Indications for Antibiotic Prophylaxis

Transcription

1 Indications for Antibiotic Prophylaxis Barbara J. Steinberg, D.D.S. Clinical Professor of Surgery Drexel University College of Medicine

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3 6/16/2016 The Use of Prophylactic Antibiotics Prior to Dental Procedures in Patients with Prosthetic Joints Evidence-based clinical practice guideline for dental practitioners- a report of the American Dental Association Council on Scientific Affairs Sollecito TP, Abt E, Lockhart PB, et al. JADA 2015:146(1):

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5 2/14/2017 American Dental Association guidance for utilizing appropriate use criteria in the management of the care of patients with orthopedic implants undergoing dental procedures American Dental Association Appointed Members of the Expert Writing and Voting Panels Contributing to the Development of American Academy of Orthopedic Surgeons Appropriate Use Criteria There may be special circumstances in which a clinician may consider antibiotic prophylaxis despite the lack of scientific evidence. The 2015 evidence-based clinical practice guidelines did not list any special circumstances Weak evidence that some patients with certain medical conditions, diseases and disorders may be at higher risk of experiencing prosthetic joint infections (PJI) independent of dental procedures The American Academy of Orthopaedic Surgeons (AAOS) contacted the ADA to participate in the development of appropriate use criteria (AUC) to assist orthopedic surgeons and dentists in managing the care of these patients They developed clinical scenarios of situations in which dental treatment might theoretically create a higher risk of experiencing PJI The following medically complex patient populations and related issues were used to develop a matrix to gain consensus on any potential benefit from antibiotic prophylaxis until more definitive scientific data becomes available: The following medically complex patient populations and related issues: PLANNED DENTAL PROCEDURES a. Dental procedures that do not result in the manipulation of gingival or periapical tissues, or perforation of the oral mucosa b. Dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or the perforation of the oral mucosa The following medically complex patient populations and related issues (cont.): IMMUNOCOMPROMISED STATUS a. Not severely immunocompromised b. Severely immunocompromised 1

6 2/14/2017 The following medically complex patient populations and related issues (cont.): GLYCEMIC CONTROL a. No current or active diabetes diagnosis Active known diabetic, Hemoglobin A1C < 8 or Blood Glucose < 200 Active known diabetic, Hemoglobin A1C 8 or Blood Glucose 200 a. Active known diabetic, Hemoglobin A1C Unknown, Glucose Unknown The following medically complex patient populations and related issues(cont): HISTORY OF PERIPROSTHETIC OR DEEP PJI OF THE HIP OR KNEE THAT REQUIRED AN OPERATION a. No b. Yes The following medically complex patient populations and related issues(cont): TIMING SINCE HIP OR KNEE JOINT REPLACEMENT PROCEDURE a. < 1 year b. 1 year The AUC is a decision-support tool to supplement clinicians in their judgement regarding antibiotic prophylaxis for patients with a prosthetic joint who are undergoing dental procedures The AUC could facilitate the treatment of defined high risk and immune compromised patients It affects a narrow cohort of patients for whom antibiotic prophylaxis might be considered TAKE HOME MESSAGES DELINIATED IN COMMENTARY There is no evidence to support an association between dental procedures and risk of experiencing PJI s Discussion of available treatment options applicable to each patient relies on communication between the patient, dentist and orthopedic surgeon weighing the potential risk and benefits for that patient criteria in the management of the care of patients with orthopedic implants undergoing dental procedures TAKE HOME MESSAGES DELINIATED IN COMMENTARY (cont.) It is appropriate for the dentist to make the final judgement to use antibiotic prophylaxis for patients potentially at higher risk of experiencing PJI (independent of dental treatment) using the AUC as a guide, without consulting the orthopedic surgeon However, if the orthopedic surgeon recommends antibiotic prophylaxis or the patient prefers it, despite the dentist s recommendation against pre-medication, the prescription should be provided by the surgeon 2

7 2/14/2017 TAKE HOME MESSAGES DELINIATED IN COMMENTARY (cont.) The 2015 ADA clinical practice guideline is valid and should continue to inform clinical decisions for dental patients in ambulatory settings The guideline states clearly that the evidence fails to demonstrate an association between dental procedures and PJI or any effectiveness for antibiotic prophylaxes. Given this information in conjunction with the potential harm from antibiotic use, using antibiotics before dental procedures is not recommended to prevent PJI TAKE HOME MESSAGES DELINIATED IN COMMENTARY (cont.) The 2015 ADA clinical practice guideline is valid and should continue to inform clinical decisions for dental patients in ambulatory settings (cont.) The ADA Council on Scientific affairs and ADAappointed expert panel members encourage dental healthcare professionals to continue to use the 2015 ADA clinical practice guideline, consult the AUC as needed, and respect the patient s specific needs and preferences when considering antibiotic prophylaxis before dental treatment Regimens for a Dental Procedure Situation Agent Regimen Single Dose minutes before procedure Adults Children Oral Amoxicillin 2 gm 50 mg/kg Unable to take oral Ampicillin 2 g IM or IV* 50 mg/kg IM or IV medication OR ceftriaxone 1 g IM or IV 50 mg/kg IM or IV Allergic to penicillins Cephalexin** t 2 g 50 mg/kg or ampicillin Oral OR Azithromycin or 500 mg 15 mg/kg clarithromycin JADA 148(2) February Allergic to penicillins Ceftriaxone t 1 g IM or IV 50 mg/kg IM or IV or ampicillin and OR unable to take oral Azithromycin or Equivalent Dose 500 Equivalent Dose medication clarithromycin mg IV *Intramuscular injections should be avoided in persons receiving anticoagulants. **Or other first-or second- generation oral cephalosporin in equivalent adult or pediatric dosage. t Cephalosporins should not be used in an individual with a history of anaphylaxis, angioedema, or urticaria with penicillins or ampicillin =224995actionxm=Terms 3

8 Additional Recommendations for Antibiotic Prophylaxis for Dentistry Made by National Organizations National Organization Conditions Antibiotic (dosage) Comments AHA (2003) Pacemakers, defibrillators, ventriculoatrial shunts, closure devices, patches, stents, vascular grafts, Dacron grafts and patches, Vena caval filters, vascular closure devices, total artificial hearts, L ventricular assist devices Select appropriate regimen and dosage listed in AHA (2007) if prophylaxis is indicated Prophylaxis is not indicated except for ID for abscess, extractions or other surgical procedures in areas of acute infections AHA (2003) Renal dialysis shunts No indication for prophylaxis CDC (2002) Intravascular catheters Intravenous Intra-arterial No indication for prophylaxis

9 Conditions Where Antibiotic Prophylaxis Has Been Used But With No National Organization Guidelines or Recommendations Conditions Antibiotic (dosage) Comments Organ transplants (heart, kidney, liver, heart-lung, bone marrow, others) HIV/AIDS Many transplant surgeons recommend AHA regimens (2007) or Amoxicillin 2.0 g and Metronidazole 500 mg one hour prior Select appropriate regimen and dosage listed in AHA (2007) if prophylaxis is indicated Most transplant surgeons recommend antibiotic prophylaxis for dental procedures; no controlled studies demonstrate benefit; prophylaxis may be appropriate during rejection phases, over-immunosupression, and if organ is functioning poorly. Prophylaxis usually is not indicated during the stable phase of transplant. Prophylaxis not recommended unless neutrophil count is < 1,000 mm3 and/or if the CD4 count is < 200 mm3 Immunosupression Select appropriate regimen and Drugs (steroids) dosage listed in AHA (2007) if Diseases prophylaxis is indicated (agranulocytosis, AIDS, cancer, systemic lupus erythematosus) Leukopenia Long-term corticosteroid therapy may be an indication for antibiotic prophylaxis. Patients with neutrophil count < 1,000 mm3 and/or CD4 count < 200 are candidates for antibiotic prophylaxis Specific medical No specific regimen conditions: recommended Poorly controlled Type-I diabetes Sickle cell anemia Antibiotic prophylaxis may be indicated for surgery in poorly controlled diabetics and in patients with sickle cell anemia especially if infection is present Splenectomy Implants Breast Penile No specific regimen recommended No specific regimen recommended Some authors suggest antibiotic prophylaxis for surgical procedures during the first 6 months following the splenectomy, others do not. No indication for antibiotic prophylaxis for any dental procedures

10 9/22/13 Oral Health and Dental Treatment for the Pregnant Patient Barbara J. Steinberg, DDS Clinical Professor of Surgery Drexel University College of Medicine Philadelphia, Pa Oral Health Care During Pregnancy Expert Workgroup Oral Health Care During Pregnancy: A National Consensus StatementSummary of an Expert Workgroup Meeting. Washington, D.C.: National Maternal and Child Oral Health Resource Center In collaboration with American College of Obstetricians and Gynecologists American Dental Association AdvisePregnantWomenAboutOral HealthCare AdvisePregnantWomenAboutOral HealthCare(cont.) Reassurewomenthatoralhealthcare, includinguseofradiographs,pain medicacon,andlocalanesthesia,issafe throughoutpregnancy EncouragewomentoconCnuetoseekoral healthcare,pracccegoodoralhygiene,eat healthyfoodsandajendprenatalclasses duringpregnancy. Advise Pregnant Women About Oral Health Care (cont.) Good oral hygiene tips: Advise Pregnant Women About Oral Health Care (cont.) Good oral hygiene tips: Brush your teeth with fluoridated toothpaste twice a day. Replace your toothbrush every 3 or 4 months, or more often if the bristles are frayed. Do not share your toothbrush. Clean between teeth daily with floss or an interdental cleaner. Rinse every night with an over-the-counter fluoridated, alcohol-free mouthrinse. After eating, chew xylitol-containing gum or use other xylitol containing products such as mints, which can help reduce bacteria that can cause tooth decay. 1

11 9/22/13 Advise Pregnant Women About Oral Health Care (cont.) Good oral hygiene tips: If you vomit, rinse your mouth with a teaspoon of baking soda in a cup of water to stop acid from attacking teeth. WorkinCollaboraConwithPrenatal CareHealth Consultwithprenatalcarehealth professionals,as#necessarykforexample, whenconsideringthefollowing(cont.): TheuseofintravenoussedaConorgeneral anesthesia. TheuseofnitrousoxideasanaduncCve analgesictolocalanestheccs. Work in Collaboration with Prenatal Care Health Consult with prenatal care health professionals, as necessary-for example, when considering the following: Co-morbid conditions that may affect management of oral problems (e.g., diabetes, hypertension, pulmonary or cardiac disease, bleeding disorders). Provide Oral Disease Management and Treatment to Pregnant Women Provide emergency or acute care at any time during the pregnancy, as indicated by the oral condition Develop, discuss with women, and provide a comprehensive care plan that includes prevention, treatment, and maintenance throughout pregnancy. Discuss benefits and risks of treatment and alternatives to treatments. ProvideOralDiseaseManagementand TreatmenttoPregnantWomen(cont.) UsestandardpracCcewhenplacing restoracvematerialssuchasamalgamand composites. UsearubberdamduringendodonCc proceduresandrestoracveprocedures. Provide Oral Disease Management and Treatment to Pregnant Women (cont.) Position pregnant women appropriately during care: Keep the woman s head at a higher level than her feet. Place women in a semi-reclining position, as tolerated, and allow frequent position changes. Place a small pillow under the right hip, or have the women turn slightly to the left as needed to avoid dizziness or nausea resulting from hypotension. 2

12 9/22/13 ProvideOralDiseaseManagementand TreatmenttoPregnantWomen(cont.) Followupwithpregnantwomento determinewhetherprevencveandrestoracve treatmenthasbeeneffeccve. FDA$Categoriza.on$of$Prescrip.on$Drugs$for$ Use$in$Pregnancy$ A=Controlledstudiesinhumansfailto demonstratearisktothefetus,andthe possibilityoffetalharmappearsremote. B=Animalstudiesdonotindicatefetalrisk andtherearenohumanstudies,oranimal studiesshowariskbutcontrolledhuman studiesdonot. C=Animalstudieshaveshownariskbut therearenocontrolledhumanstudiesor nostudiesareavailableinhumansor animals. Drug Administration The potential benefit to the patient must outweigh the potential harm to the fetus FDA$Categoriza.on$of$Prescrip.on$Drugs$for$ Use$in$Pregnancy$ $ D=PosiCveevidenceofhumanfetalrisk exists,butincertainsituaconsthedrug maybeuseddespiteitsrisk X=PosiCveevidenceofhumanfetalrisk exits,andtheriskoutweighsanypossible benefitofuse 3

13 9/22/13 Hari Cheryl Sachs, MD., FAAP and COMMITTEE ON DRUGS Published online Pediatrics, August 26, 2013 OralHealthCareDuringPregnancyExpertWorkgroup OralHealthCareDuringPregnancy:ANaConalConsensus StatementKSummaryofanExpertWorkgroupMeeCng. Washington,DC:NaConalMaternalandChildOralHealth ResourceCenter. The benefits of breastfeeding outweigh the risk of exposure to most therapeutic agents via human milk Greater vulnerability of some infants such as preemies or neonates due to immature organ function or underlying medical conditions Most up-to-date data and comprehensive information related to drugs and breastfeeding is compiled in a National Institute s of Health database called LactMed, available on the Internet and as an app for mobile devices content/early/2013/08/20/peds Most drugs and vaccines are safe for women to take while breastfeeding Caution needed for a small proportion of drugs: Those concentrated in human milk Those that have a long half-life Those with known toxicity to mother or child Those that expose the infant to relatively high doses or detectible serum concentrations LactMed database includes the following information: Levels of individual drugs found in human milk and infant serum Possible adverse effects on the infant and/or lactation Alternate drug recommendations 4

14 9/22/13 NarcoCcAnalgesics NarcoCcAnalgesics When#narco,c#agents#are#needed#to#treat# pain#in#breas3eeding#women#agents#other# codeine#are#preferred# Narcotic Analgesics The following are not recommended in the lactating mother Oxycodone- a relatively high amount excreted into human milk and therapeutic concentrations have been detected in the plasma of a nursing infant Central nervous system depression noted in 20% of infants exposed during breastfeeding Codeine'and'Hydrocodone#canreachhighlevelsin breastmilk Adverseeventsreported: Unexplainedapnea Bradycardia Cyanosis SedaCon NarcoCcAnalgesics Thefollowingarenot'recommendedin thelactacngmother Pentazocine'(Talwin) ' Meperidine'(Demerol)' NarcoCcAnalgesics Narcotic Analgesics Thefollowingare'recommendedinthe lactacngmother Regardless of choice of therapy, to minimize adverse events for both the mother and her nursing infant, the lowest dose and shortest duration of therapy should be prescribed. Butorphanol' Morphene'' Hydrpmorphone'(Dilaudid)' 5

15 9/22/13 Non-Narcotic Analgesics Non-Narcotic Analgesics Drugs acceptable for use in breastfeeding Limited published data on other NSAIDs and use is discouraged in breastfeeding Ibuprofen Acetaminophen Celecoxib (Celebrex) Flurbiprofen (Ansaid) Naproxen (short term) Low doses of aspirin ( mg/d)(high doses not advised) Etodolac Fenoprofen Meloxicam Oxaprozin Piroxicam Sulindac TolmeCn AnCdepressants,AnxiolyCcs,and AnCpsychoCcs AnCdepressants,AnxiolyCcs,and AnCpsychoCcs Someoftheseagentsappearinbreastmilkat clinicallysignificantlevels Someoftheseagentsappearinbreastmilkat clinicallysignificantlevels Bupropion(Wellbutrin) Diazepam(Valium) FluoxeCne(Prozac) Thereportrecommendedcounselingwomenwho wanttobreasceedwhiletakingthesemedicacons ontheriskkbenefitbalanceandtheunknownlongk termimpactforthechild Citalopram(Celexa) Lithium(Eskalith) Lamotrigine(Lamictal) Venlafaxine(Effexor) Herbs Herbs Reliable information on safety of many herbal products is lacking Thefollowingherbscommonlyusedduring breasceedingarenotrecommendedforuseby nursingwomen Chamomile BlackCohosh BlueCohosh Chastetree Echinacea 6

16 9/22/13 Herbs Thefollowingherbscommonlyusedduring breasceedingarenotrecommendedforuseby nursingwomen(concnued) Ginseng Gingko Hypericum#(St.John s wort) Valarian Fenugreek 7