From the Guidelines
Asymptomatic pyuria without urinary tract infection symptoms before orthopedic surgery generally does not require treatment, except in cases of prosthetic joint implantation where targeted antimicrobial therapy may be considered to reduce the risk of prosthetic infection. The presence of pus in the urine, or pyuria, in the absence of urinary tract infection (UTI) symptoms is a common finding, particularly in older adults, and routine screening and treatment are not recommended for most orthopedic procedures 1. However, for patients undergoing prosthetic joint implantation, such as hip or knee replacements, the risk of hematogenous seeding of the prosthesis may warrant treatment. Some key points to consider include:
- The decision to treat asymptomatic pyuria should be individualized based on patient risk factors, type of surgery, and institutional protocols.
- If treatment is deemed necessary, antibiotic selection should be guided by urine culture results, with common options including nitrofurantoin, trimethoprim-sulfamethoxazole, or fosfomycin 1.
- The rationale for selective treatment is that while most asymptomatic bacteriuria is benign, prosthetic joint infections are devastating complications, and some evidence suggests that treating preoperative bacteriuria may reduce postoperative infection risk in joint replacement surgery specifically.
- A clinical practice guideline update by the Infectious Diseases Society of America in 2019 provides evidence that preoperative antimicrobial therapy for patients with asymptomatic bacteriuria undergoing nonurologic surgery, including orthopedic surgery, is not routinely recommended, but may be considered in certain high-risk cases 1.
From the Research
Asymptomatic Pyuria Treatment Before Orthopedic Surgery
- The presence of pus in the urine, or pyuria, is a common finding in asymptomatic patients, but its treatment before orthopedic surgery is a topic of debate 2, 3, 4, 5, 6.
- A study published in 2020 found that preoperative pyuria was associated with postoperative Clostridioides difficile infections, but not with surgical site infections or urinary tract infections 2.
- Another study from 2014 concluded that testing and treating asymptomatic urinary tract colonization before joint replacement is unnecessary 3.
- A 2013 study found that the presence of bacteria in preoperative microscopic urinalysis of asymptomatic patients scheduled for cardiac surgery is not a reason for cancellation of elective operation 4.
- However, a 2021 study found that preoperative bacteriuria positivity on urinalysis increases wound complications in primary total hip arthroplasty, regardless of the urine culture result 5.
- A 2022 study suggested that empirical antibiotic therapy for the treatment of preoperative polymicrobial urine culture is no longer adequate, and further evaluation of organisms isolated may provide the necessary antibiograms for initiation of susceptibility-based antibiotic therapy 6.
Risks and Benefits of Treatment
- The treatment of asymptomatic pyuria before orthopedic surgery may increase the risk of antimicrobial resistance and Clostridioides difficile infections 2.
- On the other hand, not treating asymptomatic pyuria may increase the risk of postoperative wound complications and urinary tract infections 5.
- The decision to treat asymptomatic pyuria before orthopedic surgery should be based on individual patient factors and the presence of other underlying medical conditions 3, 4.
Current Recommendations
- The current evidence does not recommend screening urine culture and curing asymptomatic bacteriuria before joint arthroplasty 3, 4.
- However, some studies suggest that preoperative urinalysis may be useful in identifying patients at risk of postoperative wound complications and urinary tract infections 5, 6.
- Further research is needed to determine the optimal approach to managing asymptomatic pyuria before orthopedic surgery 2, 3, 4, 5, 6.