A Clinical Guideline recommended For use in: By: For: Division responsible for document: Key words: Name of document authors: Job titles of document authors: Name of document author s Line Manager: Job title of document author s Line Manager: Supported by: Trauma and Orthopaedics All staff involved in Orthopaedic Pre-assessment and Same Day Admission Unit All patients undergoing Hip and Knee replacement surgery Division 2 - Surgery Urinary tract infection, screening, hip replacement, knee replacement Mr Homa Arshad and Mr Jim Wimhurst Revision Hip Fellow and Trauma and Orthopaedics Consultant Nish Chirodian Clinical Director Trauma & Orthopaedics John Nolan, Consultant Trauma and Orthopaedics Surgeon, Caroline Barker, Consultant Microbiologist Sarah Wood, Consultant Urologist, Charlotte Venus, Highly Specialised Orthopaedic Pharmacist Assessed and approved by the: Clinical Guidelines Assessment Panel (CGAP) Date of approval: 02 May 2017 Ratified by or reported as approved to (if applicable): Clinical Standards Group and Effectiveness Sub Board To be reviewed before: This document remains current after this 02 May 2020 date but will be under review To be reviewed by: Mr Jim Wimhurst Reference and/or Trustdocs ID No: CA5169 ID No: 10464 Version No: 2 Description of changes: Compliance links: (is there any NICE related to guidance) If Yes does the strategy/policy deviate from the recommendations of NICE? If so, why? None No N/A This guideline has been approved by the Trust's Clinical Guidelines Assessment Panel as an aid to the diagnosis and management of relevant patients and clinical circumstances. Not every patient or situation fits neatly into a standard guideline scenario and the guideline must be interpreted and applied in practice in the light of prevailing clinical circumstances, the diagnostic and treatment options available and the professional judgement, knowledge and expertise of relevant clinicians. It is advised that the rationale for any departure from relevant guidance should be documented in the patient's case notes. The Trust's guidelines are made publicly available as part of the collective endeavour to continuously improve the quality of healthcare through sharing medical experience and knowledge. The Trust accepts no responsibility for any misunderstanding or misapplication of this document. Available via Trust Docs Version: 2 Trust Docs ID: 10464 Page 1 of 14
Quick reference guideline Available via Trust Docs Version: 2 Trust Docs ID: 10464 Page 2 of 14
Objectives Investigating for Urinary Tract Infection in Patients Undergoing Identification of patients with symptomatic urinary tract infection (UTI) should occur at preassessment clinic by the use of screening questions. Infection should be treated prior to elective orthopaedic hip and knee replacement surgery. Urinary tests in asymptomatic patients are no longer recommended. Urinalysis by dipstick tests or microscopy is used for those with symptoms as an aid to further management. Rationale The benefit of routine pre-operative urinalysis prior to joint replacements is questionable 1. At an international consensus meeting on joint replacement infection in 2013 there was strong agreement (74%) that routine urine screening for infection prior to hip and knee replacement was not indicated and that it should be reserved for patients with a history or symptoms of a urinary tract infection 2. The evidence shows no advantage in treating an asymptomatic bacteriuria prior to joint replacement surgery 3. One large retrospective study suggested that even symptomatic urinary tract infections rarely cause deep joint infections 4. It seems sensible, however, to treat an obvious infection prior to elective surgery. Definitions of Terms Used / Glossary UTI: Urinary tract infection MSU: Mid stream urine Screening Questions at Pre-assessment and on the Day of Surgery: Do you suffer from burning or stinging when you pass urine? Do you have to pass urine more frequently than usual? Have you noticed blood, discoloration or cloudiness in your urine? Do you have any difficulty passing urine? Have you had a urinary tract infection in the last month? Action Patients with positive responses are investigated with urinalysis by dipstick testing and microbiological analysis (MSU). Symptomatic patients with a positive dipstick test for leucocytes and nitrites are treated with a 5-day course of antibiotics, which will be prescribed in the pre-admission clinic. The first line antibiotic of choice is usually Co-amoxiclav 250/125mg 8 hourly. Nitrofurantoin 50mg 6 hourly or Trimethoprim 200mg 12 hourly can be used for penicillin allergic patients, but it is important that Trimethoprim is not prescribed to patients taking Methotrexate and patients prescribed Nitrofurantoin should have U&Es checked & have an egfr of at least 60ml/min/1.73m 2. Available via Trust Docs Version: 2 Trust Docs ID: 10464 Page 3 of 14
A 5-day course of antibiotics is likely to be an effective treatment for a urinary tract infection in the majority of adult male and female patients undergoing joint replacement surgery 6. A fax should be sent to the patient s GP informing them that the patient has a symptomatic UTI with a positive test, treatment has been prescribed and an MSU sent. The dipstick result and name of the antibiotic given must be written on the microscopy request form, so that the results can be interpreted efficiently and the correct information sent to the GP. A second course of antibiotics, guided by the MSU result, should be prescribed by the GP if the patient remains symptomatic. Surgery can proceed once the patient is free of symptoms. Patients with persistent symptomatic UTIs after 2 courses of antibiotics should be reviewed by their GP, and if necessary, referred to the One-Stop Urology Clinic for further investigation. Surgery should be postponed until such investigations & any necessary treatment(s) are completed. In the event of a patient having an incurable UTI despite appropriate treatment & investigations, the surgery can potentially go ahead after discussion of risks with the patient and appropriate antibiotic cover planned with microbiology advice. Patients with UTI symptoms but negative tests may have a Candida infection, sexually transmitted infections or pelvic pathology. A fax should be sent to the patient s GP requesting assessment, treatment and referral to Urology, Gynaecology or GU medicine as appropriate. Broad recommendations Identification of patients with symptomatic urinary tract infections should occur at preassessment by the use of screening questions. Infection should be treated prior to elective orthopaedic surgery. Urinary tests in asymptomatic patients are no longer recommended. Urinalysis by dipstick tests and microscopy is used for those with symptoms as an aid to further management. Clinical audit standards / monitoring compliance To ensure that this document is compliant with the above standards, the following monitoring processes will be undertaken: 1. Cancellation on the day of surgery is reported by the departmental clinical governance process. The two audit standards are: A. No patient seen at pre-assessment with a symptomatic UTI should be left untreated. B. No symptomatic patient with a persistent UTI despite 2 courses of antibiotics and appropriate investigations is cancelled for that reason 2. Incidence of peri-prosthetic joint infection with possible urinary organisms. The audit results will be sent to the Governance Lead who will ensure that these are discussed at relevant governance meetings to review the results and make recommendations for further action. Summary of development and consultation process undertaken before registration and dissemination Available via Trust Docs Version: 2 Trustdocs ID No: 10464 Page 4 of 14
The authors listed above drafted this document on behalf of the hip and knee arthroplasty surgeons of the department of Trauma and Orthopaedics, who have agreed the final content. During its development it has been circulated for comment to: Trauma and Orthopaedic Consultants, Nurse Practitioners, Pharmacists, Consultant Microbiologist Dr Caroline Barker and Consultant Urologist Miss Sarah Wood. This version has been endorsed by the Clinical Guidelines Assessment Panel. Distribution list / dissemination method Trust Intranet References 1. Bouvet C, Lübbeke A, Bandi C, Pagani L, Stern R, Hoffmeyer P, Uçkay I. Is there any benefit in pre-operative urinary analysis before elective total joint replacement? Bone Joint J. 2014 Mar;96-B(3):390-4. 2. Parvizi J, Gehrke T, Chen AF. Proceedings of the International Consensus on Periprosthetic Joint Infection. Bone Joint J. 2013 Nov;95-B(11):1450-2. 3. Cordero-Ampuero J, González-Fernández E, Martínez-Vélez D, Esteban J. Are antibiotics necessary in hip arthroplasty with asymptomatic bacteriuria? Seeding risk with/without treatment. Clin Orthop Relat Res. 2013 Dec;471(12):3822-9. 4. Koulouvaris P, Sculco P, Finerty E, Sculco T, Sharrock NE.Relationship between perioperative urinary tract infection and deep infection after joint arthroplasty. Clin Orthop Relat Res. 2009 Jul;467(7):1859-67 5. Rajamanickam A, Noor S, Usmani A. Should an asymptomatic patient with an abnormal urinalysis (bacteriuria or pyuria) be treated with antibiotics prior to major joint replacement surgery? Cleve Clin J Med. 2007 Sep;74 Suppl 1:S17-8. 6. Milo G, Katchman E, Paul M, Christiaens T, Baerheim A, Leibovici L. Duration of antibacterial treatment for uncomplicated urinary tract infection in women. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD004682. 7. Nicolle LE, Zhanel GG, Harding GK. Microbiological outcomes in women with diabetes and untreated asymptomatic bacteriuria. World J Urol. 2006 Feb;24(1):61-5. Epub 2005 Dec 31. 8. Scottish Intercollegiate Guidelines Network (SIGN). Management of suspected bacterial urinary tract infection in adults. Edinburgh: SIGN; 2012. (SIGN publication no. 88). [July 2012]. Appendices I. GP letter for treatment given for UTI 2. GP letter for symptoms with negative dipstick and microscopy tests 3. GP letter for please give treatment for UTI Available via Trust Docs Version: 2 Trustdocs ID No: 10464 Page 5 of 14
Appendix I Dr VV Bowman Paston Surgery Paston Surgery 9-11 Park Lane North Walsham Norfolk NR28 0BQ Orthopaedic Pre-Operative Assessment East block Level2 Norfolk and University Hospital Colney Lane NR4 7UY dd/mm/yyyy Dear Dr. website: www.nnuh.nhs.uk direct dial: 01603 286499 direct fax: : 01603 287 557 RE: Mrs AA DOB: 22/02/1941 Address: Norfolk Hospital No: 1111111 NHS No: 0000000000 Consultant: I am writing to request your kind assistance with this patient who attended the Orthopaedic Pre-Assessment Clinic on dd/mm/yyyy. The patient s symptoms and dipstick result suggest a urinary tract infection. We have provided the patient with a 5-day course of trimethoprim / amoxicillin / named antibiotic. We have also sent a MSU sample for microscopy to guide further management if symptoms persist. We will send MSU results by fax directly to you. If symptoms resolve, I would be grateful if you would let us know, or ask the patient to let us know. If this is the case, we do not now require any further tests prior to joint replacement surgery. We can then confirm the planned admission date with the patient. If symptoms persist, please arrange for dipstick testing and microscopy and treat for a persistent urinary tract infection with a second 5-day course of an appropriate antibiotic. If the UTI symptoms persist despite two courses of antibiotics, please consider referring the patient to Urology for further investigation and treatment. Once urological investigations and treatment are complete we can then carry out the patient s Orthopaedic operation, if necessary even in the presence of an incurable UTI. Many thanks for your help with this matter. Please do not hesitate to contact us if we can help in any way. With best wishes, yours sincerely, Orthopaedic Nurse Practitioner Available via Trust Docs Version: 2 Trustdocs ID No: 10464 Page 6 of 14
Pre-Op Date: Name: D.O.B: dd/mm/yyyy TCI Date: dd/mm/yyyy Hosp No: NHS No: Sex: Consultant: Surgery: Date/Time dd/mm/yyyy hh:mm Problem Identified Signature Actions Taken Outcome Available via Trust Docs Version: 2 Trustdocs ID No: 10464 Page 7 of 14
FAX MESSAGE Orthopaedic pre-operative assessment Level2 East block Norfolk and University Hospital Bethel Street NR2 1NR Colney Lane NR4 7UY direct dial: 01603 286499 direct fax: 01603287557 Fax Number: From: Date: dd/mm/yyyy Number of Pages: Dr GP e-mail: nnuh.nhs.uk website: www.nnuh.nhs.uk To The material contained within this facsimile message is CONFIDENTIAL. If you are not the intended recipient, please contact the sender immediately on 01603 286499. If you do not receive all the pages or they are illegible please contact the sender on: 01603 286499 Available via Trust Docs Version: 2 Trustdocs ID No: 10464 Page 8 of 14
Appendix 2 Dr VV Bowman Paston Surgery Paston Surgery 9-11 Park Lane North Walsham Norfolk NR28 0BQ Orthopaedic Pre-Operative Assessment East block Level2 Norfolk and University Hospital Colney Lane NR4 7UY Dd/mm/yyyy Dear Dr. website: www.nnuh.nhs.uk direct dial: 01603 286499 direct fax: : 01603 287 557 RE: Mrs AA DOB: 22/02/1941 Address: Norfolk Hospital No: 1111111 NHS No: 0000000000 Consultant: I am writing to request your kind assistance with this patient. This patient attended the Orthopaedic Pre-Assessment Clinic on dd/mm/yyyy. They had symptoms suggesting a possible urinary tract infection but dipstick and microscopy tests were negative. The patient may develop an obvious urinary tract infection and our recommendation would be that this is treated with a 5 day course of an appropriate antibiotic. If this is not the case and symptoms persist, I would be very grateful if you were able to assess the patient for possible other causes such as Candida infection, sexually transmitted infection or pelvic pathology. Please consider referring the patient as necessary to Urology, GU medicine or Gynaecology for further investigation and treatment if you feel this is appropriate. Once investigations and treatment are complete we are then able to carry out the patient s Orthopaedic operation. If symptoms resolve spontaneously, I would be very grateful if you would let us know, or ask the patient to let us know. If this is the case, we do not now require any further tests prior to joint replacement surgery. We can then confirm the planned admission date with the patient directly. Many thanks for your help with this matter. Please do not hesitate to contact us if we can help in any way. Best wishes, Yours sincerely, Orthopaedic Nurse Practitioner Available via Trust Docs Version: 2 Trustdocs ID No: 10464 Page 9 of 14
Pre-Op Date: Name: D.O.B: dd/mm/yyyy Hosp No: TCI Date: dd/mm/yyyy NHS No: Sex: Consultant: Surgery: Date/Time dd/mm/yyyy hh:mm Problem Identified Signature Actions Taken Outcome Available via Trust Docs Version: 2 Trustdocs ID No: 10464 Page 10 of 14
FAX MESSAGE Orthopaedic pre-operative assessment Level2 East block Norfolk and University Hospital Bethel Street NR2 1NR Colney Lane NR4 7UY direct dial: 01603 286499 direct fax: 01603287557 e-mail: nnuh.nhs.uk website: www.nnuh.nhs.uk Fax Number From: Date: dd/mm/yyyy Number of Pages: Dr GP To The material contained within this facsimile message is CONFIDENTIAL. If you are not the intended recipient, please contact the sender immediately on 01603 286499. If you do not receive all the pages or they are illegible please contact the sender on: 01603 286499 Available via Trust Docs Version: 2 Trustdocs ID No: 10464 Page 11 of 14
Appendix 3 Dr VV Bowman Paston Surgery Paston Surgery 9-11 Park Lane North Walsham Norfolk NR28 0BQ Orthopaedic Pre-Operative Assessment East block Level2 Norfolk and University Hospital Colney Lane NR4 7UY dd/mm/yyyy Dear Dr. website: www.nnuh.nhs.uk direct dial: 01603 286499 direct fax: : 01603 287 557 RE: Mrs AA DOB: 22/02/1941 Address: Norfolk Hospital No: 1111111 NHS No: 0000000000 Consultant: I am writing to request your kind assistance with this patient who attended the Orthopaedic Pre-Assessment Clinic on dd/mm/yyyy. Their MSU result shows a urinary tract infection, as per the attached result. If the patient has completed a course of antibiotics and symptoms have resolved, we do not now recommend any further tests prior to joint replacement surgery. I would be very grateful if you were able to let us know, or ask the patient to let us know if this is the case. We can then confirm the planned admission date. If this is not the case, please treat the patient s infection with a 5-day course of an appropriate antibiotic. If symptoms persist, please arrange for dipstick testing and microscopy and treat for a persistent urinary tract infection with a second 5-day course of an appropriate antibiotic. If symptoms persist despite two courses of antibiotics, please consider referring the patient to Urology for further investigation and treatment. Once urological investigations and treatment are complete, we can carry out the patient s Orthopaedic operation, if necessary even in the presence of an incurable urinary tract infection. Many thanks for your help with this matter. Please do not hesitate to contact us if we can help in any way. Yours sincerely, Orthopaedic Nurse Practitioner Available via Trust Docs Version: 2 Trustdocs ID No: 10464 Page 12 of 14
Pre-Op Date: Name: D.O.B: dd/mm/yyyy TCI Date: dd/mm/yyyy Hosp No: NHS No: Sex: Consultant: Surgery: Date/Time dd/mm/yyyy hh:mm Problem Identified Signature Actions Taken Outcome Available via Trust Docs Version: 2 Trustdocs ID No: 10464 Page 13 of 14
FAX MESSAGE Orthopaedic pre-operative assessment Level2 East block Norfolk and University Hospital Bethel Street NR2 1NR Colney Lane NR4 7UY direct dial: 01603 286499 direct fax: 01603287557 e-mail: nnuh.nhs.uk website: www.nnuh.nhs.uk Fax Number From: Date: dd/mm/yyyy Number of Pages: Dr GP To The material contained within this facsimile message is CONFIDENTIAL. If you are not the intended recipient, please contact the sender immediately on 01603 286499. If you do not receive all the pages or they are illegible please contact the sender on: 01603 286499 Available via Trust Docs Version: 2 Trustdocs ID No: 10464 Page 14 of 14