using a Uricult dip-slide system (Orion Diagnostica Oy,. Espoo, Finland). A urinary specimen for urinary status analysis was regarded as positive if there was ...
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Geriatr Gerontol Int 2017
O R I G I N A L A R T I C L E : E P I D E M I O L O G Y, C L I N I C A L P R A C T I C E A N D H E A LT H
Urinary tract infection in patients with hip fracture: An underestimated event? Christopher Bliemel, Benjamin Buecking, Juliana Hack, Rene Aigner, Daphne-Asimenia Eschbach, Steffen Ruchholtz and Ludwig Oberkircher 1
Center for Orthopedics and Trauma Surgery, University Hospital Marburg, Marburg, Germany
Aim: Urinary tract infections (UTI) represent a common perioperative complication among elderly patients with hip fracture. To determine the impact of UTI on the perioperative course of elderly patients with hip fractures, a prospective study was carried out. Methods: A total of 402 surgically-treated geriatric hip fracture patients were consecutively enrolled at a level 1 trauma center. On admission, all patients received an indwelling urinary catheter. Clinically symptomatic patients were screened more closely for UTI. Patients diagnosed with UTI were compared with asymptomatic patients. Outcomes in both patient groups were measured using in-hospital mortality, overall length of hospital stay, wound infection, functional results and mobility at discharge. Multivariate regression analysis was carried out to control for influencing factors. Results: A total of 97 patients (24%) sustained a UTI during in-hospital treatment. UTI were independently associated with inferior functional outcomes as assessed by the Barthel Index (β = 0.091; P = 0.031), Timed Up and Go test (β = 0.364; P = 0.001) and Tinetti test (β = 0.169; P = 0.001) at discharge. Additionally, length of hospital stay was significantly longer for patients with a UTI diagnosis (β = 0.123; P = 0.029) after controlling for all other variables. No differences were observed in the rate of wound infection (odds ratio 1.185; P = 0.898) or in-hospital mortality (P < 0.997). Conclusions: Patients with UTI seem to be at risk of inferior functional outcomes. In addition to an early detection of symptomatic UTI and a targeted antibiotic therapy, perioperative care should focus on preserving functional ability to protect these patients from further loss of independence and prolonged clinical courses. Geriatr Gerontol Int 2017; ••: ••–••. Keywords: hip fracture, length of hospital stay, mobility, mortality, urinary tract infection.
Introduction Elderly patients who have sustained a hip fracture represent a highly vulnerable population, with complication rates ranging from 7% to 40% during inpatient treatment.1,2 To prevent these patients from acquiring secondary damages, such as pressure sores or pulmonary infection, immediate full weight-bearing mobilization is targeted. Nevertheless, mobilization often remains difficult, because of these patients’ pre-existing comorbidities and unsteadiness of gait.3 The perioperative use of indwelling urinary catheters has become routine practice in orthopedic and trauma surgery wards to enable Accepted for publication 8 March 2017. Correspondence: Dr Christopher Bliemel MD, Center for Orthopaedics and Trauma Surgery, University Hospital Marburg, Baldingerstrasse, 35043 Marburg, Germany. Email: bliemel@med. uni-marburg.de
© 2017 Japan Geriatrics Society
improved care of these immobile patients.4 Nevertheless, the benefits of indwelling catheters in the postoperative period are reduced by the substantial risk of urinary tract infection (UTI) accrued in direct relationship to the duration of catheterization. Specifically, the rate of UTI is estimated to increase 3–10% each day that the catheter is left beyond the first 48 h of catheterization.5,6 Although UTI represent one of the most common postoperative complications in many fields of surgery, less attention is paid to this complication compared with, for instance, postoperative wound infections, pneumonia, bleeding, ileus or delirium.7–9 Hence, little is known about the impact of UTI on the perioperative course of patients with hip fractures. Following this, UTI might be an underestimated event. Nevertheless, a better understanding of its influence on the perioperative course of this vulnerable patient population is urgently required, especially in terms of its effect on associated wound infections, and overall morbidity and mortality. This knowledge would help optimize the care of affected
doi: 10.1111/ggi.13077
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patients, and would provide important prognostic information for both clinicians and patients. To determine the effect of UTI on the perioperative course of elderly patients with hip fractures, we carried out a study including more than 400 patients. We hypothesized that the occurrence of UTI would be associated with higher rates of wound infection, and higher morbidity and mortality.
preferred.10 When selecting a suitable antibiotic, several criteria were taken into account, such as,. patient’s individual risk including known allergic reactions against certain antibiotics, the spectrum of pathogens and its antibiotic sensitivity, the individual effectivity of the antimicrobial substance, eventual adverse drug effects, and possible effects on the individual resistance situation of a patient (collateral damage).
Methods
Surgical procedure
The present prospective, observational cohort study included 402 consecutive patients aged ≥60 years with hip fractures who were admitted to a single level 1 trauma center. Patients were only included in this study if they had not sustained a hip fracture as a result of polytrauma (Injury Severity Score ≥16) or a malignancy-related fracture. The recruitment period ranged from 1 April 2009 to 30 September 2011. The local ethics committee approved this study (AZ 175/08). All patients or their legal representatives provided written informed consent for participation. Trained study staff (physicians and study nurses) recorded the patients’ sociodemographic data (e.g. age, sex and pre-fracture residential status), type of fracture, American Society of Anesthesiologists (ASA) score, pre-fracture Charlson Comorbidity Index (CCI), pre-fracture Barthel Index (BI) and Mini-Mental State Examination (MMSE) score at hospital admission. Additionally, pre-existing comorbidities were documented.
Indwelling urinary catheter management and detection of UTI All patients received an indwelling urinary catheter at the time of hospital admission to receive better care during the perioperative phase. Indwelling urinary catheters were removed when the patients were mobile enough to use the toilet again, at least with the support of the nursing staff. Patients presenting with clinical signs of UTI, such as characteristic odor, pain or burning while urinating, but also with more diffuse symptoms, such as increased inflammation values and a lack of well-being including fatigue, fever and weakness, were screened more closely by analyzing a urinary specimen for urinary status and/or using a Uricult dip-slide system (Orion Diagnostica Oy, Espoo, Finland). A urinary specimen for urinary status analysis was regarded as positive if there was proof of leucocytes and nitrite. A urine culture was regarded as positive in the Uricult dip-slide system if bacteriuria was greater than 105 CFU/mL, respectively.
Treatment of UTI In the case of pathogen detection, antibiotic therapy was commenced as soon as possible. In accordance with national guidelines, oral antibiotic therapy was 2
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Surgical fixation was carried out within the first 48 h after the fracture, using a prosthetic replacement for intracapsular fractures or internal fixation for extracapsular fractures. To account for possible postoperative wound infections, patients received intraoperative single-shot antibiotic prophylaxis. According to standard operating procedures, a secondgeneration cephalosporin (cefuroxime) was administered. In the case of known allergic reactions to cefuroxime, clindamycin – a lincosamide antibiotic – was administered.
Outcome parameters The frequency of UTI, in-hospital mortality rate and the occurrence of wound infection were documented. A wound infection was diagnosed in the synopsis of clinical, laboratory and sonographic examinations with an additional exclusion of other infectious foci at the same time. As clinical signs of wound infection, redness, swelling, hyperthermia, local pain and persistent wound secretion were assessed. As systemic markers of inflammation, which can also indicate a wound infection, increased leukocyte values as well as increased values of C-reactive protein were considered, especially if these parameters did not gradually decline over the postoperative period and other infectious foci could be excluded. If the above mentioned values suggested a wound infection, in addition a sonographic examination of the hip was carried out to detect an existing seroma/hematoma as further proof of a wound infection. Patients’ functional results were monitored using the BI at discharge. Mobility at discharge was assessed using the Timed Up and Go test (TUG) and Tinetti test (TT). Furthermore, the patients’ overall length of hospital stay was documented.
Statistical analysis Data were collected using a FileMaker database (FileMaker, Santa Clara, CA, USA). Double entry with a plausibility check was carried out to ensure data quality. IBM SPSS 22 (IBM, Armonk, NY, USA) was used for the data analysis. The data are presented as the means, medians, standard deviations and ranges. Continuous variables, such as age, ASA score, CCI and BI, were examined using the Mann–Whitney test according to the © 2017 Japan Geriatrics Society
Urinary tract infection in patients with hip fracture
results of the Shapiro–Wilk test for normal distribution. Fisher’s exact test was carried out to compare categorical variables, such as sex distribution, mortality rate, pre-existing comorbidities and the occurrence of wound infections, between the patient groups. To determine the distribution of the different fracture types, χ 2-tests were carried out. Significance was defined as P < 0.05 for all tests. Finally, multivariate linear regression analysis with backward selection was carried out to assess the influence of UTI on functional outcome parameters (BI, TUG, TT), wound infection and in-hospital mortality. This analysis included the following covariates that are known to influence patient outcomes after hip fracture: age, sex, pre-fracture BI and CCI, ASA score, hemoglobin value at admission, time between admission and surgery, duration of surgery, type of surgical treatment (internal fixation vs prosthesis), pre-existing dementia, and depression.
Results Overall, 402 hip fracture patients were included in the present study. A total of 97 patients (24%) sustained a UTI during in-hospital treatment. The baseline characteristics of all patients are shown in Table 1. Compared with male patients, significantly more female patients were affected by a UTI (13% vs 28%; P = 0.001). No significant differences occurred in age (P = 0.120), fracture localization (P = 0.599), ASA score (P = 0.500),
pre-fracture BI (P = 0.052), pre-fracture CCI (P = 0.897), MMSE score (P = 0.057) or pre-fracture residential status (P = 0.210; Table 1). Of the pre-existing comorbidities on admission to the hospital, significantly higher rates of UTI were observed in patients with a diagnosis of Parkinson’s disease (P = 0.025). Cardiovascular disease (P = 0.873), diabetes mellitus (P = 0.145) and dementia (P = 0.387) showed no significant correlations with the occurrence of UTI in hip fracture patients (Table 2). In 90 patients (93%), a urinary status analysis was carried out, and in 62 patients (64%), the Uricult dip-slide system was used for further pathogen detection. The specific urinary analysis for pathogenic germs showed that the bacterial spectrum was predominantly Gram-negative (72%), with 21% Gram-positive bacteria and urinary yeast infection in approximately 6% (Fig. 1). The bivariate statistical analysis showed significantly worse functional outcomes in patients with a diagnosis of UTI, as shown by the results of the BI (P < 0.003), the TUG (P < 0.002) test and the TT (P < 0.001) at discharge (Table 3). Furthermore, the mean length of hospital stay of patients with a diagnosis of UTI was significantly longer than that of patients without a diagnosis of UTI (15 ± 6 vs 12 ± 6 days; P < 0.018). Regarding the rate of perioperative wound infection, no significant differences were observed (P = 1.000; Table 3). None of the patients diagnosed with UTI died during inpatient treatment, whereas in the group of patients without a UTI diagnosis, 25 patients died
Table 1 Baseline data for patients included in the study
Age, years (mean ± SD) Sex Male Female Fracture location Femoral neck Trochanteric Subtrochanteric ASA score (mean ± SD) Pre-fracture BI (mean ± SD) Pre-fracture CCI (mean ± SD) MMSE score (mean ± SD) Pre-fracture residential status Communitydwelling Living in a nursing home
Whole study population (n = 402)
Patients with UTI (n = 97)
Patients without UTI (n = 305)
81 ± 8
82 ± 8
81 ± 8
P = 0.120*
109 (27%) 293 (73%)
14 (13%) 83 (28%)
95 (87%) 210 (72%)
P = 0.001**
195 (49%) 186 (46%) 21 (5%) 2.9 ± 0.6 80 ± 25
46 (24%) 44 (24%) 7 (33%) 2.9 ± 0.5 76 ± 24
149 (76%) 142 (76%) 14 (67%) 2.9 ± 0.6 81 ± 25
P = 0.599*** P = 0.500* P = 0.052*
2.4 ± 2.3
2.1 ± 1.7
2.5 ± 2.5
P = 0.897*
20 ± 9.1
19 ± 10
21 ± 9
P = 0.057*
336 (84%)
77 (23%)
259 (77%)
66 (16%)
20 (33%)
46 (67%)
P-value
P = 0.210**
*Mann–Whitney test; **Fisher’s exact test; ***χ2-test. ASA, American Society of Anesthesiologists; BI, Barthel Index; CCI, Charlson Comorbidity Index; SD, standard deviation; UTI, urinary tract infection. © 2017 Japan Geriatrics Society
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Table 2 Association of pre-existing comorbidities with urinary tract infection in patients with hip fractures Patients with UTI
Patients without UTI
P-value
81 (24%) 36 (27%) 31 (30%) 9 (47%)
258 (76%) 97 (73%) 74 (71%) 10 (53%)
P = 0.873* P = 0.387* P = 0.145* P = 0.025*
Cardiovascular disease Dementia Diabetes mellitus Parkinson’s disease *Fisher’s exact test. UTI, urinary tract infection.
Figure 1 Spectrum of pathogens detected in patients diagnosed with urinary tract infection. Gram-positive germs are marked with dots, Gram-negative germs are marked with lines and fungal infection agents are marked with small boxes.
Table 3 Functional outcome parameters, length of hospital stay, and complication and mortality rate
Barthel Index at discharge (mean ± SD) TUG at discharge, s (mean ± SD) TT at discharge (mean ± SD) Length of hospital stay (mean ± SD) Rate of wound infection In-hospital mortality rate
Patients with UTI
Patients without UTI
P-value
41 ± 25 75 ± 79 7±6 15 ± 6 6 0
51 ± 29 32 ± 24 10 ± 9 13 ± 6 1 25
P < 0.003* P < 0.002* P < 0.001* P < 0.018* P = 1.000* P < 0.001*
*Multiple regression analysis. SD, standard deviation; UTI, urinary tract infection.
during their hospital stay. Reasons for death were related to the cardiovascular system in 10 patients and to insufficiency of the kidneys in five patients, with all of them suffering from acute renal failure. In four patients, death was due to insufficiency of the respiratory tract, twice each due to liver failure, sepsis and multiorgan failure. This difference in in-hospital mortality rate between groups was statistically significant in the univariate analysis (P < 0.001; Table 3). 4
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To further analyze the effects of UTI on functional outcomes, length of hospital stay, complication and mortality rate, a multivariate regression analysis adjusting for the aforementioned influencing factors was carried out. Additionally, in the multivariate regression analysis, significant differences were observed in BI at discharge (R2 = 0.541, β = 0.091, P < 0.031), TUG at discharge (R2 = 0.446, β = 0.364, P < 0.001), TT at discharge (R2 = 0.405, β = 0.169, P < 0.001) © 2017 Japan Geriatrics Society
Urinary tract infection in patients with hip fracture
and length of hospital stay (R2 = 0.121, β = 0.123, P < 0.029). However, no differences were observed in the multivariate regression analysis for the in-hospital mortality rate (R2 = 0.289, OR not available, P = 0.997) or the rate of wound infection (R2 = 0.388, OR 1.185, P = 0.898; Table 4).
Discussion The aim of the current study was to analyze the impact of UTI on the rate of complications and early functional outcomes at the end of in-hospital treatment among geriatric patients with hip fractures. UTI was associated with an increased length of hospital stay and an increased risk of inferior functional outcomes, as shown by the reduced BI, TUG and TT values at discharge. UTI was not associated with an increased rate of wound infection or an increased in-hospital mortality rate. UTI represent one of the most common bacterial infections in elderly patients with hip fractures.11 Causes for UTI in hip fracture patients are manifold, including postoperative urinary retention12 or neurogenic bladder dysfunction. As Schumm and Lam could show, even the use of indwelling urinary catheters leads to UTI in a considerable number of cases.13 In terms of its clinical appearance, UTI can be divided into symptomatic UTI and asymptomatic bacteriuria. In accordance with current literature on hip surgery,14 asymptomatic colonization of the lower urinary tract was not determined among patients included into the present study. Nevertheless, patients with clinical symptoms were more closely screened. With UTI occurring in almost one-quarter of all patients, it was the most common complication in our observational study. UTI were diagnosed predominantly in female patients, with Escherichia coli being the most common pathogen. These results are in line with several preexisting studies reporting on UTI in hip fracture patients.15–17 Although Hälleberg Nyman et al. showed that diabetes was a risk factor for UTI, the results of the present study failed to support this finding. These conflicting results
might be related to the much smaller percentage of patients diagnosed with diabetes in the population studied by Hälleberg Nyman et al. (9/86 patients, 11%) compared with our own study (105/402 patients, 26%). Despite this difference in diabetes, the present results are consistent with the findings of Hälleberg Nyman et al., who determined that pre-existing coronary disease was not associated with UTI.16 Having carried out a randomized controlled trial, Stenvall et al. could show that hip fracture patients with an additional diagnosis of dementia benefit from a multidisciplinary geriatric assessment as determined by a significantly reduced number of UTI.18 Even though there was no multidisciplinary treatment in the present study, no differences were observed in the rate of UTI between hip fracture patients with and without a diagnosis of dementia. Patients with lower urinary tract dysfunction, such as neurogenic bladder dysfunction, are more likely to develop asymptomatic pyuria, bacteriuria and symptomatic UTI. In this context Zarowitz et al. could show among more than 175 000 nursing facility residents that an overactive bladder, which is a quite common comorbidity (1%) amongst elderly patients, and additionally presents with similar symptoms to those of UTI, was significantly associated with hip fractures.19 Among the comorbidities assessed in the present study, neurogenic bladder dysfunction was not explicitly recorded during the hospital stay. However, Parkinson’s disease was recorded, which itself is a common cause for the development of an acquired neurogenic bladder dysfunction. Furthermore Parkinson’s disease was the only pre-existing condition that was significantly associated with UTI in the present patient population. Similar results have been published by Weber et al., who reported elevated rates of UTI after total hip arthroplasty in Parkinson’s disease patients.20 These increased rates of UTI after hip fracture might be explained by Parkinson’s disease-related bladder dysfunction as a result of postmicturitional residual urine.21 The delayed mobilization of these patients might have additional negative effects on independent urine control and toilet use, potentially prolonging the use of urinary catheters.
Table 4 Multivariate analysis of outcome parameters.
Barthel Index at discharge TUG at discharge TT at discharge Length of hospital stay Rate of wound infection In-hospital mortality rate
R2
B
β
CI of B
P-value
0.541 0.446 0.405 0.121 0.388 0.289
–5.758 33.413 –3.387 1.705 0.169 –18.074
–0.091 0.364 –0.169 0.123 OR 1.185 OR NA
–10.979 to 0.538 20.863 to 45.964 –5.283 to 1.491 0.172 to 3.283 0.089 to 1.5678 NA
P = 0.031* P = 0.001* P = 0.001* P = 0.029* P = 0.898* P < 0.997*
The matched variables of influence were patient age, sex, pre-fracture Barthel Index and Charlson Comorbidity Index, American Society of Anesthesiologists score, hemoglobin value at admission, time between admission and surgery, duration of surgery, type of surgical treatment (internal fixation vs prosthesis), pre-existing dementia, and depression. *Multiple regression analysis. β, standardized regression coefficient; B, unstandardized regression coefficient; CI, confidence interval; NA, not available; R2, adjusted R2; TT, Tinetti test; TUG, Timed Up and Go test. © 2017 Japan Geriatrics Society
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Furthermore, the results of the present study showed that UTI was independently associated with inferior mobility outcomes, not only for patients with Parkinson’s disease, but also in general for patients sustaining a hip fracture. This decrease in mobility was indicated by reduced values for TUG and TTat discharge, as well as in activities of daily living, represented by lower values of BI at discharge. The inferior mobility results remained evident after adjusting for common risk factors, such as hemoglobin value at admission,22 time between admission and surgery,23 duration of surgery,24 type of surgical treatment,25 pre-existing dementia,26 and depression.27 In addition to the reduced mobility, UTI also had a significant impact on patients’ length of hospital stay, with affected patients having a later discharge. In this context, shorter length of hospital stay for non-UTI patients might have been influenced by the fact that in this group, 25 patients have died during their treatment in the acute care hospital. Regarding this question, the present data showed that even if those 25 patients were excluded from the analysis, the remaining 280 non-UTI patients also had significantly shorter length of hospital stays as compared with the 97 UTI patients (13.5 vs 14.8 days; P = 0.038). Similar results have been published by Hedström et al., who found additionally increased ASA scores in UTI patients. Therefore, they concluded that the prolonged hospital stay of these patients was more due to their underlying disease than to the UTI for which they were treated.15 In the present study, patients with and without UTI had similar ASA scores, and the increased length of hospital stay could therefore be attributed to the UTI. Kamel et al. supported these findings in their publication on an observational study that was retrospectively carried out at a university hospital. In their study with 138 patients, participants with a UTI diagnosis had a significantly longer mean length of hospital stay than the unaffected patients.28 Interestingly, according to the results of the present study, UTI diagnosis did not affect the rate of perioperative wound infection nor the rate of in-hospital mortality. Contrary to these findings, a descriptive case series of 84 postmenopausal women carried out by Ashraf and Umer reported a high occurrence of wound infection in hip fracture patients with a UTI.29 These different findings could certainly be related to the nearly 10-fold higher rate of wound infection in their study (16.7%) compared with the present study (1.7%). This tremendously high rate of wound infection can be assumed to be related to the fact that Ashraf and Umer carried out their study in a developing country with estimated reduced hygienic standards. Other studies reporting on postoperative infections in hip fracture patients failed to show an association between wound infection and UTI, and therefore support the findings of the present study.30,31 After analyzing the comorbidities, complications and causes of death among 199 people with fractured neck of 6
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femur in a prospectively enrolled study, Berggren et al. failed to show that UTI was associated with an increased mortality rate.32 Furthermore, Ishidou et al. were unable to find a relationship between UTI and mortality in a prospectively conducted multicenter study that included 387 patients.33 Therefore, the current literature supports the present findings in terms of the lack of evidence for a relationship between UTI and in-hospital mortality in hip fracture patients. Despite the thorough study design, the results should be interpreted within the context of certain limitations. First, the results are from an observational study, and thus conclusions cannot be drawn in terms of causality, and the relationships described can only be interpreted as associations. The present study examined and followed 402 prospectively enrolled patients with hip fractures, making it a large study compared with other single-center studies reporting on this topic.16,34 Second, patients were only screened for UTI if they presented with typical clinical signs. However, there is a lack of association between bacteriuria and UTI symptoms, and therefore some patients with UTI might have been undetected.35 Nevertheless, the value of implementing general urinary screening of patients is questionable, as according to a recent Cochrane review, treating asymptomatic bacteriuria in elderly patients provides no clinical benefit, but does result in significantly more adverse events.36
Acknowledgements The authors acknowledge Lutz Waschnick, Natalie Schubert, Anna Waldermann, Kristin Horstmann, Anne Hemesath and Anke Thomas for their contributions to the acquisition of data.
Disclosure statement The authors declare no conflict of interest.
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