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Please note that information on this site was NOT authored by Dr. Frederic A Matsen III and has not been proofread or intended for general public use. Information was intended for internal use only and is a compilation for random notes and resources.
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Da Book
Standard Operating Procedures and Notes for the Shoulder Team
UA Standard Operating Procedure (SOP)
Our team is concerned about the possibility of UTIs in the setting of surgery, particularly with arthroplasties.
What's the big deal with the UAs? There is always the possibility that bacteria in the urinary tract can seed itself in the joint leading to a significant infection. This is rare, but we have seen shoulder infections from urinary tract bugs. UTIs are comon in many of our female patients and will probably clear after a week of ABx treatment. Some will not clear thier UTIs and will need to be worked up by a urologist prior to surgery. Causes of recurrent UTIs include urine acidity, stones, urinary stasis or retention, insuseption of ureter, immunologic and mucosal barriers, and other anatomical problems. These issues will only be temporarily resolved with ABx, and the patient and surgical team will be facing a lifelong increased risk of joint infection unless the cause of there UTIs are definitively addressed prior to their arthroplasty.
All Matsen patients and all arthroplasty patients will need a clean catch UA with C+S prior to surgery. This should be done within a month of surgery and done early enough to treat an UTI for 7 days followed by 14 days of no ABx use prior to surgery. Because many of our patients are from out of town or even out of state, they will have their labs done outside of the UW system. The shoulder PA and shoulder nurse should have their lab information. Labs should also be in their Yellow preop packet filed by the PCC.
Someone needs to explain to the pt how to do a clean catch UA. If a nurse is not available to do this, it will need to be done by the physician or PA seeing the patient. Significant points include:
- Uncircumcised males need to retract foreskin and cleanse glans penis
- Females need to cleanse the perineum and keep labia separated during voiding
- Midstream sample give you the best chance at an uncontaminated specimen
- Patients don't need to fill the bottle all the way (telling this will increase the chance of getting a midstream sample)
A positive UA consists of any of the following:
- Symptoms of frequency, urgency or dysuria, with or without fever, cloudy or foul smelling urine or gross hematuria
- Leukocyte Esterase Positive (75-96% sensitive, 94-98% specific) without an unremarkable culture
- Nitrite Positive (35-85% sensitive, 92-100% specific)
- Microscopy 5+ WBC/hpf spun clean catch urine sample
- Colony Count >50,000
- Colony Count of >10,000 with less than 3 bugs with one being E coli or Staph
Patients that have colony counts of > 3 bugs most likely have a contaminated UA and will need a straight catheter UA done.
All Female UTIs must be treated prior to surgery and require a negative UA following completion of treatment and prior to surgery.
Our treatment protocol is generally Cipro 500 mg PO bid x 7 days
After treatment, patients will need a repeat and clear UA - questionable repeat UAs will require a urology consult.
Note: even though many practice guidelines recommend treatment courses of less than 7 days, even as low as a single dose treatment, the standard of care for females is 7 days for uncomplicated UTIs and 14 days for complicated UTIs (febrile, flank/back pain, etc.)
All Males with UTIs need to be worked up by a urologist, treated, have a letter of clearance by a urologist and demonstrate a clean UA prior to surgery
Note: We don't treat male UTIs - we send them to get worked up and get clearance
The standard of care for epididymitis - 21 days of ABx treatment
The standard of care for prostitis - 28 dyas of ABx treatment
Pathogenic bugs:
Uncomplicated UTIs:
Escherichia coli (80%)
Staphylococcus saprophyticus (10-15%)
Klebsiella pneumoniae
Proteus mirabilis
Enterococcus faecalis
Complicated UTIs:
Escherichia coli
Klebsiella spp
Enterobacter cloacae
Serratia marcescens
Pseudomonas aeruginosa
Enterococcus faecalis
Group B streptococci
Patients scheduled for soft tissue repairs may proceed with surgery if started on ABx treatment prior to surgery on a case by case basis.
Patients will severe joint problems that really need a joint replacement in conjunction with chronic urinary problems may potentially proceed with surgery after assessment of risk versus benefits by the attending, work-up by urologist, and a face to face talk with the patient and attending to include need for life long prophylactic ABx use. This is an attending issue.
"One Stop Shop"
"One Stop Shops" are folks that fly/drive in from far away places to get their surgeries done. Because of travel factors, we allow them to be seen on Monday prior to surgery and may be scheduled for surgery the following day. Since there is no time to treat a UTI if found the evening prior to surgery, all One Stoppers will need a UA completed three weeks prior to surgery, which can be done by their family practice provider. This gives us one week to treat with antibiotics without cutting into our "2 weeks of no antibiotics prior to arthroplasty" rule. Those not getting a UA three weeks prior to surgery are subject to cancellation.
We are planning in-house UA dips for one stop shoppers. More to follow.