Relation between mouth and haematogenous infection in total joint replacements

The Dutch version of the Oral Health Assessment Tool: Translation and inter-rater reliability among community nurses

OBJECTIVES

Translating the Oral Health Assessment Tool (OHAT) into Dutch and assessing the inter-rater reliability among community nurses.

METHODS

The original version of the OHAT was translated following the five stages of the 'Guidelines for the Process of Cross-Cultural Adaptation'. After a forward and backward translation, consensus on the pre-final version was obtained in an expert panel discussion. This version was pre-tested on its comprehensibility among 31 nurses and hereafter finalized. Then, inter-rater reliability of the OHAT-NL was determined by two trained nurses during oral assessments of 37 care-dependent community-dwelling older people. Intraclass correlation coefficient (ICC) and the Cohen's kappa statistic for individual items were estimated.

RESULTS

Feedback from nurses in the pre-test did lead to minor changes of the OHAT-NL. Inter-rater reliability was good (ICC 0.79; 95% CI 0.63-0.89) on the total score. Agreement on item level ranged from fair to very good, the kappa ranged from 0.36-0.89.

CONCLUSIONS

OHAT is now available in Dutch having good inter-rater reliability among trained community nurses. Future research can further validate the OHAT-NL and develop intervention according to total OHAT-NL scores.

Acute haematogenous periprosthetic joint infection due to Streptococcus sanguinis along with coexistent crystalline arthropathy after total knee arthroplasty: a rare combination

A man in his 60s, with a medical history of gout, underwent total knee arthroplasty of his right knee followed by expeditious rehabilitation. Seven months after surgery, he was referred to the emergency ward with sudden onset of pain and swelling of his right knee accompanied with fever. Further inquiry revealed no trauma, infection or skin lesions besides a tongue bite several weeks earlier. An impaired range motion of the knee was seen on physical examination along with a tachycardia. Laboratory studies showed a C reactive protein of 345 mg/L, after which a debridement, antibiotics and implant retention procedure was performed. Intraoperatively obtained synovial fluid showed monosodium urate crystals consistent with crystalline arthropathy (ie, gout). However, unexpectedly, Streptococcus sanguinis was identified in all microbiological cultures too, confirming a coexistent periprosthetic joint infection. After comprehensive antibiotic treatment and gout flare therapy, this patient made a full recovery with retention of the implant.

Micromonas micros Infection of a Prosthetic Hip Joint: A Case Report and Review of the Literature

Micromonas micros is an oral anaerobic Gram-positive coccus and is a commensal of the mouth, and it is rarely isolated in prosthetic joint infections (PJIs) and even less frequently related to a preceding dental procedure with eventual hematogenous seeding of the prosthetic joint. Here, we present a case of a 56-year-old male with a prosthetic hip joint who developed Micromonas micros prosthetic hip joint infection with symptoms starting a few days after a dental procedure and not having received periprocedural antibiotic prophylaxis. He recovered well with surgical intervention and antimicrobial therapy. We conducted a literature review of prosthetic hip joint infections caused by Micromonas micros as well as briefly discuss current guidelines on antibiotic prophylaxis in patients with prosthetic joints undergoing dental procedures and some knowledge gaps.

Oral health implications in total hip and knee arthroplasty patients: A review

Over the past two decades, oral health has emerged as a health care priority. Historically, patients greater than 65 years of age, the economically disadvantaged, members of racial or ethnic minority groups, or the disabled or home bound have experienced significant barriers to routine dental care. The connection between oral health care and periprosthetic joint infections (PJI) continues to be of importance to the orthopedic surgeon, as such infections are significantly morbid and costly. This review aims to introduce the importance of oral health as a small but crucial portion of an arthroplasty patient's overall perioperative management.

A context analysis on how oral care is delivered in hospitalised patients: A mixed-methods study

AIMS AND OBJECTIVES

To analyse oral care delivery in one hospital through exploring experiences from both nurses' and patients' perspectives and examining patients' oral health.

BACKGROUND

Oral health problems are associated with undernutrition and other general health outcomes. Although oral care belongs to the essentials of nursing, it is often neglected. Improving oral health may require behaviour change of both nurses and patients. Defining tailored strategies need a clear view on the context.

DESIGN

A context analysis in one hospital using a convergent parallel mixed-methods design was reported following the EQUATOR guidelines using two checklists: COnsolidated criteria for REporting Qualitative research (qualitative research) and STROBE (observational research).

METHODS

Semi-structured interviews were conducted with 19 nurses and 11 patients. The topic list was based on the Integrated Change Model. Prospective oral examination was performed among 91 surgical patients using the Oral Health Assessment Tool (OHAT).

RESULTS

Nurses acknowledged that they did not prioritise oral care in daily practice. Furthermore, they lacked knowledge and skills to identify and provide care for oral problems. Nurses mentioned helpful resources to perform oral care, like standardised language and instruments. However, they had no access to or were unaware of them. Patients admitted that they did not prioritise oral care due to their sickness during hospitalisation, were unaware of the importance of oral care, but felt responsible for their oral care. The most prominent oral problems identified with the OHAT were unclean mouths (n = 75, 82%), unhealthy gum and tissues (n = 55, 60%) and dry mouth (n = 42, 46%).

CONCLUSIONS

This context analysis identified inadequate oral care due to lack of positive attitude and knowledge in both nurses and patients, skills for nurses, and resources.

RELEVANCE TO CLINICAL PRACTICE

The behavioural factors indicate strategies for development of a multicomponent intervention to improve oral care in this hospital, nutritional status and general health outcomes.

Is there scientific evidence to support antibiotic prophylaxis in patients with periodontal disease as a means to decrease the risk of prosthetic joint infections? A systematic review

PURPOSE

To re-assess the scientific literature to ascertain if there is scientific evidence to support antibiotic prophylaxis in patients with periodontal disease as a means to decrease the risk of prosthetic joint infections.

INTRODUCTION

Prosthetic joint infections occur in approximately 0.3-2% of patients and, of these, around 6-13% are thought to be caused by oral bacteria. Antibiotic prophylaxis prior to dental procedures as a means to prevent a prosthetic joint infection has been controversial throughout the years. However, it remains unclear to what extent it has a beneficial effect. We do know that bacteraemia of oral origin is directly proportional to any ongoing inflammation or infection, and that a diseased periodontium may act as an entry for bacteria to spread to distant locations, through the bloodstream, and potentially be the cause of distant site infections.

MATERIALS AND METHODS

Updated literature search using the PubMed (Medline), and the Clarivate Analytics databases, to identify eligible articles since the previous searches up to April 2019 (last 5 years).

RESULTS

No studies that relate periodontal disease to the development of a prosthetic joint infection were found.

CONCLUSION

Currently, there is no evidence to support or exclude the need of antibiotic prophylaxis as a means to decrease the risk of prosthetic joint infections in patients with periodontal disease.

Knee septic arthritis caused by α-hemolytic Streptococcus in a patient with a recent history of knee arthroscopy: a case report

Background

Arthroscopic partial meniscectomy is a common procedure in orthopedic practice. Infections are uncommon complications of this procedure with an incidence rate of 0,01% - 3,4%. Staphylococcus spp are the predominant causative agents in such cases. We present a case of knee septic arthritis caused by α-hemolytic Streptococcus.

Case presentation

A 22-year-old woman diagnosed with obesity (body mass index [BMI] 35 kg/m²) but with no other major comorbidities underwent an arthroscopic selective meniscectomy with administration of intravenous cefazolin for antibiotic prophylaxis. After an uneventful period of 2 months, the patient returned with pain, fever and a discharging sinus at the site of anterolateral arthroscopic portal. Blood tests and magnetic resonance imaging revealed osteomyelitis involving the tibial plate. Cultures of synovial fluid obtained from the knee and a pharyngeal swab yielded α-hemolytic Streptococcus. Five days later, the patient underwent arthroscopic debridement with partial synovectomy. Intraoperative specimens yielded α-hemolytic Streptococcus. The patient received intravenous piperacillin/tazobactam, followed by an associative regimen of amoxicillin and clindamycin with clinical, laboratory and instrumental evidence of symptom resolution.

Conclusion

The incidence of knee septic arthritis after arthroscopic partial meniscectomy is 0.01–3.4%. This infection is usually caused by Staphylococcus spp. and in rare cases by commensal bacteria, such as α-hemolytic streptococci, secondary to transient bacteremia. Screening of the colonized area is important to prevent possible transient bacteremia. Diagnosis is based on isolation of the causative organisms from synovial fluid cultures, and treatment comprises arthroscopic debridement with individualized systemic antibiotic therapy based on the results of an antibiogram.

Dental assessment prior to orthopedic surgery: A systematic review

BACKGROUND

To reduce the risk of infection after orthopedic surgery, patients are asked to undergo preoperative assessments in various medical domains. However, to our knowledge, there has been no systematic review to evaluate the performance of a preoperative dental assessment before orthopedic surgery. We focus on two questions as follows: (1) is there a link between the presence of preoperative dental assessment and orthopedic infections?; (2) is the probability of an orthopedic infection increased in the presence of dental risk factors and comorbidities?

PATIENTS AND METHODS

Databases including PubMed, the Cochrane Library databases and Google Scholar were searched for English-language articles until November 2018. The inclusion criteria were descriptions of infections of joint prostheses and dental infections, and potential dental origins of pathogenic infections. Studies dealing with oral assessments performed before orthopedic surgery were included.

RESULTS

Based on eligibility criteria, 12 case series, 4 case-control studies and 12 cohort studies were included. In case-controls, prosthesis infection was presumably associated with a dental abscess in 6/224 of cases (2.9%). In cohort studies, exposure was defined as "any dental assessment or dental treatment performed before surgery". Even if only 4 cohort studies provide this information exposure, it would seem that the presence of an infectious complication is less frequent if the preoperative examination has been performed. Dental treatment given before surgery was mainly for scaling-polishing in 78/205 (38%), extraction in 49/205 of cases (24%) and restorative work in 37/205 (18%).

DISCUSSION

The literature review was made complex by the substantial heterogeneity among included studies. Although there is no formal evidence for or against preoperative dental assessment, it is advisable to perform this with the aim of maintaining favorable oral hygiene and thus reduce the risk factors.

LEVEL OF EVIDENCE

Level III, systematic review.

Antibiotic prophylaxis is not indicated prior to dental procedures for prevention of periprosthetic joint infections

Background and purpose - To minimize the risk of hematogenous periprosthetic joint infection (HPJI), international and Dutch guidelines recommended antibiotic prophylaxis prior to dental procedures. Unclear definitions and contradictory recommendations in these guidelines have led to unnecessary antibiotic prescriptions. To formulate new guidelines, a joint committee of the Dutch Orthopaedic and Dental Societies conducted a systematic literature review to answer the following question: can antibiotic prophylaxis be recommended for patients (with joint prostheses) undergoing dental procedures in order to prevent dental HPJI? Methods - The Medline, Embase, and Cochrane databases were searched for randomized controlled trials (RCTs), reviews, and observational studies up to July 2015. Studies were included if they involved patients with joint implants undergoing dental procedures, and either considered HPJI as an outcome measure or described a correlation between HPJI and prophylactic antibiotics. A guideline was formulated using the GRADE method and AGREE II guidelines. Results - 9 studies were included in this systematic review. All were rated "very low quality of evidence". Additional literature was therefore consulted to address clinical questions that provide further insight into pathophysiology and risk factors. The 9 studies did not provide evidence that use of antibiotic prophylaxis reduces the incidence of dental HPJI, and the additional literature supported the conclusion that antibiotic prophylaxis should be discouraged in dental procedures. Interpretation - Prophylactic antibiotics in order to prevent dental HPJI should not be prescribed to patients with a normal or an impaired immune system function. Patients are recommended to maintain good oral hygiene and visit the dentist regularly.

Secondary Breast Augmentation

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Assess common clinical problems in the secondary breast augmentation patient. 2. Describe a treatment plan to correct the most common complications of breast augmentation. 3. Provide surgical and nonsurgical options for managing complications of breast augmentation. 4. Decrease the incidence of future complications through accurate assessment, preoperative planning, and precise surgical technique.

SUMMARY

Breast augmentation has been increasing steadily in popularity over the past three decades. Many of these patients present with secondary problems or complications following their primary breast augmentation. Two of the most common complications are capsular contracture and implant malposition. Familiarity and comfort with the assessment and management of these complications is necessary for all plastic surgeons. An up-to-date understanding of current devices and techniques may decrease the need to manage future complications from the current cohort of breast augmentation patients.

Prevention of Infection in Orthopedic Prosthetic Surgery

Total joint arthroplasty is a generally safe orthopedic procedure; however, infection is a potentially devastating complication. Multiple risk factors have been identified for development of prosthetic joint infections. Identification of patients at risk and preoperative correction of known risk factors, such as smoking, diabetes mellitus, anemia, malnutrition, and decolonization of Staphylococcus carriers, represent well-established actions to decrease the infection risk. Careful operative technique, proper draping and skin preparation, and appropriate selection and dosing of antimicrobials for perioperative prophylaxis are also very important in prevention of infection.

The Prevention of Periprosthetic Joint Infections

Periprosthetic joint infection (PJI) following total joint arthroplasty (TJA) adversely affects patient quality of life and health status, and places a huge financial burden on the health care. The first step in combating this complication is prevention, which may include implementation of strategies during the preoperative, intraoperative, or postoperative period. Optimization of the patient with appreciation of the modifiable and non-modifiable factors is crucial. Preoperative optimization involves medical optimization of patients with comorbidities such as diabetes, anemia, malnutrition and other conditions that may predispose the patient to PJI. Among the intraoperative strategies, administration of appropriate and timely antibiotics, blood conservation, gentle soft tissue handling, and expeditious surgery in an ultra clean operating room are among the most effective strategies. During the postoperative period, all efforts should be made to minimize ingress or proliferation of bacteria at the site of the index arthroplasty from draining the wound and hematoma formation. Although the important role of some preventative measures is known, further research is needed to evaluate the role of unproven measures that are currently employed and to devise further strategies for prevention of this feared complication.

Antibiotic Prophylaxis During Dental Procedures in Patients with Prosthetic Joints

In patients with artificial joints, the need for antimicrobial prophylaxis during dental procedures is often raised. The present document describes the pathogenic mechanisms and epidemiological data on the subject of periprosthetic joint infections (PJI) after dental procedures. The document reflects the opinion and recommendations of the expert group 'Infection' of Swiss Orthopaedics. Microorganisms belonging to oral flora can seed haematogenously to an artificial joint. The proof of a causative relation with dental procedures is not possible, because the responsible bacteraemia can originate from the oral cavity at any time, irrespective of when the dental procedure occurs. Good oral hygiene is associated with a lower risk for PJI. Transient bacteraemia occurs during daily oral hygiene activity (e.g., tooth brushing) and thus the cumulative risk for a haematogenous PJI from tooth brushing is higher than that from a dental procedure. PJI after a dental procedure are rarely reported. On the basis of an epidemiological model, several thousand patients with artificial joints must receive antimicrobial prophylaxis to prevent a single PJI. Considering this ratio, the number of adverse events due to the antimicrobial compound exceeds the benefit of administering it by a large magnitude. Therefore, as a rule for the vast majority of cases, antimicrobial prophylaxis during dental procedures is not recommended. It is important that a patient has a good oral health status before joint implantation and that good oral hygiene is continuously maintained in patients with artificial joints.

Dental disease and periprosthetic joint infection

➤ The number of patients with end-stage osteoarthritis is increasing, and treatment with hip and knee arthroplasty is expected to increase over the next several decades. ➤ Dental disease has long been anecdotally associated with increased periprosthetic joint infections, although case-control studies do not support this relationship. ➤ While most recent guidelines for the prevention of endocarditis have favored treatment of fewer patients, the most recent recommendations for prevention of periprosthetic joint infection have increased the number of patients who would receive antibiotics before a dental procedure. ➤ Antibiotics given before a dental procedure decrease the risk of bacteremia from the oral cavity, but this is of uncertain clinical importance. ➤ The number of patients who would require antibiotics before dental procedures to prevent one periprosthetic joint infection greatly outnumbers the number of patients who would experience an adverse event associated with antibiotics given before a dental procedure.

Postarthroscopic Infection in the Knee following Medical or Dental Procedures

Knee infection is a relatively rare complication after arthroscopic knee surgery (Babcok et al., 2002), with reported incidences ranging from 0.1% to 3.4% (Babcok et al., 2002 and Bert et al., 2007). Although postoperative dental and surgical procedures were formerly considered a risk factor for infection in arthroplasty patients, the American Dental Association (ADA) and Academy of Orthopaedic Surgery (AAOS) no longer recommend prophylactic antibiotics for patients with prosthetic joints and do not make recommendations concerning patients who have recently undergone arthroscopic surgery (J. M. Bert and T. M. Bert, 2010). We report two patients who had an uncomplicated postoperative course until having a procedure and then developed a septic knee.

Dual-plane breast augmentation for minimal ptosis pseudoptosis (the "in-between" patient)

BACKGROUND

Dual-plane breast augmentation (DPBA) can be an effective technique for treating patients with ptotic breasts who fall somewhere in between the traditional requirements for breast augmentation versus a more extensive augmentation-mastopexy.

OBJECTIVES

The author outlines indications for DPBA, describes the technique, and presents outcomes data from patients receiving gel or saline implants in an effort to clarify the advantages of DPBA compared with breast augmentation with or without mastopexy.

METHODS

This 8-year retrospective comparative study reviewed the results of saline implants placed with a DPBA technique in a single surgeon's practice during the final 4 years of the FDA moratorium (phase 1) compared with both gel and saline implants placed during the 4 years after the moratorium was lifted (phase 2). Patients were consecutive. The entire patient cohort (n = 1999 for primary BA; 3998 implants) was assessed for outcomes.

RESULTS

Of the entire cohort, 24.2% were followed for over 1 year; 23.5% of the 256 DPBA patients were followed for over 1 year. Mean (SD) age was 33.6 (8.7) years. The difference in revision rates between BA versus DPBA was 4.6% (95% confidence interval [CI], 0.7-8.5).

CONCLUSION

The DPBA approach is most likely suited for patients with minimal ptosis who fall into a "gray area" between normal anatomy (treated with a traditional BA) and frank ptosis (which would require mastopexy). Knowledge of this approach will allow surgeons to more effectively treat patients who present with unique "in-between" anatomy not addressed by ordinary BA and avoid more extensive mastopexy scars.

LEVEL OF EVIDENCE

3.

Gemella haemolysans Infection in Total Hip Arthroplasty

Gemella haemolysans is a Gram-positive coccus and commensal of the upper respiratory tract and oral mucosa that rarely causes clinically important infections. There is only one previous report of this organism causing periprosthetic infection, in a total knee arthroplasty. We present a case of septic loosening of an uncemented total hip arthroplasty due to G. haemolysans, in an asplenic patient with insulin dependent diabetes mellitus. Treatment with two-stage revision has been successful at 7 years of follow-up.

Antibiotic prophylaxis to reduce the risk of joint implant contamination during dental surgery seems unnecessary

INTRODUCTION

Joint implant infection rates range between 0.5% and 3%. Contamination may be hematogenous, originating in oro-dental infection and, as in endocarditis, antibiotic prophylaxis has been recommended to cover oro-dental surgery in immunodepressed patients with joint implants less than 2 years old, despite the lack of any formal proof of efficacy. In this context, the cost and side effects of such prophylaxis raise the question of its real utility.

MATERIALS AND METHODS

A search of Pubmed was performed using the following keywords: prosthetic joint infection, dental procedure, antibiotic prophylaxis, hematogenous infection, dental infection, bacteremia, and endocarditis. Six hundred and fifty articles were retrieved, 68 of which were analyzed in terms of orthopedic prosthetic infection and/or endocarditis and oro-dental prophylaxis, as relevant to the following questions: frequency and intensity of bacteremia of oro-dental origin, frequency of prosthetic joint infection secondary to dental surgery, and objective efficacy of antibiotic prophylaxis in dental surgery in patients with joint implants.

RESULTS

Bacteremia of oro-dental origin is more frequently associated with everyday activities such as mastication than with tooth extraction. Isolated cases of prosthetic contamination from dental infection have been reported, but epidemiological studies in joint implant bearers found that absence of antibiotic prophylaxis during oro-dental surgery did not increase the rate of prosthetic infection. The analysis was not able to answer the question of the efficacy of dental antibiotic prophylaxis in immunodepressed patients; however, oro-dental hygiene and regular dental treatment reduce the risk of prosthetic infection by 30%.

DISCUSSION AND CONCLUSION

The present update is in agreement with the conclusions of ANSM expert group, which advised against antibiotic prophylaxis in oro-dental surgery in implant bearers, regardless of implant duration or comorbidity: the associated costs and risks are disproportional to efficacy. LEVEL OF EVIDENCE AND TYPE OF STUDY: Level V; expert opinion.

What is the true incidence of dental pathology in the total joint arthroplasty population?

One million total joint arthroplasties (TJAs) are performed annually in the United States. The incidence of oral disease has not been documented in this population. To understand the scope of disease, a descriptive longitudinal population-based study sought to define the true incidence of dental pathology in the TJA population. One hundred consecutive TJA patients from a dedicated arthroplasty practice were sent for dental clearance, including oral examination, cleaning, radiographs, and treatment of active decay. The incidence of pathology was documented. Of 10 patients, 23 (23%) were treated before being cleared for arthroplasty. Sixty-six procedures were performed--2.9 problems per patient. No patient developed TJA infection. Routine preoperative dental clearance revealed 23% incidence of pathology, and no patient developed TJA infection.

Perioperative, postoperative, and prophylactic use of antibiotics in alloplastic total temporomandibular joint replacement surgery: a survey and preliminary guidelines

PURPOSE

In 2009, the American Academy Of Orthopedic Surgeons recommended lifelong prophylaxis after orthopedic total joint replacement (TJR) before these patients undergo dental, aerodigestive, genitourinary (GU), and gastrointestinal (GI) procedures. Because oral and maxillofacial surgeons worldwide are implanting alloplastic total temporomandibular joint replacements (TMJ TJRs), it appeared reasonable to survey these surgeons to obtain data that might shed some light, not only on this issue, but also to obtain some data to begin to develop preliminary guidelines for the peri- and postoperative use of antibiotics for TMJ TJR using these results and the orthopedic data.

MATERIALS AND METHODS

A total of 35 surgeons worldwide, members of either the TMJ Concepts or Biomet Microfixation online networks were e-mailed a standard questionnaire surveying their perioperative, postoperative, and prophylactic use of antibiotics for their TMJ TJR cases.

RESULTS

Of the 35 surgeons, 26 (74.2%) from 8 different countries responded. A total of 2,476 cases (3,368 joints) were retrospectively surveyed. Of the responding surgeons, 96.2% used, in order of frequency, cefazolin, clindamycin, cephalosporin, or penicillin-based antibiotics in the perioperative period and continued their use for a mean of 7 days (range 5 to 14) postoperatively. Also, 46.2% soaked the TJR components either in the perioperative antibiotic or in vancomycin, poviodine, gentamycin, or peroxide before implantation. In addition, 61.5% irrigated the wounds after device implantation with bacitracin, vancomycin, poviodine, peroxide, or the perioperative antibiotic. These surgeons reported that 51 joints (1.51%) had become infected within a mean of 6 months (range 2 weeks to 12 years) postoperatively. A total of 32 devices (0.95%) required removal and/or replacement. In cases in which the organisms were isolated, the organisms commonly associated with biofilm infection of TJR devices, Staphylococcus aureus, S epidermidis, Peptostreptococcus, and Pseudamonas aeruginosa, were cultured. In only 1 joint (0.003%) was there a suggestion of an association with an invasive dental/aerodigestive, GU/GI procedure. Regarding prophylaxis after TMJ TJRs and before dental/aerodigestive, GU, or GI procedures, 53.8% of the respondents reported that they provided prophylaxis. Of these, 1 recommended doing this for 6 months and 4 for 2 years, such as has been the American Dental Association/American Academy of Orthopedic Surgeons recommendation since 2003; and 9 reported they believe these TMJ TJR patients should have lifetime antibiotic prophylaxis before invasive dental/aerodigestive, GU, or GI procedures.

CONCLUSION

The evidence provided from the present small study survey and a review of the orthopedic data could provide the opportunity to develop guidelines for the preoperative, intraoperative, and postoperative antibiotic management for TMJ TJRs and spur additional research into this important area of patient management.

Should patients with hip joint prosthesis receive antibiotic prophylaxis before dental treatment?

The safety committee of the American Academy of Orthopedic Surgeons (AAOS) recommended in 2009 that clinicians should consider antibiotic prophylaxis for all patients with total joint replacement before any invasive procedure that may cause bacteremia. This has aroused confusion and anger among dentists asking for the evidence. The present review deals with different aspects of the rationale for this recommendation giving attention to views both in favor of and against it.

Molecular detection of transcriptionally active bacteria from failed prosthetic hip joints removed during revision arthroplasty

The purpose of this study was to use microbiological culture and bacterial 16S rRNA gene sequencing methods to detect transcriptionally active bacteria present on the surface of failed prosthetic hip joints removed during revision arthroplasty. Five failed prosthetic hip joints were sonicated to dislodge adherent bacteria and subjected to microbiological culture. Bacterial RNA was extracted from each sonicate, cDNA prepared by reverse transcription and the 16S rRNA gene amplified using universal primers. Polymerase chain reaction (PCR) products were cloned, assigned to distinct groups by restriction fragment length polymorphism (RFLP) analysis and one representative clone from each group was sequenced. Bacteria were identified by comparison of the obtained 16S rRNA gene sequences with those deposited in public access sequence databases. All five specimens were positive for the presence of bacteria by both culture and PCR. Culture methods identified species from eight genera. Molecular detection of transcriptionally active bacteria identified a wider range of species. A total of 42 phylotypes were identified, of which Lysobacter gummosus was the most abundant (31.6%). Thirty-four clones (14.5%) represented uncultivable phylotypes. No potentially novel species were identified. It is concluded that a diverse range of transcriptionally active bacterial species are present within biofilms on the surface of failed prosthetic hip joints.

Pyogenic liver abscess with Prevotella species and Fusobacterium necrophorum as causative pathogens in an immunocompetent patient

Pyogenic liver abscess of odontogenic origin in an immunocompetent patient is extremely rare. We report an immunocompetent 25-year-old male hepatitis B carrier with severe dental disease that led to the development of liver abscess. A periapical abscess in the upper left molar area was seen on his dental X-ray. Two sets of blood cultures grew Prevotella species, bacteria that are commonly found inside the oral cavity. Bacterial culture of the liver abscess drainage sample grew both Prevotella and Fusobacterium necrophorum. This led to our diagnosis of pyogenic liver abscess of dental origin, since we found no other source of infection in our patient except for his dental disease. After antibiotic therapy with drainage, abdominal sonography showed resolution of the abscess. The diseased teeth were also extracted. During 1 year of follow-up, there was no sign of abscess recurrence. A diagnosis of pyogenic liver abscess necessitates a complete evaluation to rule out possible biliary, colonic or other associated diseases. However, when a liver abscess is thought to be cryptogenic, we also recommend a careful dental examination to help identify the source of infection.

Prosthetic joint infection, dental treatment and antibiotic prophylaxis

Current international and national prophylactic antibiotic regimens have been analyzed in respect of the prevention of bacteremia after dental and surgical procedures and, therefore, of joint prosthesis infection. This information was used to formulate guidelines for the Department of Maxillofacial and Oral Surgery. Publications since 2003 were used in this research. In addition, recommendations of accredited institutions and associations were examined. These included the guidelines of the American Dental Association in association with the American Academy of Orthopaedic Surgeons (2003), the American Heart Association (2007), the Working Party of the British Society for Antimicrobial Chemotherapy (2006) and the Australian Dental Guidelines (2005). No guidelines published by any institution in South Africa were found. The general rationale for the use of antibiotic prophylaxis for surgical (including dental) interventions is that those procedures may result in a bacteremia that may cause infection in joint prostheses. Antibiotics, however, should therefore be administered to susceptible patients, e.g. immunocompromised patients, prior to the development of bacteremia. The guidelines recommended for use in South Africa are based solely on those used outside South Africa. South Africa is regarded as a developing country with its own population and demographic characteristics. Eleven percent of our population is infected with HIV, and a specific guideline for prophylactic antibiotic treatment is, therefore, essential.

Antibiotic prophylaxis before invasive dental procedures in patients with arthroplasties of the hip and knee

More than a million hip replacements are carried out each year worldwide, and the number of other artificial joints inserted is also rising, so that infections associated with arthroplasties have become more common. However, there is a paucity of literature on infections due to haematogenous seeding following dental procedures. We reviewed the published literature to establish the current knowledge on this problem and to determine the evidence for routine antibiotic prophylaxis prior to a dental procedure.

We found that antimicrobial prophylaxis before dental interventions in patients with artificial joints lacks evidence-based information and thus cannot be universally recommended.

Identification of bacteria on the surface of clinically infected and non-infected prosthetic hip joints removed during revision arthroplasties by 16S rRNA gene sequencing and by microbiological culture

It has been postulated that bacteria attached to the surface of prosthetic hip joints can cause localised inflammation, resulting in failure of the replacement joint. However, diagnosis of infection is difficult with traditional microbiological culture methods, and evidence exists that highly fastidious or non-cultivable organisms have a role in implant infections. The purpose of this study was to use culture and culture-independent methods to detect the bacteria present on the surface of prosthetic hip joints removed during revision arthroplasties. Ten consecutive revisions were performed by two surgeons, which were all clinically and radiologically loose. Five of the hip replacement revision surgeries were performed because of clinical infections and five because of aseptic loosening. Preoperative and perioperative specimens were obtained from each patient and subjected to routine microbiological culture. The prostheses removed from each patient were subjected to mild ultrasonication to dislodge adherent bacteria, followed by aerobic and anaerobic microbiological culture. Bacterial DNA was extracted from each sonicate and the 16S rRNA gene was amplified with the universal primer pair 27f/1387r. All 10 specimens were positive for the presence of bacteria by both culture and PCR. PCR products were then cloned, organised into groups by RFLP analysis and one clone from each group was sequenced. Bacteria were identified by comparison of the 16S rRNA gene sequences obtained with those deposited in public access sequence databases. A total of 512 clones were analysed by RFLP analysis, of which 118 were sequenced. Culture methods identified species from the genera Leifsonia (54.3%), Staphylococcus (21.7%), Proteus (8.7%), Brevundimonas (6.5%), Salibacillus (4.3%), Methylobacterium (2.2%) and Zimmermannella (2.2%). Molecular detection methods identified a more diverse microflora. The predominant genus detected was Lysobacter, representing 312 (60.9%) of 512 clones analysed. In all, 28 phylotypes were identified: Lysobacter enzymogenes was the most abundant phylotype (31.4%), followed by Lysobacter sp. C3 (28.3%), gamma proteobacterium N4-7 (6.6%), Methylobacterium SM4 (4.7%) and Staphylococcus epidermidis (4.7%); 36 clones (7.0%) represented uncultivable phylotypes. We conclude that a diverse range of bacterial species are found within biofilms on the surface of clinically infected and non-infected prosthetic hip joints removed during revision arthroplasties.

The evidence base for the efficacy of antibiotic prophylaxis in dental practice

INTRODUCTION

People with various medical conditions and devices are suggested candidates for receiving antibiotic prophylaxis before undergoing dental procedures. This practice is controversial, however, owing to the lack of proof of efficacy. The authors conducted a qualitative, systematic review to determine the level of evidence for this practice and whether antibiotic prophylaxis prevents distant site infections in these patients.

METHODS

The authors selected eight groups of patients with specific medical conditions and devices who often are given antibiotic prophylaxis before undergoing invasive dental procedures. The conditions and devices were cardiac-native heart valve disease, prosthetic heart valves and pacemakers; hip, knee and shoulder prosthetic joints; renal dialysis shunts; cerebrospinal fluid shunts; vascular grafts; immunosuppression secondary to cancer and cancer chemotherapy; systemic lupus erythematosus; and insulin-dependent (type 1) diabetes mellitus. The authors thoroughly searched the literature for the years 1966 through 2005 for references indicating some level of support for this practice and graded each publication on the basis of level of evidence.

RESULTS

The authors found formal recommendations in favor of antibiotic prophylaxis for only three of the eight medical conditions: native heart disease, prosthetic heart valves and prosthetic joints. They found no prospective randomized clinical trials and only one clinical study of antibiotic prophylaxis. Only one systematic review and two case series provided weak, if any, support for antibiotic prophylaxis in patients with cardiac conditions. The authors found little or no evidence to support this practice or to demonstrate that it prevents distant site infections for any of these eight groups of patients.

CONCLUSIONS

No definitive, scientific basis exists for the use of prophylactic antibiotics before dental procedures for these eight groups of patients.

Antimicrobial agents in orthopaedic surgery: Prophylaxis and treatment

The pathogenesis of implant-associated infection involves interaction between the microorganisms (biofilm formation), the implant and the host. Despite improvement of perioperative prophylaxis, orthopaedic implants still remain highly susceptible to bacterial or fungal contamination, generally resulting in persistent implant-associated infection. Therefore, perioperative and life-long prevention of infection is important. For perioperative prophylaxis, a first- or second-generation cephalosporin is recommended, which should be administered between 60 and 30 minutes before incision. The duration of prophylaxis should not exceed 1 day. In centres with a low incidence of infection, a single dose is sufficient. Treatment of infections associated with orthopaedic devices usually requires appropriate surgical intervention combined with prolonged antimicrobial therapy. The choice of the antimicrobial regimen depends on the duration and pathogenesis of infection, stability of the implant, antimicrobial susceptibility of the pathogen and condition of the surrounding soft tissue. The role of rifampicin (rifampin), which has excellent activity on adherent staphylococci, in combination with beta-lactams, glycopeptides, fluoroquinolones, minocycline, cotrimoxazole or fusidic acid, in the treatment of staphylococcal infections is outlined. Increasing antimicrobial resistance requires the use of alternative agents, such as quinupristin/dalfopristin, linezolid and daptomycin, but results of clinical trials with these agents are limited. Also reviewed are potential new antimicrobial agents currently undergoing investigation, such as the novel oxazolidinone RWJ-416457, the new glycopeptide dalbavancin, the glycylcycline compound tigecycline, the new carbacephem BP-102 and novel rifamycin derivatives. Vaccination against Staphylococcus aureus with StaphVAX induced specific antibodies potentially preventing bacteraemia; however, there are no studies on efficacy in the prophylaxis of device-associated infections with this vaccine.

Patients with artificial joints: do they need antibiotic cover for dental treatment?

This study reviews whether patients with artificial joints need antibiotic cover for dental treatment. Generally in Australia the practice has developed of giving most patients with artificial joints antibiotic prophylaxis for a wide range of dental procedures. This is partly on anecdotal grounds, partly historical and partly for legal concerns. It has been encouraged by some guidelines. Scientifically, the risk and the benefit of each step in the process needs to be analysed. This review shows that the risk of an artificial joint becoming infected from a bacteraemia of oral origin is exceedingly low whereas the risk of an adverse reaction to the antibiotic prophylaxis is higher than the risk of infection. If all patients with artificial joints receive antibiotic prophylaxis then more will die from anaphylaxis than develop infections. Factors which balance the risk benefit are if the patient is seriously immunocompromised, if the joint prosthesis is failing or chronically inflamed and if the dental procedures, such as from extractions and deep periodontal scaling, produce high level bacteraemias. Recommendations to rationalize antibiotic prophylaxis for patients with artificial joints are presented.

Micromonas (Peptostreptococcus) micros: unusual case of prosthetic joint infection associated with dental procedures

Micromonas (Peptostreptococcus) micros is frequently associated with periodontal disease as well as respiratory, gastrointestinal and female genitourinary tract infections, but only rarely has been reported as a pathogenic agent of prosthetic joint infections. Here we describe a case of a 63-year-old woman with prosthetic joint infection of total hip arthroplasty caused by the anaerobic species Micromonas micros, associated with tooth extraction. Samples obtained intraoperatively and from the oral cavity were positive for the presence of M. micros by culture and by real-time PCR. This case report indicates that infections of prosthetic joints can be associated with dental procedures and that sensitive molecular techniques are necessary for their routine diagnostic.

Isolation and characterization of subgingival staphylococci from periodontitis patients and controls

OBJECTIVES

To isolate and characterize subgingival staphylococci from patients with periodontal disease and from periodontally healthy controls, to evaluate the periodontal environment as a potential source for systemic staphylococcal infections.

METHODS

Periopaper strips were used to isolate subgingival staphylococci from 28 patients with chronic periodontitis and 28 periodontally healthy age and sex-matched controls. Staphylococci were identified by microbiological methods and antibiotic resistance profiles determined.

RESULTS

Staphylococci were isolated from 54% diseased subgingival and 43% healthy subgingival sites in over 50% periodontitis patients and from 29% healthy subgingival sites in 54% controls. No significant differences in the frequency of isolation or numbers of staphylococci isolated from diseased and healthy sites were noted. Staphylococcus epidermidis was the predominant oral species. Seventy per cent (115 of 165) of all isolates were penicillin-resistant.

CONCLUSIONS

Subgingival staphylococci are present in both periodontitis patients and controls. In periodontitis there is an increased risk of bacteraemia because of the increased dentogingival surface area. The dental and periodontal health of patients at risk from haematogenous infections should therefore be maintained at a high level. Antibiotic resistance profiles of the oral staphylococcal isolates suggest that amoxicillin may no longer be a suitable antibiotic for prophylaxis against systemic infections such as prosthetic valve endocarditis.

Infection of a total hip arthroplasty with Prevotella loeschii

Infection is a serious complication of total hip replacement. It has been proposed that 6% of all infections after total hip arthroplasty may be of dental origin through hematogenous spread. However, no conclusive evidence that the mouth is a definitive source for infection of a total hip replacement has been reported. In the current case, Prevotella loeschii, a pigmented bacteroides species was identified in a total hip replacement. Prevotella loeschii is an organism which exclusively inhabits the dental region. Hematogenous spread of Prevotella loeschii may occur after penetration of the mucosal barrier in cases of endodontic or periodontic lesions, pericoronitis, or complications of tooth extraction. The involvement of Prevotella loescheii in an infection in a patient who had a total hip arthroplasty is strong evidence for the mechanism of a hematogenous infection from a dental source.

Antibiotic prophylaxis: problems in paradise

The age of antibiotic prophylaxis may be receding into its twilight years because the assumption upon which it was based has not proved generally true. Although antibiotics treat infections, limited benefit has been demonstrated in preventing infections. These are two entirely different biologic entities, a distinction which appears to have gone unappreciated by many for more than 50 years. If the principles of antibiotic prophylaxis established more than 40 years ago had been assiduously followed, many of its abuses could have been avoided. This may not have stopped our legal colleagues, but it would have been worth an effort on behalf of our patients. It is likely that the massive overuse of antibiotics as litigation prevention has contributed to the global epidemic of antibiotic-resistant micro-organisms and an unknown number of serious adverse effects to the antibiotics themselves. Even with this abuse, much money has still flowed from defendant to plaintiff. Substantial data exist that antibiotics do not prevent bacteremias. The absolute risk rate for bacterial endocarditis after dental treatment even in at-risk patients is very low. Antibiotic prophylaxis for surgical infections requires specific dosing schedules (perioperative surgical prophylaxis) to be successful. Hopefully the difficulties presented herein regarding antibiotic prophylaxis will lead to their more enlightened use in the future.

Antibiotic prophylaxis for dental patients with total joint replacements

BACKGROUND AND OVERVIEW

In 1997, the American Dental Association and the American Academy of Orthopaedic Surgeons convened an expert panel of dentists, orthopaedic surgeons and infectious disease specialists and published their first Advisory Statement on Antibiotic Prophylaxis for Dental Patients with Prosthetic Joints. This represented the first time that national health organizations had gone on record on this topic. This 2003 advisory statement is the first periodic update of the 1997 statement. In addition, the organizations have created a new patient handout (included at the end of the statement) that dentists may share with their patients. The 1997 Advisory Statement has been well-used by dentists and orthopaedic surgeons. Following their standard protocols for periodic review of existing advisory statements, the ADA and AAOS and their expert consultants recently reviewed the 1997 statement.

CONCLUSIONS AND CLINICAL IMPLICATIONS

The 2003 statement includes some modifications of the classification of patients at potential risk and of the incidence stratification of bacteremic dental procedures, but no changes in terms of suggested antibiotics and antibiotic regimens. The statement concludes 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.

Antibiotic prophylaxis for patients with joint prostheses - still a dilemma for dental practitioners

OBJECTIVES

To provide a critical review of the current evidence that implicates dental-induced bacteraemia as a risk for joint infections in patients fitted with joint prostheses and appraise the need for antibiotic prophylaxis.

DESIGN

Retrospective analysis.

SETTING

Mainly hospital-based patients or subjects.

OUTCOME MEASURES

The relationship between joint infections and dental treatment is equivocal at the best and there is no evidence that antibiotic prophylaxis provides such patients with any protection.

RESULTS

Microbiological evidence linking dental treatment-induced bacteraemia to joint infections is weak and if an oral commensal is implicated, it is more likely to have arisen either from a spontaneous bacteraemia or from a dental infection. As a consequence of the latter, we recommended the institution of good dental health prior to joint replacement. There may be a case for providing prophylaxis to the immuno-compromised patient, but only if the immuno-suppression is associated with a neutropenia. In such circumstances, only emergency treatment should be considered until the neutropenia is resolved. Antibiotic regimens that are recommended by orthopaedic surgeons have not been evaluated in a randomised placebo-controlled study and many of the drugs are not licensed for this purpose. The evidence on cost-risk benefit seems to demonstrate that antibiotic prophylaxis with either amoxicillin or penicillin is not cost effective when compared with no prophylaxis.

CONCLUSION

The case for providing antibiotic prophylaxis prior to dental treatment in patients fitted with a joint prosthesis is weak or virtually non-existent. Furthermore, the risk from providing prophylaxis is greater than the risk of a joint infection.

Improving oral health care for the frail elderly: a review of widespread problems and best practices

Oral health is an important component of overall health, well-being, and quality of life for institutionalized elders. Despite reports by nurses of the importance of oral hygiene, empirical evidence shows that daily oral care interventions have not been effective in safeguarding the oral and general health of this vulnerable population. Effective practice must involve not only recognizing its importance but also ensuring that daily oral hygiene receives the same priority as other care practices.

Endodontics in the adult patient: the role of antibiotics

OBJECTIVES

The aim of this study was to review the published work on the indications and efficacy for antibiotics in endodontic therapy.

DATA SOURCES

Published works in the medical and dental literature.

STUDY SELECTION

Evaluation of published clinical trials in endodontic and other pertinent literature.

CONCLUSIONS

Antibiotics are not routinely indicated in the practice of endodontics. Therapeutic antibiotics may be required as an adjunct to operative treatment when there is pyrexia and/or gross local swelling; they are only rarely indicated in the absence of operative intervention. Prophylactic antibiotics may be required for certain patients who are susceptible to serious infective sequaelae.