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Should Patients with Prosthetic Joints Routinely Receive Antibiotic Prophylaxis When Undergoing Dental Pocedures?
Abstract & Commentary
By Stan Deresinski, MD, FACP, Clinical Professor of Medicine, Stanford, Associate Chief of Infectious Diseases, Santa Clara Valley Medical Center, is Editor for Infectious Disease Alert.
Synopsis: A case-control study found no evidence supporting the use of routine antibiotic prophylaxis in patients with prosthetic knee or hip joints when undergoing dental procedures.
Source: Berbari EF, et al. Dental prodecures as risk factors for prosthetic hip or knee infection: A hospital-based prospective case-control study. Clin Infect Dis. 2009 Dec 1. [Epub ahead of print].
In 2003, the american academy of orthopedic surgeons (AAOS) and the American Dental Association jointly published recommendations regarding antibiotic prophylaxis for dental patients who had had total joint replacements.1 They concluded that "antibiotic prophylaxis is not indicated for dental patients with pins, plates, or screws, nor is it routinely indicated for most dental patients with total joint replacements. However, it is advisable to consider premedication in a small number of patients who may be at potential increased risk of experiencing hematogenous total joint infection." In 2009, however, the AAOS electronically published an "Information Statement" with a radically different recommendation: "the AAOS recommends that clinicians consider antibiotic prophylaxis for most patients with total joint replacements."2 The following disclaimer accompanied the recommendation: "This Information Statement was developed as an educational tool based on the opinion of the authors. Readers are encouraged to consider the information presented and reach their own conclusions." This change in position by the AAOS was made in the apparent absence of new data in its support. Berbari et al at the Mayo Clinic in Rochester, Minnesota, have now published a case-control study that instead supports the previous position and provides a more solid basis for clinicians to come to a rational conclusion.
Case patients were individuals hospitalized with hip or knee prosthetic infections from 2001-2006, while controls were patients who had undergone hip or knee replacements who were hospitalized during the same time period on the same orthopedic floor. Dental records were examined directly or indirectly for each subject. Among patients who received no dental prophylaxis, there was no evidence of an increased risk of prosthetic joint infection (PJI). This was true whether they had undergone a low-risk or high-risk dental procedure.
Only 35 of the 339 infections (10.3%) were caused by organisms that were potentially of oral or dental origin. Analysis of this group along with 35 controls also failed to demonstrate an increased risk of infection in association with a lack of antibiotic prophylaxis. This was also true in subset analyses of patients who were immunocompromised, had diabetes mellitus, prior arthroplasty, or who had undergone joint replacement in the previous 12 months. The investigators concluded that "Dental procedures were not risk factors for subsequent total hip or knee infection. The use of antibiotic prophylaxis prior to dental procedures did not decrease the risk of subsequent total hip or knee infection."
Most PJI occurring in the months following joint implantation are the result of inoculation of the surgical site at the time of the procedure. Hematogenous infection is much more likely to occur later — generally more than 1 or 2 years after the procedure and the majority of these are due to staphylococci. As in this study, only approximately 10% of PJI are caused by organisms that could potentially be considered of oral or dental origin. This is true despite the fact that bacteria, including those of dental origin, enter the bloodstream with amazing frequency as the result of activities of daily living, such as toothbrushing and even the chewing of food. Thus, it has been estimated that such activities result in approximately 5,370 minutes (89.5 hours) of bacteremia each month.3 If correct, this means that 12.4% of our lives are spent with bacteria in our bloodstream. Bacteremia resulting from a dental extraction generally lasts for only 6 to 30 minutes. Thus, for an individual who has a single dental extraction in a year, the resulting bacteremia accounts for only 0.01%-0.05% of the total duration of bacteremia in those 12 months.
Thus, there appears to be no rationale for the routine administration of antibiotic prophylaxis to patients with prosthetic hip or knee joints who are undergoing either dental procedures, including those considered high risk. The optimal approach to prevention of late PJI of dental origin is, instead, the provision of optimal dental hygiene.