New Antibiotic policy on anvil

The available evidence is insufficient to recommend routine antibiotics for dental procedures in persons with joint replacement, according to a new clinical practice guideline from the American Academy of Orthopaedic Surgeons (AAOS) and the American Dental Association (ADA). This guideline, titled "Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures," replaces the previous AAOS Information Statement, "Antibiotic Prophylaxis for Bacteremia in Patients with Joint Replacement."

A collaborative systematic review of the correlation between dental procedures and prosthetic joint infection (PJI) found no direct evidence of a causal link.

"It has been long debated that patients with orthopaedic implants, primarily hip and knee replacements, are prone to implant infections from routine dental procedures," David Jevsevar, MD, MBA, chair of the AAOS Evidence Based Practice Committee, said in a news release. "What we found in this analysis is that there is no conclusive evidence that demonstrates a need to routinely administer antibiotics to patients with an orthopaedic implant, who undergo dental procedures."

In the United States, patients underwent a total of more than 302,000 hip replacements and 658,000 knee replacements in 2010. Mean infection rate is 2%, according to findings from hip and knee replacement studies reviewed by the guideline authors. Infectious organisms may enter the surgical wound during or after the joint replacement procedure, and complications may include surgical drainage or debridement and long courses of antibiotics.

"This guideline was based primarily on clinical research which examined a large group of patients, all having a prosthetic hip or knee and half with an infected prosthetic joint," AAOS-ADA work group member Elliot Abt, DDS, a general dentist in Skokie, Illinois, and a member of the ADA Council on Scientific Affairs, said in the release. "The research showed that invasive dental procedures, with or without antibiotics, did not increase the odds of developing a prosthetic joint infection."

The clinical practice guideline includes 3 specific recommendations:

Practitioners should consider changing their customary practice of prescribing prophylactic antibiotics to patients undergoing dental procedures. This recommendation is based on limited evidence that dental procedures are unrelated to PJI.

There is no direct evidence that the use of oral topical antimicrobials (ie, topical antibiotic administered by the dentist) before dental procedures will prevent PJI. This is an inconclusive recommendation, in that the guidelines authors were unable to recommend for or against the use of topical oral antimicrobials in patients with prosthetic joint implants or other orthopedic implants

Good oral hygiene should be maintained. This is the only consensus recommendation in the guideline.

"As clinicians, we want what is in the best interest of our patients, so this clinical practice guideline is not meant to be a stand-alone document," Dr. Jevsevar, who also is an orthopaedic surgeon in St. George, Utah, said in the release. "Instead it should be used as an educational tool to guide clinicians through treatment decisions with their patients in an effort to improve quality and effectiveness of care."

Included with the guideline is a shared decision-making tool to facilitate collaborative decision making between patient and clinician and to supplement, but not replace, informed consent procedures. The tool notes that potential adverse effects of routine antibiotic use may include increased bacterial resistance, allergic reactions, diarrhea, and even death. It also notes that immunocompromised patients might be at greater risk for implant infections and that antibiotic use might be considered in this group.

Those that the authors included as "immunocompromised" were patients who have diabetes mellitus type 1 and type 2, have autoimmune diseases, have post–organ transplant, were receiving chemotherapy, are a bone marrow transplant recipient, were HIV positive, were a chronic steroid user, have obesity, have hemophilia, have malnutrition, have tobacco exposure, have alcohol use, have leukemia or other cancers, have a history of radiation therapy, were taking immunomodulated therapy, or who are elderly.

Decision about use of prophylactic antibiotics may also be influenced by the oral health status of the patient (eg, is there gingivitis, periodontitis, caries, nonodontogenic infection, or an odontogenic infection?), previous implant infection, time from implant, multiple implants performed, or the presence of at-risk prosthesis (eg, revision prosthesis, prosthesis mechanically failed, megaprosthesis, or endoprosthetic reconstruction).

"Research is always changing and we need to work to improve clinical research databases, so in the future any type of prospective research done in this area will help shed light on prophylaxis and orthopaedic infection rates," Dr. Jevsevar said in the release.

In an accompanying editorial, Dr. Jevsevar and Dr. Abt discuss the history of changing recommendations regarding antibiotic prophylaxis for patients with joint replacements undergoing dental procedures, as well as the methodology underlying the current recommendations.

"The new clinical practice guideline was developed using the published AAOS [clinical practice guideline] development process, and meets or exceeds all recommended Institute of Medicine standards for the development of systematic reviews and clinical practice guidelines except for allowing patient input in the selection of topics and questions," the editorialists write. "Of note, the AAOS [clinical practice guideline] program does not allow members with relevant conflicts of interest, and the collaborating societies followed the same conflict of interest rules in selecting their members."