ASYMPTOMATIC BACTERIURIA AND PROSTHETIC JOINT INFECTION IN TOTAL HIP AND KNEE ARTHROPLASTY: A SYSTEMATIC REVIEW AND META-ANALYSIS OF THE LITERATURE

Asymptomatic bacteriuria has previously been reported as a risk factor for prosthetic joint infection (PJI) in total hip and knee arthroplasty. There remains no definitive conclusion whether asymptomatic bacteriuria should be treated with antimicrobials prior to hip and knee arthroplasty. A systematic review and meta-analyisis of comparative articles related to the effect of asymptomatic bacteriuria on hip and knee arthroplasty PJI was performed using PubMed, Ovid and Cochrane Library Embase. The search was performed on March 1st 2024 and included the MeSH terms “asymptomatic bacteriuria”, AND “arthroplasty”; “asymptomatic bacteriuria” AND “prosthetic joint infection”; “asymptomatic bacteriuria” AND “periprosthetic joint infection”; “asymptomatic bacteriuria' AND ‘joint replacement’. A random-effects meta-analysis model was performed to allow for missing data. Results were presented as risk ratios. A p value of < 0 .05 was deemed significant. Review Manager 5.3 software was used for the statistical analysis. Eleven articles were included. In total, there were 31,401 arthroplasty procedures included. There were 2,616 cases of asymptomatic bacteriuria and 28,785 controls without ASB. There was a higher incidence of PJI seen in the ASB cohort, compared to the control group (Risk Ratio: RR = 2.62 [1.15 – 5.95], P=0.0001). Subgroup analysis of all ASB cases demonstrated that the incidence of PJI following empiric antibiotic treatment for ASB was higher than ASB cases that were not treated with antibiotics. This was a clinically significant finding with an increase in PJI for ASB cases treated with antibiotics (Risk ratio: RR = 1.63 [0.80 – 3.29], P=0.18). In all cases bar one, the bacteria in the urine differed from the bacteria causing the joint infection. There is an increased incidence of PJI in patients with asymptomatic bacteriuria. Additionally, the use of empiric antibiotics to treat ASB in the perioperative period may actually increase the risk of PJI. Therefore, if treating ASB with antibiotics, it may be prudent to delay any arthroplasty procedure until such a time as the normal hip or knee microbiome has been restored to the pre-antibiotic status. Further study is required to examine this phenomenon of increased PJI associated with the antibiotic management of ASB.