Antibiotic Prophylaxis and Prosthetic Joint Replacement. Frieda A. Pickett, RDH, MS.

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1 Antibiotic Prophylaxis and Prosthetic Joint Replacement Frieda A. Pickett, RDH, MS. A Continuing Education Home Study Course-1 (one) hour CEU. Objectives The participant will be able to 1. Describe changes in guidelines for dental management of the client with a total joint replacement. 2. Identify best evidence studying the effectiveness for antibiotic prophylaxis prior to dental treatment to prevent prosthetic joint infection. 3. Identify potential adverse effects from taking antibiotics indiscriminately. 4. Review the recent ADA position statement and systematic review (2015) regarding the use of antibiotic prophylaxis prior to dental procedures for individuals with a prosthetic joint. Introduction Total joint replacement, or arthroplasty, represents a significant advance in the treatment of disabling joint pathologies. Surgical replacement can be performed on any joint of the body, including hips, knees, ankles, shoulders, elbows, wrists, and fingers. The majority of joint replacements involve the knee and the hip. Surgical replacement of total hip and knee joint arthroplasty is expected to increase due to an aging population, the most common reason for

2 replacement being disabling effects of arthritis (both osteoarthritis and rheumatoid arthritis). 1,2 Although the world-wide prevalence of total joint replacements is unclear, what is clear is that hip and knee replacement is a common procedure in orthopedic practice of medicine. Prosthetic joint infections (PJIs) are the most common reason for prosthetic joint failure. PJIs are rare, but serious complications do occur in a small percentage (0.3 to 1.0%) of patients after primary total hip replacement and (1.0 to 2.0%) of patients after primary total knee replacements. 2 The greatest risk occurs during the first two postoperative years (6.5, 3.2, and 1.4 infections per 1000 patient-years during the first year, second year, and after the second year, respectively). 3 Staphylococci (S. aureus) are the most common bacterial cause of PJI. This microorganism is uncommon in the oral cavity. 3 Devastating personal and financial consequences can arise following PJI. Treatment often requires removal of the infected prosthesis and prolonged intravenous antimicrobial therapy, along with an estimated cost exceeding $50, for each episode. 4 It was for this reason that orthopaedists supported the use of antibiotic prophylaxis (AP) prior the dental procedures, believing it might prevent the infection. Antibiotic prophylaxis is a practice of administering antibiotics when no infection exists, but with the goal of preventing an infection. Efficacy for Antibiotic Prophylaxis to Prevent PJI Guidelines for the efficacy of antibiotic prophylaxis (AP) prior to oral procedures for individuals with a joint replacement have gone through several revisions. Guidelines have changed from using AP before dental procedures for all individuals with a prosthetic joint, to using AP for only selected patients considered to be at high risk for joint infection, then to no recommendation

3 for AP prior to dental procedures. In December 2012 the American Academy of Orthopedic Surgeons (AAOS) in collaboration with the American Dental Association (ADA) published three clinical practice guidelines based on a systematic review (SR) of best evidence related to factors that might cause joint infection and risk factors for prosthetic joint infection (PJI), followed by an explanation of the guidelines for practitioners in These included (1) The practitioner might consider discontinuing the practice of routinely prescribing prophylactic antibiotics for patients with hip and knee prosthetic joint implants undergoing dental procedures. (2) We are unable to recommend for or against the use of topical oral antimicrobials in patients with prosthetic joint implants or other orthopaedic implants undergoing dental procedures. (3) In the absence of reliable evidence linking poor oral health to prosthetic joint infection, it is the opinion of the work group that patients with prosthetic joint implants or other orthopaedic implants maintain appropriate oral hygiene. A main goal of the SR was to examine the evidence directed towards efficacy (do they work, and if so, how well?) of AP to prevent PJI. 2 The 2012 AAOS/ADA guideline #1 called for practitioners to consider discontinuing the use of AP prior to dental procedures when the client has a knee or hip prosthetic joint. The guideline statement was followed however, by an explanation that the recommendation was based on only one prospective case control study 5, considered to be limited evidence. 1 The guideline authors wrote that practitioners should not feel compelled to follow a guideline based on limited evidence. This negative statement was confusing to many. Multiple groups involved in the scientific investigation agreed there was an absence of level 1 evidence (randomized controlled trials) for or against the use of prophylactic antibiotics in patients with prosthetic joints undergoing invasive dental treatment. The 2012

4 ADA/AAOS guidelines were published, but they did little to guide practitioners regarding evidence-based professional decisions for dental management of the client with a joint replacement. This was because the guideline stated only one case control study 5 was not enough evidence to convince practitioners to change former practices of universally using AP prior to dental procedures. As well, that study only included hip and knee replacements, so the guideline to reconsider AP practices only applied to those joints. Most authorities in dentistry agree professional judgment must depend on the client history of infection in the joint space following joint replacement, and the strength of the host immune response to resolve infection. In 2008 a thorough review of the literature concluded there was no evidence to support giving AP prior to dental procedures for the purpose of preventing joint infection. 6 In January of 2015 the ADA Council of Scientific Affairs Expert Panel on Antibiotic Prophylaxis attempted to resolve the confusion regarding if AP was needed for individuals having a prosthetic joint, seeking dental treatment. 7 In the Clinical Guidelines publication the Expert Panel used four studies which were deemed to answer the focused question Does antibiotic prophylaxis prevent prosthetic joint infection? Critical appraisals of the included studies determined appropriate methods were used to answer the clinical question and the subjects were recruited in an acceptable way. Two of the four studies were deemed to have selected study subjects in an acceptable way, and selection in the other two studies was unable to be determined. The Expert Panel determined In general, for patients with prosthetic joint implants, prophylactic antibiotics are not recommended prior to dental procedures to prevent prosthetic joint infection. 7 For patients who have had previous complications (such as previous joint infection, or are immunocompromised) and who will have gingival manipulation (scaling/periodontal

5 debridement) or mucosal incision, consultation with the physician is advised before making final decisions regarding whether or not to use antibiotic prophylaxis. Statement of the Problem In 2009, without collaboration with the ADA, a committee of the AAOS published a new statement calling for antibiotic prophylaxis prior to oral procedures in all individuals with a TJR. 8 This caused a flurry of worldwide confusion since an examination of worldwide professional guidelines for AP at that time revealed many professional organizations in the United Kingdom (UK), Japan and European countries did not recommend AP prior to dental procedures to prevent PJIs. National guidelines in the United Kingdom determined AP does not eliminate bacteremia, 9 a randomized clinical study found that administration of AP prior to tooth extraction did not eliminate bacteremia formation, 10 and a recent 3 year prospective case control study reported that AP did not reduce prosthetic joint infection nor were dental procedures risk factors for subsequent prosthetic joint infection. 5 One factor associated with a lower risk of PJI was good oral hygiene or oral health (OR 0.7; 95% CI ). 11 This study was considered in the 2012 ADA/AAOS third recommendation. In the proceedings of a symposium on antimicrobial therapy published in researchers expressed the need for evidence-based guidelines for deciding to use AP prior to dental procedures when the client has a prosthetic joint. Despite the routine use of AP perioperatively (during joint replacement surgery), most PJIs result from bacterial seeding during the replacement surgical procedure. Late prosthesis infection via hematogenous seeding (bacteremia) is a less common cause. In fact, some researchers in the 2012 Clinical Guidelines

6 (ADA/AAOS) stated that bacteremia was a surrogate marker and should not be considered as a factor likely to result in PJI. 1 Researchers felt that the actual development of joint infection following dental procedures is the most reliable outcome to study in research. Support for the unreliability of bacteremia as a major cause of PJI came from research showing bacteremia developed hundreds of times daily from normal daily activities (tooth brushing, use of toothpicks, flossing, chewing, etc.) and AP is not recommended prior to these behaviors in those with a prosthetic joint. Among PJIs occurring via the hematogenous route, most result from S. aureus bacteremia, skin infections, or urosepsis. 4,6 The development of a PJI due to hematogenous seeding after dental procedures is a rare event. According to a 2008 literature review, this occurred in up to 0.20% (that is two tenths of one percent) of PJI case reports, and many of these infections were not documented with microbiological verification of bacterium from the oral cavity. 6 It is now current best practice to culture microorganisms in PJI to determine the bacterium causing the infection. Whether AP will prevent PJI following dental procedures in clients with a prosthetic joint is unknown as no randomized trials have been completed in this population. 12 Furthermore, the 2012 guidelines only addressed hip and knee joint replacements, and practitioners did not receive guidance for other types of joint replacements. The 2015 evidence-based clinical practice guideline for dental practitioners expanded the rejection of AP to any joint replacement. 7 Adverse Effects of AP Prior to 1997, any patient with a history of total joint replacement (TJR) was advised to receive AP prior to oral procedures. During this time concern increased regarding development of antibiotic resistance and the connection to unnecessary use of antibiotics. Antibiotic

7 prophylaxis was suggested as a practice promoting antibiotic resistance. This adverse effect led the professional associations expert committees to identify appropriate uses for AP in the patient with TJR. 13 The 2003 ADA/AAOS guidelines determined that only selected individuals with TJR would likely benefit from AP, and only when specified oral procedures involved significant bleeding. It was thought at that time that procedures resulting in bleeding were likely to result in bacteremia. Later research revealed bacteremia resulted in practices unrelated to bleeding, such as chewing or restorative dental treatment Other adverse factors associated with AP include nausea, risk for antibiotic-associated colitis (C. difficile), candidiasis, drug interactions, and cost. 7 Role of Oral Health to Reduce Magnitude of Bacteremia Randomized studies have demonstrated that bacteremia after tooth brushing is associated with poor oral hygiene and gingival bleeding. 10, 11 The tooth brushing study 10 reported an almost eightfold increase in the risk for bacteremia in the group with generalized bleeding. An analysis of data from this study reported the incidence of bacteremia in the group with high plaque and calculus scores was not significantly different from the group having a single tooth extraction. 11 Results, such as this, support the recommendation for individuals with prosthetic joints to maintain oral cleanliness and healthy oral tissues. The recommendation for individuals to maintain healthy periodontal tissues and reduce apical or other oral infection comes from the logic that healthy tissues would lower the magnitude of bacteremia. Since having bacteria in the circulation is the perceived avenue for late prosthetic joint infection (occurring at least 3 months after prosthetic placement), this recommendation seems logical. It must be stated, however, that no research has demonstrated that healthy oral tissues prevents PJI. Good oral

8 hygiene and prevention of dental disease could possibly decrease the frequency of bacteremia from daily activities and may protect against PJI. One must remember, developing a recommendation to give AP before oral procedures for the purpose of preventing associated bacteremia formation and PJI when research does not demonstrate the practice to be successful, is not an evidence based clinical decision. Conclusion The 2015 SR and development of clinical guidelines for dentistry (ADA alone) clarify the confusion that resulted from the 2012 ADA/AAOS guidelines. The 2014 Panel judged with moderate certainty that there is no association between dental procedures and the occurrence of PJIs. 7 The Panel stated there is no recommendation for AP prior to oral procedures for individuals with a prosthetic joint. The Panel made the decision based on results of 3, out of 4 studies, reporting no association between PJI and dental procedures. Since adverse effects of taking antibiotics injudiciously include the development of antibiotic resistance, as well as other potential infections (antibiotic-associated colitis, candidiasis, etc.) this clinical judgement must be based on evidence-based science. The benefits and risks of AP to the patient with a prosthetic joint who seeks oral procedures must be clearly defined. For individuals with a history of complications associated with joint replacement and who will have oral procedures involving manipulation of the gingivae or mucosal incision, medical consultation is recommended regarding the benefit of AP.The ADA recently posted a summary of the Expert Committee Findings at

9 References 1. Gross L. AAOS, ADA release CPG for prophylactic antibiotics. [internet] J Am Acad Orthop Surg. 2013;21: Available at Guidelines on AAOS website at Accessed March 22, Jevsevar DS, Abt E. The new AAOS-ADA clinical practice guideline on prevention of orthopaedic implant infection in patients undergoing dental procedures. J Am Acad Orthop Surg 2013;21: Available at Accessed March 16, Enzler MJ, Berbari E, Osmon DR. Antimicrobial Prophylaxis in Adults. Mayo Clin Proc. 2011;86(7): Available at Accessed March 24, Gomez EO, Osmon DR, Berbari EF. Do patients with prosthetic joints require dental antimicrobial prophylaxis? Cleveland Clinic J Med 2011;78(1): Berbari EF, Osmon DR, Carr A et al. Dental procedures as risk factors for prosthetic hip or knee infection: A hospital-based prospective case control study. Clin Infect Dis. 2010;50:8 16. Available at Accessed March 22, Uckay I, Pittet D, Bernard L, Lew D, Perrier A, Peter R. Antibiotic prophylaxis before invasive dental procedures in patients with arthroplasties of the hip and knee. J Bone Joint Surg Br. 2008;90: Available at

10 7. Sollecito TP, Abt E, Lockhart PB, et al. The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints. JADA 2015:146(1): Available at Accessed March 22, American Academy of Orthopaedic Surgeons. Information Statement Antibiotic prophylaxis for bacteremia in patients with joint replacements. February Accessed March 24, National Institute for Health and Clinical Excellence. Antimicrobial Prophylaxis Against Infective Endocarditis. London: National Institute for Health and Clinical Excellence, NICE clinical guideline Accessed January 14, Lockhart PB, Brennan MT, Sasser HC et al. Bacteremia associated with toothbrushing and dental extraction. Circulation. 2008;117(24): Lockhart PB, Brennan MT, Thornhill M et al. Poor oral hygiene as a risk factor for infective endocarditis-related bacteremia. J Am Dent Assoc. 2009;140: Lockhart BP, Loven B, Brennan MT, Fox PC. The evidence base for the efficacy of antibiotic prophylaxis in dental practice. JADA 2007;138: American Dental Association and American Academy of Orthopaedic Surgeons: Advisory statement: Antibiotic prophylaxis for dental patients with prosthetic joint replacements. J Am Dent Assoc 2003;134:

11 Antibiotic Prophylaxis and Prosthetic Joint Replacement Test Questions- Home Study Assessment After completing the course reading the participant should answer the following questions with a 70% accuracy rate to receive credit for the course. 1. All of the following factors lead to prosthetic joint replacement EXCEPT one. Which is the EXCEPTION? a. Aging b. Broken bones c. Osteoarthritis d. Rheumatoid arthritis 2. The most common reason for failure of a prosthetic joint is a. Having dental procedures. b. Improper fit of prosthesis c. Infection d. Postsurgical pain and swelling 3. The most common bacterium to cause prosthetic joint infection is a. Actinomycetes actinomycetemcomitans b. Clostridium difficile c. Staphylococcus aureus d. Streptococcus mutans

12 4. The 2012 American Dental Association/American Academy of Orthopaedic Surgeons Guidelines for Antibiotic Prophylaxis in Prosthetic Joint Replacement advised to a. Provide antibiotic prophylaxis to patients with hip or knee joint replacements b. Provide antibiotic prophylaxis to patients with any prosthetic joint c. Consider discontinuing the practice of giving antibiotic prophylaxis to patients with prosthetic joint replacement prior to dental procedures d. None of these 5. The 2015 American Dental Association Expert Panel on antibiotic prophylaxis produced which of the following clinical guidelines for dentists? a. Antibiotic prophylaxis is not recommended prior to dental procedures for individuals with prosthetic joint replacements. b. Antibiotic prophylaxis can be considered for patients with complications following joint replacement, and when gingival manipulation is planned, after physician consultation. c. Studies have failed to show an association between dental procedures and prosthetic joint infection. d. All of the above

13 6. Which of the following countries recommend antibiotic prophylaxis prior to oral procedures when the patient has a total joint replacement? a. United Kingdom b. Japan c. U.S.A. d. None of the above 7. Which of the following factors is recommended to reduce the risk for prosthetic joint infection? a. Antibiotic prophylaxis b. Good oral hygiene c. Regular dental examinations d. Tooth removal and fabrication of dentures 8. Current practice is to identify microorganisms in a prosthetic joint infection by a. Culturing microorganisms b. Examining for presence of purulent exudate c. Questioning about recent dental appointments d. None of these

14 9. Potential adverse effects associated with antibiotic prophylaxis include all the following EXCEPT one. Which is the EXCEPTION? a. Antibiotic associated colitis b. Antibiotic resistance c. Candidiasis d. Drug Interactions e. Increase in bacteremia 10. Which of the following statements is TRUE? a. Antibiotic prophylaxis prior to dental procedures prevents prosthetic joint infection. b. No association exists between dental procedures and the occurrence of prosthetic joint infection. c. Rinsing with an antimicrobial oral product reduces the risk for prosthetic joint infection. d. Bacteremia is a strong risk factor for causing prosthetic joint infection.

15 Antibiotic Prophylaxis and Prosthetic Joint Replacement Answer Sheet Enter answers below. Please submit this answer sheet TDHA for grading. Upon receiving a passing score of 80%, the course participant will be sent a Certificate of Completion within two weeks. The cost of the course is $20.00 for ADHA members and $40.00 for all other participants. Please send this test answer sheet, appropriate payment and, if applicable, a copy of ADHA membership card to the TDHA Treasurer Jennifer Byerley, RDH jenbyerley@yahoo.com 2923 Antioch Road Johnson City, TN Participant Information NAME ADDRESS ZIP PHONE METHOD OF PAYMENT o CHECK-Payable to TDHA OR CREDIT CARD CC# Exp. CVV CHOOSE ONE: o ADHA MEMBER $20.00-must submit copy of membership card o NON-MEMBER $40.00 Use this section to record your answers to the exam on the previous page. Please place the corresponding letter answer for each question in the blank provided. Only one answer is correct. Question/Answer