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Perioperative Lower Urinary Tract Infections and Deep Sepsis in Patients Undergoing Total Joint Arthroplasty

Dr. David is Orthopedic Fellow, Kerlan-Jobe Orthopedic Clinic, Los Angeles. Dr. Vrahas is Chief of Orthopedic Services, Massachusetts General Hospital, Brigham and Women’s Hospital, Boston.

Reprint requests: Dr. David, Kerlan-Jobe Orthopaedic Clinic, 6801 Park Terrace, Los Angeles, CA 90045.

Deep sepsis in the involved joint after hip or knee arthroplasty may be the result of hematogenous seeding from a remote infectious source. This mechanism has been used to explain the well-documented association between postoperative urinary tract infections and subsequent joint infection after hip or knee arthroplasty. However, it is unclear whether there is an association between preoperative bacteriuria and deep prosthetic infection. The purpose of this review is to identify perioperative risk factors associated with bacteriuria that have a positive correlation with deep joint sepsis following total hip or knee arthroplasty. The classic symptoms of dysuria, urgency, and frequency seen with urinary tract infections are often absent in the elderly despite the presence of urine coliforms; in these patients, pyuria (as indicated by the presence of more than 1x 10⁴ white blood cells per milliliter of noncentrifuged urine) may be used as a preliminary screening criterion. If there are irritative symptoms, the presence of more than 1x 10³ bacteria per milliliter of urine should be regarded as indicative of a urinary tract infection. If there is bacteriuria without symptoms of urinary irritation or obstruction, the current literature supports proceeding with total joint arthroplasty and treating those patients with urine colony counts greater than 1x 10³/mL with an 8- to 10-day postoperative course of an appropriate oral antibiotic. Postponement of total joint surgery should be considered if preoperative evaluation reveals symptoms related to obstruction of the urinary pathway. Irritative symptoms in combination with a bacterial count greater than 1 x 10³/mL should also serve as an indication to postpone surgery. To diminish postoperative urinary tract infection, a bladder catheter should be inserted immediately preoperatively and removed within 24 hours of surgery to diminish the risk of urinary retention, which has been shown to increase the likelihood of a postoperative urinary tract infection.