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Original Investigation
December 12, 2018

Association of Screening and Treatment for Preoperative Asymptomatic Bacteriuria With Postoperative Outcomes Among US Veterans

Author Affiliations
  • 1Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts
  • 2Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
  • 3VA Center for Healthcare Organization and Implementation Research, Boston, Massachusetts
  • 4Department of Medicine, Harvard Medical School, Boston, Massachusetts
  • 5Department of Surgery, VA Boston Healthcare System, Boston, Massachusetts
  • 6Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
JAMA Surg. Published online December 12, 2018. doi:10.1001/jamasurg.2018.4759
Key Points

Question  Is routine screening and treatment for asymptomatic bacteriuria in patients undergoing orthopedic, cardiac, or vascular surgical procedures warranted?

Findings  In this national cohort study of 68 265 US veterans, preoperative asymptomatic bacteriuria was associated with higher rates of postoperative urine cultures with bacteriuria among patients who underwent cardiac, orthopedic, and vascular surgical procedures and with 30-day surgical-site infection in patients who had a cardiac surgical procedure. However, active antimicrobial therapy with activity against the uropathogen was not associated with improvement in any measurable postoperative clinical outcome.

Meaning  Findings from this study provide evidence against screening or treating preoperative asymptomatic bacteriuria.

Abstract

Importance  Limited data suggest that screening for asymptomatic bacteriuria (ASB) prior to nonurologic procedures is not useful. However, high-quality evidence to support consensus recommendations and influence clinical practice is lacking.

Objective  To characterize the association between detection and treatment of preoperative ASB and postoperative outcomes.

Design, Setting, and Participants  This retrospective cohort study involved patients, predominantly male veterans, who underwent surgical procedures in 109 US facilities within the US Department of Veterans Affairs health care system from October 1, 2008, to September 30, 2013. Participants included patients (n = 68 265) who had cardiac, orthopedic, or vascular surgical procedures. Each received a planned clinician review of complete medical records for antimicrobial prophylaxis as well as 30-day surgical-site infection (SSI) and urinary tract infection (UTI) outcomes, and each had a preoperative urine culture result available within the 30 days prior to the procedure. Data analysis was performed from December 2016 to August 2018.

Main Outcome and Measures  The primary outcome was the association between preoperative ASB and postoperative SSI. The secondary outcomes included postoperative UTI and the association between antimicrobial therapy for ASB and postoperative infectious outcomes.

Results  In total, 68 265 patients (65 664 [96.2%] were men and 2601 [3.8%] were women, with a mean [SD] age of 64.6 [9.2] years) were identified, and 17 611 (25.8%) were eligible for inclusion in the primary analysis. Preoperative urine cultures were performed in 17 749 (26.0%) patients, and the results were positive in 755 (4.3%), of which 617 (81.7%) were classified as ASB. With adjustments for age, American Society of Anesthesiologists class, smoking status, race/ethnicity, sex, and diabetes status, patients with or without ASB had similar odds of SSI (2.4% vs 1.6%; adjusted odds ratio [aOR], 1.58; 95% CI, 0.93-2.70; P = .08). Receipt of antimicrobial therapy with activity against the ASB organism was not associated with a reduced SSI risk (aOR, 1.01; 95% CI, 0.28-3.65; P = .99). Urinary tract infection occurred in 14 (3.3%) of 423 patients with ASB and 196 (1.5%) of 12 913 patients without ASB (aOR, 1.42; 95% CI, 0.80-2.49; P = .22). Treatment or prophylaxis for the ASB organism similarly was not associated with reduced odds of postoperative UTI (aOR 0.68; 95% CI, 0.20-2.30; P = .54). The ASB organisms matched a postoperative wound culture in 2 cases, both Staphylococcus aureus.

Conclusions and Relevance  The findings of this study suggest that receipt of antimicrobial therapy with activity against ASB organisms identified in preoperative urine cultures was not associated with reductions in the risk for postoperative infections, including UTI and SSI; such findings suggest there is evidence for discontinuing the practice of screening and treatment for preoperative ASB.

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