics for
ASB &
standard
surgical
antibiotic
prophylaxis
(4)
Standard
surgical
antibiotic
prophylaxis
only
(7)
Prevalence of
PJI with and
without
treatment of
ASB
(1 PJI in
treated ASB
group)
Preoperative
treatment of
ASB does
not modify
risk
Overall: high
Selection high
Performance
low
Detection low
Attrition low
Score: 18/32
Lamb
et al.;
2016
Canad
a;
single
centre
Interrup
ted
time
series
analysi
s
May 2013-
June
2016;
24 month
control
period &
12 month
interventio
n period
5414
undergoing
hip (2118)
and knee
(3024);
other
arthroplasty
(272)
Age 66-
67yrs
ASB (105
CFU per
mL) / urine
cultured at
preoperativ
e
assessment
/ 11.5 (352)
Routine
urine culture
processing
discontinued
; therefore
ASB not
treated
(1891)
Routine
urine culture
at
preoperative
assessment;
(3523- 352
with ASB of
which 42
treated
(12.2%)
Rate of PJI
secondary
outcome:
(4 PJI –
1/3523 in
control
period,
3/1891 in
intervention
period)
Discontinuati
on of
preoperative
urine culture
did not
increase r ate
of PJI
Overall: high
Selection high
Performance
unclear
Detection high
Attrition
unclear
Score: 17/32
Observational Studies
Bouvet
et al.;
2014
Switzer
land;
single
centre
Prospe
ctive
Nov 2011-
Sept 2012;
FU for 12
months
(questionn
aires to
GP and
patient)
510
undergoing
THA (386)
or TKA
(229); Age
69.1yrs
ASB (103
CFU per
mL)/urine
cultured on
admission/
35.7 (182)
N/A
Standard
surgical
antibiotic
prophylaxis
in all
patients
Rate of PJI
secondary
outcome ( 0
cases)
No
association
between
ASB & PJI
Overall:
moderat e
Selection low
Performance
low
Detection
unclear
Attrition low
Score: 23/32
Singh
et al.;
2015
India;
single
centre
Prospe
ctive
June
2012- Nov
2012; FU
for
3months
(methods
not
reported)
128
females
undergoing
bilateral
TKA (89) &
unilateral
TKA (39) ;
mean age
not reported
ASB
(definition
not
specified)/
urine
cultured say
before
surgery/
35.9 (46)
N/A
Standard
surgical
antibiotic
prophylaxis
in all
patients
Delayed
wound
healing (1
case in non-
ASB group)
No
association
between
ASB &
delayed
wound
healing
Overall: high
Selection
unclear
Performance
high
Detection high
Attrition
unclear
Score: 14/32

36 International Journal of Orthopedics and Rehabilitation, 2018 Vol. 5 Sathanandan et al.
Ollivere
et al.;
2009
UK;
single
centre
Prospe
ctive
Recruitme
nt period
not
reported;
no FU
after
discharge
558
undergoing
elective
arthroplasty
(type of
surgery not
specified);
Age 62yrs
ASB (105
CFU per
mL)/ urine
cultured at
preoperativ
e
assessment
/ 7 (39)
N/A
All ASB
treated with
antibiotics
via GP. All
patients
received
standard
surgical
antibiotic
prophylaxis.
Rate of SSI
(15/39 with
ASB; 83/519
without ASB)
ASB
associated
with SSI
despite
preoperative
treatment
Overall: high
Selection high
Performance
high
Detection high
Attrition
unclear
Score: 9/32
Koulouva
ris
et al.;
2009
USA;
single
centre
Retrosp
ective
case
control
Jan 2000-
Dec 2004;
FU for 12
months
(methods
not
reported)
19735
participants
– 58
undergoing
hip (23) or
knee (36)
arthroplasty
developed
postoperati
ve wound
infection
Age 66.7yrs
ASB
(definition
not
specified)
but also
included
UTI / urine
cultured 1
week before
surgery/ 9.5
(11)
N/A
ASB treated
with 5-8
days of
antibiotics;
all received
standard
surgical
antibiotic
prophylaxis
(11 with
ASB; 105
without
ASB)
Rate of PJI
/SSI in those
with and
without
ASB/UTI
(3/11 with
ASB; 55/105
without ASB)
No
association
between
ASB/UTI &
PJI/SSI
Overall:
moderat e
Selection
unclear
Performance
unclear
Detection low
Attrition low
Score: 23/32
Glynn
et al.;
1984
Ireland;
single
centre
Retrosp
ective
9 months
recruitmen
t; FU for
3months
(at routine
postoperat
ive clinic)
299
undergoing
total joint
arthroplasty
with less
than 10%
TKA (exact
figures not
reported);
mean age
not reported
ASB (105
CFU per
mL)/ urine
cultured day
after
admission/
19.1 (57)
N/A
ASB treated
inconsistentl
y (39 did not
complete
antibiotics
preoperative
ly); surgical
antibiotic
prophylaxis
not given
consistently
Rate of
PJI/SSI
secondary
outcome (Nil
PJI cases;
2/57 SSI with
ASB; nil SSI
without ASB)
No
association
between
ASB &
PJI/SSI
Overall: high
Selection
unclear
Performance
high
Detection high
Attrition
unclear
Score: 14/32
Gou
et al.;
2014
China;
single
centre
Retrosp
ective
June
2008-June
2010; FU
for 36
months
(methods
not
reported)
739
undergoing
THA (540)
or TKA
(455); Age
53.7yrs
ASL (over
10
leucocytes
per high-
power field
at ×400
magnific atio
n in 2
samples/
urine
cultured day
of
admission/
17.7 (131)
N/A
Standard
surgical
antibiotic
prophylaxis
in all
patients
Rates of PJI
(1/131 with
ASL; 6/608
without ASL)
No
association
between
ASL & PJI
Overall: low
Selection low
Performance
low
Detection low
Attrition low
Score: 22/32
Drekonja
et al.;
2013
US;
single
centre
Retrosp
ective
2010; FU
not
reported
1291
participants
undergoing
orthopaedic
procedures
(sub group
of total
study
population
of 19344)
Age 61.8yrs
ASB (105
CFU per
mL)/
inconsistent
urine
sampling –
only in 25%/
13
(absolute
number not
reported for
orthopaedic
subgroup,
54 in total
study
population)
N/A
Practice not
reported;
number of
ASB in
orthopaedic
subgroup
treated
preoperative
ly not
reported (11
in total study
population)
Rates of SSI
secondary
outcome
(orthopaedic
subgroup not
individually
reported; total
study
population:
20% with
ASB – 45% in
treated &
14% in
untreated;
16% without
ASB)
No
association
between
ASV & SSI
Overall: high
Selection high
Performance
high
Detection high
Attrition
unclear
Score: 11/32
Abbreviations: THA – total hip arthroplasty; HA –hemi arthroplasty; TKA – total knee arthroplasty; FU – follow up; ASB – asymptomatic
bacteriuria; PJI – prosthetic joint infection; CFU – colony forming units
Quality Assessment
Meta-analysis was precluded by significant
heterogeneity in study methodology and outcome
reporting. Within eligible studies the overall risk of bias
[21] was high in eight studies, [23-29,33] moderate in
two studies [30-31] and low in one study [32]. The

Asymptomatic Bacteriuria Reduce the Rate of Postoperative Prosthetic International Journal of Orthopedics and Rehabilitation, 2018 Vol. 5 37
mean quality score [22] across included studies was 17
(range 9 to 23; median 17).
Outcome Measures
Is preoperative asymptomatic bacteriuria in patients
awaiting elective hip and knee arthroplasty associated
with increased risk of PJI and SSI?
Randomised Control and Quasiexperimental
Studies
In a randomised control trial, Cordero-Ampuero et
al. recruited 471 patients undergoing hip arthroplasty
[24]. All patients were randomised to either group A or
B, with urinalysis being performed 12 hours prior to
surgery and subsequent urine culture if abnormal. All
patients received standard surgical prophylactic
antibiotics. Urine cultures returned several hours after
surgery. Patients with negative urine cultures in both
groups received no further antibiotics. Patients in group
A with confirmed ASB received an additional seven
days of antibiotics, whilst those with ASB in group B
received no further antibiotics. Follow up was
undertaken at external offices with subsequent
comparison of PJI rates between both patients with
ASB and sterile urine culture, and between those with
ASB who were treated with and without further
antibiotics (the results of which are discussed later).
There was no significant difference in incidence of PJI
among patients with negative urine cultures (12/425;
2.82%) and those with ASB (1/46; 2.17%).
Similar results were described by Lamb et al. in an
interrupted time series analysis which recruited 5414
participants undergoing predominantly elective hip and
knee arthroplasty (5% were other limb arthroplasties)
[26]. Preoperative urinalysis for ASB was standard
practice at this Canadian centre, with positive results
being treated with outpatient antibiotics. The
intervention instigated was the cessation of routine
preoperative urine culture processing by the laboratory
unless telephone confirmation was received by the
requesting clinician. There was no statistically
significant change in the rates of PJI, which was
measured as a secondary outcome during the 24
month control period (1/3523; 0.03% PJI per 100 EJA;
95% CI, 0.001-0.2) and the 12 month intervention
period (3/1891;0.2% PJI per 100 EJA;95% CI, 0.05-
0.5;p=0.1).
In contrast, Sousa et al. concluded that ASB was an
independent risk factor for PJI. Urine cultures were
sent in 2497 participants undergoing total hip and knee
arthroplasty across three European centres [25].
Collection of demographic data was incomplete in one
centre and catheterised patients were not explicitly
excluded. Whilst 149 cases of ASB were not treated,
154 received an eight day course of antibiotics
according to surgeon’s preference. Twenty six of these
had repeat urine cultures sent to ensure preoperative
eradication. Forty three PJIs were diagnosed over 12
months. Patients with ASB were reported to have a
significantly higher rate of PJI compared to those with
normal urine cultures (4.3% vs 1.4%, OR 3.23; 95% CI
1.67–6.27;p =0.001).
In all three studies the pathogens cultured from joint
and urine differed.
Observational Studies
Only one observational study reported an
association between ASB and SSI. In a prospective
consecutive case series, Ollivere et al. analysed
medical records of 558 patients undergoing elective
arthroplasty at a UK centre [28]. All 39 patients with
ASB at preoperative assessment were treated with
outpatient antibiotics. MSU was not resent prior to
surgery. Following discharge, patients were allocated
to three cohorts according to their wound status during
hospital admission: uneventful wound healing;
superficial wound infection but with negative cultures;
superficial wound infection with positive cultures.
Fifteen patients with ASB developed superficial wound
infections with a reported relative risk of 2.4 (p<0.02).
Four cases grew the same microorganism in urine and
wound culture.
Contrary to this, two further prospective
observational studies found no association between
ASB and PJI/SSI. Singh et al. examined SSI in 128
females undergoing total knee arthroplasty where all 46
cases of preoperative ASB were untreated with
antimicrobial agents [29]. Despite a high prevalence of
both diabetes (38%) and obesity (53%) within the study
population, there was only a single case of delayed
wound healing in the cohort, occurring in a patient with
negative urine cultures. In a Swiss study, Bouvet et al.
assessed rates of PJI as a secondary outcome in 615
patients undergoing hip and knee arthroplasty [30].
One hundred and eighty two patients had preoperative
ASB. Patients with prolonged catheterisation (two) and
who were already established on antibiotics (11) were
excluded. No cases of PJI were identified during the
study period. Additionally on retrospective analysis of
their joint replacement registry, the authors reported
that none of the 71 infected prostheses over a 12 year
period had preoperative bacteriuria.

38 International Journal of Orthopedics and Rehabilitation, 2018 Vol. 5 Sathanandan et al.
Four retrospective studies have reported a similar
lack of association between preoperative ASB and
PJI/SSI [23, 31-33]. A four year case control study
used robust methodology to identify and compare 58
cases of infective wound complications with controls
matched to demographic and surgical criteria [31]. No
association between ASB and prosthetic joint or deep
surgical site infection was reported (OR 0.341; CI
0.086-1.357;p=0.127).
Using leucocyturia as a marker for ASB, Gou et al.
reported a prevalence of ASB of 17.7% in a study
population of 739 patients awaiting primary total hip
and knee arthroplasty [32]. Only one of the seven
cases who developed PJI had preoperative
leucocyturia. On logistic regression analysis
preoperative ASB was not found to be a risk factor for
the development of early PJI.
Two studies examined the association between
ASB and SSI as a secondary outcome. Glynn et al.
analysed the records of 299 patients undergoing hip
and knee arthroplasty [33]. Thirty-nine of the 57 cases
with ASB underwent surgery before completing
antibiotic therapy. Only two patients developed
superficial wound infections with different urinary and
wound pathogens cultured. No cases of PJI occurred.
Drekonja et al. analysed the medical records of all
patients undergoing orthopaedic, cardiothoracic or
vascular surgery at the Minneapolis Veterans
Association Medical Centre [23]. Due to retrospective
analysis of routinely collected data not all patients had
a preoperative urine culture sent. Despite this the
prevalence of ASB was 13% within the subgroup of
1291 patients awaiting orthopaedic procedures. Data
was not reported according to surgical subspecialty,
but within the entire study population, wound infection
rates were comparable between those with and without
ASB (20% vs 16%, p=0.56).
Does Treatment of ASB Preoperatively Modify this
Association?
Three trials specifically explored whether treatment
of ASB affected rates of PJI [24-25, 27].
A non-randomised control trial recruited 215
patients undergoing total knee arthroplasty [27]. Eleven
patients were diagnosed with ASB, four were allocated
to receive standard surgical antibiotic prophylaxis only
and seven cases, according to the surgeon’s
preference, received an additional seven days of
sensitive antibiotics to treat ASB. The only PJI
identified was within the treated group. Similarly in two
previously described trials [24-25] there was no
reported difference in PJI between the treated and
untreated group. The authors of all three trials
concluded that identification and treatment of
preoperative ASB was not justified in the prevention of
PJI.
DISCUSSION
This narrative synthesis suggests there is no
association between preoperative ASB and
postoperative PJI/SSI. Furthermore there is no
evidence that treatment of ASB reduces the risk of
PJI/SSI.
Eight studies reported no association between ASB
and PJI/SSI. These included a randomised study [24],
two quasiexperimental studies [26-27] and six
observational studies (two prospective [29-30] and four
retrospective [23, 31-33]). Two of these eight studies
reported on rates of SSI only, [23, 29] five on rates of
PJI only, [24, 26-27, 30, 32] and two on rates of both
[31, 33]. Rates of PJI/SSI were secondary outcomes in
four of these studies [23, 26, 30, 31] and primary
outcomes in the remainder. The mean quality score
[22] across these eight studies was 18 (range 11 to 23;
median 18).
Two studies found a positive relationship between
ASB and PJI/SSI, which were primary outcomes in
both [25, 28]. However these studies should be
interpreted with caution as both have quality
assessment scores [22] below the mean. In the
multicentre trial performed by Sousa et al., participants
were non-randomised with inclusion of catheterised
patients, and a lack of clarity regarding practice
variance between international study centres [25].
Additionally statistical analyses of confounders are
somewhat diminished by incomplete data collection
from the UK centre regarding diabetes mellitus, an
important risk factor for PJI [4]. Similarly in the
prospective cohort study by Ollivere et al. [28]
there
were high levels of bias in all domains and the lowest
quality assessment score (9/32). There was poor
reporting of baseline characteristics, ambiguity
regarding standardisation of wound assessment, lack
of blinding, short follow up, and poorly reported
statistics with no confidence intervals.
Notably neither author (Sousa nor Ollivere)
attributes direct causality of infective wound
complication to ASB. This conclusion is supported by
the fact that in only four [28] of the 239 cases of wound
infection across all studies was the same pathogen
isolated from preoperative urine and from the

Asymptomatic Bacteriuria Reduce the Rate of Postoperative Prosthetic International Journal of Orthopedics and Rehabilitation, 2018 Vol. 5 39
postoperative wound. Sousa et al. in particular reflect
that ASB may be an indicator of a patient’s vulnerability
to infection, and emphasizes that routine preoperative
urinalysis is not proposed as antibiotic therapy did not
modify the risk of infective complications. [25] This
finding is echoed in the two further studies addressing
this question [24, 27].
The strengths of this review lie in the robust and
comprehensive methodology employed to identify and
evaluate all relevant trials. Attempts to minimise
publication bias were addressed by searching grey
literature, although this did not yield any further
material of interest. Due to resource limitations, we
restricted results to English language papers only,
which may exclude some potentially relevant items.
A limitation of this systematic review is the small
sample size within included studies, stemming from the
low incidence of PJI, a constraint some authors
commented on when developing their study
methodology [30]. Additionally there were potentially
high levels of bias within included studies, especially
with regards to subject selection, with a mean quality
score [22] of only 17 out of 32 across included studies.
The heterogeneity in study populations, standardised
care and outcome measures could be considered a
further limitation but in practical terms does reflect the
variability observed in routine clinical practice.
With financial pressures in healthcare provision,
NICE guidelines outline that preoperative tests should
only be undertaken if an abnormal result would change
perioperative management or influence decision to
operate [34]. This review suggests that not only is there
is insufficient evidence of a relationship between ASB
and PJI/SSI, but treatment of ASB does not impact on
rates of PJI/SSI. Furthermore Lamb et al. estimated
that national annual savings of $ 3,202,500 USD could
be effected from simply reducing preoperative urine
culture requests prior to elective joint arthroplasty, even
without consideration of additional savings from
reduced antimicrobial prescriptions [26]. Similarly an
economic analysis study found that routine urinalysis
prior to joint procedures was economically unsound
[35].
Moreover treatment of ASB confers no morbidity or
mortality benefits [6-7], with an estimated number
needed to harm of three when treating ASB in older
women [17]. Adverse antimicrobial events and
multiresistant bacteria has also raised the awareness
amongst health professionals of antibiotic stewardship
[7].
ASB continues to be treated in a variety of settings,
contrary to the established evidence base [19]. This
systematic review has identified inadequate evidence
for a causal relationship between preoperative ASB
and increased rates of PJI/SSI following elective joint
arthroplasty. Given the proven financial cost and
adverse outcomes associated with the treatment of
ASB, we propose there is necessity to have quality
randomised and controlled trials into this topic prior to
preoperative urinalysis and culture in asymptomatic
patients becoming routine practice before elective joint
arthroplasty. This sentiment is echoed by expert
opinion within the orthopaedic community, [14, 19, 36]
including delegates at the 2013 international
periprosthetic joint consensus meeting, also suggesting
that routine urine screening prior to arthroplasty is not
warranted in the absence of urinary symptoms [4].
CONFLICT OF INTEREST STATEMENT
Each author certifies that he or she has no
commercial associations that might pose a conflict of
interest in connection with the submitted article
ETHICAL APPROVAL
This article does not contain any studies with
human participants or animals performed by any of the
authors.
APPENDIX 1: Pre-Specified Search Strategy for
Systematic Review (Formulated in
Collaboration With Helen Elwell, Senior
Medical Librarian, Search Services, Bma
Library.)
Database: Embase <1974 to 2017 Week 04>, Epub
Ahead of Print, In-Process & Other Non-Indexed Citations,
Ovid MEDLINE(R) Daily and Ovid MEDLINE(R) <1946 to
Present>, HMIC Health Management Information Consortium
<1979 to November 2016>
1. exp Arthroplasty/ (116982)
2. (arthroplasty or arthroplasties).mp. (154922)
3. bone graft$.mp. (62719)
4. ((ankle or elbow or knee or hip or shoulder or finger or
disc or joint) adj3 (replace$ or reconstruct$ or
prosthes#s)).mp. (181221)
5. orthop?edic.mp. (201088)
6. joint.mp. (789628)
7. su.fs. (3810314)
8. surg$.mp. (5553534)
9. procedure$.mp. (3112185)
10. 5 or 6 (949918)
11. 7 or 8 or 9 (8269025)
12. 10 and 11 (403295)
13. 1 or 2 or 3 or 4 or 12 (583863)
14. urinary tract infections/ or bacteriuria/ or pyuria.mp.

40 International Journal of Orthopedics and Rehabilitation, 2018 Vol. 5 Sathanandan et al.
[mp=ti, ab, hw, tn, ot, dm, mf, dv, kw, fs, nm, kf, px, rx,
ui] (89823)
15. (urinary tract infection$ or bacteriuria or pyuria).mp.
(163441)
16. 14 or 15 (163441)
17. (asymptomatic or covert).mp. (336010)
18. 16 and 17 (7407)
19. asymptomatic bacteriuria/ (1591)
20. Urine/an, ch, cy, di, mi [Analysis, Chemistry, Cytology,
Diagnosis, Microbiology] (14880)
21. Urinalysis/ (91957)
22. exp urinalysis/ or urine culture/ (100099)
23. (urinalys$s or urin$ culture$).mp. (18316)
24. 20 or 21 or 22 or 23 (120394)
25. ((abnormal$ or positive) adj5 (Urine or Urinalysis or
(urinalysis or urine culture) or (urinalys$s or urin$
culture$))).mp. (17412)
26. 18 or 19 or 25 (24278)
27. 13 and 26 (139)
28. remove duplicates from 27 (97)
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APPENDIX 2: Customised Data Collection Form
GENERAL INFORMATION
Citation
Competing interests/ funding
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Country of origin
STUDY CHARACTERISTICS
Study aim/objective
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Eligibility criteria
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Support for Judgement
Bias Outcome
Selection Bias:
Performance Bias:
Detection Bias:
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OVERALL BIAS
QUALITY SCORE

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Received on 15-05-2018 Accepted on 09-08-2018 Published on 30-12-2018
DOI: http://dx.doi.org/10.12974/2313-0954.2018.05.4
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