JAMA Surgery: Preoperative Surgical Screening for Asymptomatic Bacteriuria is Not Beneficial

April 2, 2020

Takeaway: This study – the largest and most robust to date – provides strong evidence that pre-operative screening of asymptomatic patients is of little value and should be discontinued as routine clinical practice. Findings support the approach of “Don’t Test and Don’t Treat” the urine in asymptomatic pre-operative patients. Several VA facilities will participate in an HSR&D trial developing a de-implementation strategy.

Previous studies suggest that asymptomatic bacteriuria (ASB) is a risk marker for post-operative adverse events, such as surgical-site infection (SSI) and urinary tract infection (UTI). However, strong evidence of improved clinical outcomes was lacking for pre-operative screening for bacteria in the urine and treatment with antibiotics if found to be positive. This study sought to measure the association between ASB and key post-operative infectious outcomes, including SSI and UTI, and determine if directed antimicrobial therapy was associated with reduced rates of infection after major surgical procedures. To address the effectiveness of screening and treatment, investigators identified 68,265 Veterans who underwent cardiac, orthopedic, or vascular surgical procedures at 109 VA facilities from October 1, 2008, to September 30, 2013. Findings show:

• Routine screening of pre-operative urine cultures before major cardiac, orthopedic, and vascular surgical procedures was a low-yield clinical practice. ASB was identified in 4% of urine cultures, and after adjustments for other factors associated with postoperative infections (i.e., age, physical status, smoking status, demographics, and diabetes status); Veterans with or without ASB had similar chances of surgical site infection (2.4% vs 1.6%).
• Antibiotic treatment of asymptomatic patients with ASB did not lead to improvement in any measurable post-operative clinical outcome. The incidence of SSI, UTI, and positive wound and urine culture results were the same in patients who were treated as in those who were untreated.

Findings will be implemented through an HSR&D study, and several VA facilities will participate in developing a de-implementation strategy which will be piloted in a randomized controlled trial.

CITATION: Salazar J, O’Brien W, Strymish J, Itani K, Branch-Elliman W, and Gupta K. Association of screening and treatment for preoperative asymptomatic bacteriuria with postoperative outcomes among US Veterans. JAMA Surgery. March 2019;154(3):241-248.