Effect Of Urinary Tract Infection And Asymptomatic Bacteriuria On The Risk Of Prosthetic Joint Infection-A Meta-analysis

Objective: Many orthopaedic surgeons worry about asymptomatic bacteriuria(ASB)as a possible risk factor for prosthetic joint infection(PJI).However,available evidence establishing a direct link between ASB and PJI is limited.Urinary tract infection(UTI)are very common in the general population,however it is unclear whether UTI is a risk factor of prosthetic joint infection(PJI).Our purposes were:(1)to investigate whether ASB is a factor for PJI,(2)whether pre-operative antibiotic treatment shows benefit,(3)to determine whether UTI is a risk factor of PJI after joint replacement,and(4)to determine whether the microorganisms causing PJI and UTI are the same.Methods: We systematically searched major databases such as Pub Med,Web of Science,the Cochrane Library,EMBASE,CMKI and VIP for studies from inception up to 11 th June 2018.Two reviewers independently assessed the quality of the included studies using the nine-star Newcastle-Ottawa Scale(NOS).Risk ratio(RR)was calculated for included studies that reported raw counts with 95% confidence interval(CI).All P-values were two-sided,and P<0.05 indicated statistical significance.Heterogeneity between studies was quantified by calculating the I2 statistic.P<0.1 or I2 >50% was considered to be significantly inconsistent.Therefore,the RR and 95% CI were derived using a random-effects model.Otherwise,a fixed-effects model was used.To evaluate the robustness of our results,the method of omitting an article one by one was used in the sensitivity analysis.In addition,publication bias was assessed by funnel plots and Egger’s test.All statistical analyses were performed using STATA(version 12.0)Results: Aim 1and 2(ASB and PJI)Finally,five studies were included in the meta-analysis,which involved3588 cases of joint arthroplasty and 441 of ASB(overall incidence,12.3%).The publications dated from 1987 to 2015.However,one study comprised women only.The methodological quality ofthe five included studies varied from five to nine.Five included studies compared the risk of PJI between ASB and control groups.No significant heterogeneity was observed between studies(I2 = 39.5%,P =0.175);therefore,a fixed-effects model was used to pool the results.Compared with the control group,PJI was more common in patients in the ASB group(RR=2.87;95% CI,1.65–5.00).Three of the five studies reported that the antibiotic treated the ASB prior to joint arthroplasty and compared the untreated ASB group with a control group.A fixed-effects model was used to pool the results,because no significant heterogeneity was observed between the studies(I2 =0%,P=0.40).There was no significant difference between the treated ASB and control groups(RR=0.89;95%CI 0.36–2.20).Aim 3and 4(UTI and PJI)Aim 3Finally,five studies that met the inclusion criteria were included;there were 21 819 cases of joint arthroplasty,237 cases of PJI(overall incidence,1.1%),and 1144 cases of perioperative UTI(overall incidence,5.2%).The publications were dated from1992 to 2018.The included articles consisted of 1028 cases of primary THA,17 959 of primary TKA,and 181 of primary HA.In addition,2651 hip arthroplasties could not be differentiated between THA and HA.One study reported zero cases of PJI.Four studies did not report the microorganisms isolated from UTI.The methodological quality of the five included studies varied from a score of 7 to 9.Because no heterogeneity was observed between the studies(I2 =0%,P=0.425),a fixed-effects model was used to pool the results..The risk of PJI was significantly higher in the UTI group than in the control group(RR=3.17;95% CI,2.19–4.59).Aim 4Finally,four studies that met the inclusion criteria were included,which involved 20401 cases of joint arthroplasty.The publications were dated from1976 to 2009.The included articles consisted of hip arthroplasties,and knee arthroplasties.In nine cases,the microorganisms of perioperative UTI and PJI were the same in the same patient,and these included Staphylococcus aureus,Enterococcus faecalis,and Pseudomonas.Conclusion:1.ASB increased the risk of PJI.2.Current evidence does not support systematic antibiotherapy prior to joint arthroplasty and screening for ASB.3.UTI as being significantly associated with PJI after joint arthroplasty.4.PJI occurring via the haematogenous route from the genitourinary tract harbouring bacteria in UTI.Postponing surgery and even treating patients with known UTI preoperatively are recommended.