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

Antibiotic Prophylaxis is Often Unnecessary for Screening Colonoscopies Following Total Knee Arthroplasty

INTRODUCTION

Incidence of bacteremia following screening colonoscopy is low, but risk of hematogenous spread causing prosthetic joint infection (PJI) may exist in total knee arthroplasty (TKA) patients. In multivariate analyses, we examined PJI risk among three TKA cohorts: (1) colonoscopy recipients given antibiotic prophylaxis; (2) colonoscopy recipients not given antibiotic prophylaxis; and (3) no colonoscopy. We assessed: 90-day to one-year (A) PJI risk, and (B) risk factors for post-colonoscopy PJI.

METHODS

We queried a national, all-payer database for primary TKA recipients from 2010 to 2020. Patients who had colonoscopies and who did (n=2,558) or did not have antibiotic prophylaxis (n=20,000) were identified. These were compared those who did not undergo colonoscopy (n=20,000). The 20,000 patients were randomly selected to mitigate type 1 errors. Multivariate regressions compared PJI risk factors, such as alcohol abuse (AA), rheumatoid arthritis (RA), and diabetes.

RESULTS

Both colonoscopy cohorts had no increased PJI risk compared to non-colonoscopy (odds ratio (OR)<2.20, P≥0.064). Alcohol abuse, diabetes, and RA were found to be risk factors further enhancing likelihood of PJI for TKA patients not receiving antibiotics undergoing colonoscopies (OR>1.35, P≤0.044).

CONCLUSION

Overall, antibiotic prophylaxis does not decrease PJI risk following colonoscopy TKA recipients. After adjusting for known risk factors, both colonoscopy cohorts demonstrated similar PJI risks compared to the non-colonoscopy cohort. However, AA, diabetes, and RA were associated with further increased PJI risk for TKA patients undergoing colonoscopies compared to those who did not. Therefore, if undergoing colonoscopy after TKA, our findings suggest that most patients do not need to have antibiotics except for these high-risk patients.

Antibiotic Prophylaxis Is Not Necessary for Invasive Dental Procedures in Existing Total Knee Arthroplasty Implants

Antibiotic prophylaxis before an invasive dental procedure (IDP) for patients with preexisting knee implants has been suggested, but its use has yet to reach consensus. Therefore, we sought to examine antibiotic prophylaxis before an IDP for patients who had undergone a total knee arthroplasty (TKA). We specifically assessed 90-day to 1-year (1) periprosthetic joint infection (PJI) and (2) revision. We queried a national, all-payer database for patients undergoing primary TKA between 2010 and 2020 (n=1,952,917). We identified IDP, as defined by any procedure that involves gingival manipulation, and stratified according to antibiotic prophylaxis. A control cohort of TKA recipients without subsequent IDP was then established. All 3 cohorts were matched according to demographic and health metrics (n=496). Chi-square testing generated the odds ratio (OR) with 95% CI for postoperative PJI and revision. The odds for PJI and revision at all time points were statistically similar between antibiotic prophylaxis and no antibiotic prophylaxis (PJI: OR, 0.62; 95% CI, 0.11-4.00; P≥.479; revision: OR, ≥0.33; 95% CI, 0.03-4.00; P≥.248). Additionally, both IDP cohorts and the control cohort had similar rates of postoperative PJI (P≥.367) and revision (P≥.173) at all time points. Antibiotic prophylaxis before an IDP for TKA recipients did not decrease the risk of PJI or revision up to 1 year after the index procedure. These results support the trend by dentists and orthopedic surgeons to refrain from antibiotic prophylaxis. However, it likely has utility in patients at high risk, as suggested by current guidelines. [Orthopedics. 2023;46(2):76-81.].

Quantifying the risk of prosthetic joint infections after invasive dental procedures and the effect of antibiotic prophylaxis

BACKGROUND

Dentists face the expectations of orthopedic surgeons and patients with prosthetic joints to provide antibiotic prophylaxis (AP) before invasive dental procedures (IDPs) to reduce the risk of late periprosthetic joint infections (LPJIs), despite the lack of evidence associating IDPs with LPJIs, lack of evidence of AP efficacy, risk of AP-related adverse reactions, and potential for promoting antibiotic resistance. The authors aimed to identify any association between IDPs and LPJIs and whether AP reduces LPJI incidence after IDPs.

METHOD

The authors performed a case-crossover analysis comparing IDP incidence in the 3 months immediately before LPJI hospital admission (case period) with the preceding 12-month control period for all LPJI hospital admissions with commercial or Medicare supplemental or Medicaid health care coverage and linked dental and prescription benefits data.

RESULTS

Overall, 2,344 LPJI hospital admissions with dental and prescription records (n = 1,160 commercial or Medicare supplemental and n = 1,184 Medicaid) were identified. Patients underwent 4,614 dental procedures in the 15 months before LPJI admission, including 1,821 IDPs (of which 18.3% had AP). Our analysis identified no significant positive association between IDPs and subsequent development of LPJIs and no significant effect of AP in reducing LPJIs.

CONCLUSIONS

The authors identified no significant association between IDPs and LPJIs and no effect of AP cover of IDPs in reducing the risk of LPJIs.

PRACTICAL IMPLICATIONS

In the absence of benefit, the continued use of AP poses an unnecessary risk to patients from adverse drug reactions and to society from the potential of AP to promote development of antibiotic resistance. Dental AP use to prevent LPJIs should, therefore, cease.

Necrotizing Fasciitis of the Hand After a Prolonged Endodontic Procedure: A Case Report

CASE

In this article, we present a case report of a patient with limited medical history and without apparent local injury, who developed left hand Group A Streptococcus-induced necrotizing fasciitis after undergoing a prolonged endodontic procedure.

CONCLUSION

In addition to host factors, perhaps, the virulence of the bacteria present in the oropharynx and the expected bacterial load based on the length and complexity of a dental procedure need to be considered when deciding on whether or not to administer prophylactic antibiotics to patients undergoing dental procedures.

Analysis of Prosthetic Joint Infections Following Invasive Dental Procedures in England

Importance

Dentists in the United States are under pressure from orthopedic surgeons and their patients with prosthetic joints to provide antibiotic prophylaxis before invasive dental procedures (IDP) to reduce the risk of late prosthetic joint infection (LPJI). This has been a common practice for decades, despite a lack of evidence for an association between IDP and LPJI, a lack of evidence of antibiotic prophylaxis efficacy, cost of providing antibiotic prophylaxis, and risk of both adverse drug reactions and the potential for promoting antibiotic resistance.

Objective

To quantify any temporal association between IDP and subsequent LPJI.

Design, Setting, and Participants

This cohort study used a case-crossover and time trend design to examine any potential association between IDP and LPJI. The population of England (55 million) was chosen because antibiotic prophylaxis has never been recommended to prevent LPJI in England, and any association between IDP and LPJI would therefore be fully exposed. All patients admitted to hospitals in England for LPJI from December 25, 2011, through March 31, 2017, and for whom dental records were available were included. Analyses were performed between May 2018 and June 2021.

Exposures

Exposure to IDP.

Main Outcomes and Measures

The main outcome was the incidence of IDP in the 3 months before LPJI hospital admission (case period) compared with the incidence in the 12 months before that (control period).

Results

A total of 9427 LPJI hospital admissions with dental records (mean [SD] patient age, 67.8 [13.1] years) were identified, including 4897 (52.0%) men and 4529 (48.0%) women. Of these, 2385 (25.3%) had hip prosthetic joints, 3168 (33.6%) had knee prosthetic joints, 259 (2.8%) had other prosthetic joints, and 3615 (38.4%) had unknown prosthetic joint types. There was no significant temporal association between IDP and subsequent LPJI. Indeed, there was a lower incidence of IDP in the 3 months prior to LPJI (incidence rate ratio, 0.89; 95% CI, 0.82-0.96; P = .002).

Conclusions and Relevance

These findings suggest that there is no rationale to administer antibiotic prophylaxis before IDP in patients with prosthetic joints.

Osteoarticular infections: a specific program for older patients?

BACKGROUND

With the increasing number of elderly patients, arthroplasties, fractures and diabetic foot infections, the worldwide number of osteoarticular infections (OAI) among the elderly is concomitantly expected to rise.

AIMS

We explore existing scientific knowledge about OAI in the frail elderly population.

METHODS

We performed a literature search linking OAIs to geriatric patients and comparing elderly patients (> 65 years) with average adults (range 18-65 years).

RESULTS

In this literature, financial aspects, comparison of diverse therapies on quality of life, reimbursement policies, or specific guidelines or nursing recommendations are missing. Age itself was not an independent factor related to particular pathogens, prevention of OAI, nursing care, and outcomes of OAI. However, geriatric patients were significantly more exposed to adverse events of therapy. They had more co-morbidities and more conservative surgery for OAI.

CONCLUSION

Available literature regarding OAI management among elderly patients is sparse. In recent evaluations, age itself does not seem an independent factor related to particular epidemiology, pathogens, prevention, nursing care, rehabilitation and therapeutic outcomes of OAI. Future clinical research will concern more conservative surgical indications, but certainly reduce inappropriate antibiotic use.

Antibiotic prophylaxis for urinary catheter manipulation following arthroplasty: a systematic review

BACKGROUND

Urinary catheter use in the peri- and post-operative phase following arthroplasty may be associated with urinary tract infection (UTI) and deep prosthetic joint infection (PJI). These can be catastrophic complications in joint arthroplasty. We performed a systematic review of the evidence on use of antibiotics for urinary catheter insertion and removal following arthroplasty.

METHODS

Electronic databases were searched using the Healthcare Databases Advanced Search interface. Grey literature was searched. From 219 citations, six studies were deemed eligible for review. Due to study heterogeneity, a narrative approach was adopted. Methodological quality of each study was assessed using the Critical Appraisal Skills Programme appraisal tool.

RESULTS

A total of 4696 hip and knee arthroplasties were performed on 4578 participants across all studies. Of these, 1475 (31%) were on men and 3189 (68%) on women. The mean age of study participants was 69 years. Three thousand four hundred and eighty-nine cases (74.3%) were related to hip arthroplasty and 629 (13.4%) to knee arthroplasty. Five hundred and seventy-eight (12.3%) were either hip or knee arthroplasty. Forty-five PJIs were reported across all studies (0.96%). Two studies found either no PJI or no statistical difference in the rate of PJI when no antibiotic prophylaxis was used for catheter manipulation. Another study found no statistical difference in PJI rates between patients with or without preoperative bacteriuria. Where studies report potential haematogenous spread from UTIs, this association can only be assumed. Increased duration of urinary catheterization is positively associated with UTI.

CONCLUSION

It remains difficult to justify the use of prophylactic antibiotics for catheter manipulation in well patients. Their use is not recommended for this indication.

Prosthetic Joint Infection After Dental Work: Is the Correct Prophylaxis Being Prescribed? A Systematic Review

Background

Prosthetic joint infection (PJI) of total hip (THA) or total knee arthroplasty (TKA) after dental procedures is uncommon, and antibiotic prophylaxis remains controversial. For high-risk patients, the American Academy of Orthopedic Surgeons recommends amoxicillin prophylaxis. However, no systematic review of the literature of PJIs associated with dental procedures explores if amoxicillin is suitable for the reported organisms.

Methods

A librarian-assisted search of the major databases (PubMed, Medline, Embase, Scopus) identified 954 articles. Only case reports, case series, and reviews with patient level data were included. After exclusions, 79 articles were fully reviewed.

Results

Forty-four PJIs after dental procedures were identified, 22 in primary THA, 20 in primary TKA, one in revision THA, and one in a hip resurfacing procedure. Antibiotic prophylaxis was documented for 5 patients. The dental procedure was invasive in 35 (79.5%). Comorbidities were present in 17 patients (38.7%). The organisms reported were Streptococcus spp. in 44%, other aerobic gram-positives in 27%, anaerobic gram-positives in 18%, and gram-negative organisms in 11%. An estimated 46% of organisms may be resistant to amoxicillin. The outcomes of treatment were reported for 35 patients (79.5%). Twenty-seven patients (61.4%) had no clinical signs of PJI at the final follow-up visit.

Conclusions

Lower extremity PJI associated with dental procedures is often caused by organisms unlikely to be prevented with amoxicillin. Additional studies are warranted to determine the choice and efficacy of antibiotic prophylaxis to prevent dental-associated PJI in the highest risk patients. Insufficient data exist to recommend the optimal treatment for patients with PJI in THA and TKA associated with dental procedures.

In vitro antimicrobial activity against Abiotrophia defectiva and Granulicatella elegans biofilms

OBJECTIVES

To determine the efficacy of different antibiotics (alone or in combination) against Abiotrophia defectiva and Granulicatella elegans biofilms and to investigate the anti-biofilm activity of gentamicin alone versus blood culture isolates from both species.

METHODS

The activity of benzylpenicillin, clindamycin, daptomycin, fosfomycin, gentamicin, levofloxacin and rifampicin against 24-hour-old biofilms of A. defectiva and G. elegans was investigated in vitro by conventional microbiological methods and isothermal microcalorimetry.

RESULTS

For planktonic bacteria, the MIC values of tested antibiotics ranged from 0.016 to 64 mg/L, as determined by microcalorimetry. Higher antibiotic concentrations, ranging from 1 to >1024 mg/L, were needed to produce an effect on biofilm bacteria. Gentamicin was an exception as it was active at 1 mg/L against both planktonic and biofilm G. elegans. A synergistic effect was observed when daptomycin was combined with benzylpenicillin, gentamicin or rifampicin against A. defectiva biofilms and when gentamicin was combined with rifampicin or levofloxacin against G. elegans biofilms. A. defectiva clinical isolates displayed greater variability in gentamicin susceptibility as compared with G. elegans strains.

CONCLUSIONS

Antimicrobial susceptibility profiles vary widely between Abiotrophia and Granulicatella biofilms, and synergistic effects of the tested antibiotics were heterogeneous. The clinical relevance of these in vitro observations needs to be confirmed in experimental in vivo conditions and human trials, before guidelines for the treatment of A. defectiva and G. elegans infections are established. This study suggests the benefit of further clinical exploration of antibiotic combinations with anti-biofilm effect.

Erysipelas or cellulitis with a prosthetic joint in situ

We describe a case of a 60-year old male who developed an acute prosthetic joint infection (PJI) of the knee, secondary to erysipelas of the lower leg due to beta-hemolytic Group G streptococci. As it is unknown how often this phenomenon occurs in patients with prosthetic implants and which patients are most prone to develop this complication, we analyzed: i) the incidence of the development of a PJI in these patients and ii) the clinical characteristics of streptococcal PJI during an episode of erysipelas/cellulitis. Based on a retrospective analysis of patients with a prosthetic implant in situ presenting at the emergency department with erysipelas/cellulitis, 1 out of 10 patients developed a PJI. An additional analysis within a multicenter cohort on streptococcal PJI demonstrated in 22 patients that a secondary PJI due to erysipelas/cellulitis mostly develops in young implants (<5 years old). In 20 cases (91%), the skin infection was in the same limb as the joint prosthesis suggesting contiguous spread of bacteria. These data emphasizes the importance of preventive measures to reduce the occurrence of skin infections in patients with prosthetic implants, and if an erysipelas or cellulitis does occur, to monitor patients carefully.

The role of poor oral health in surgical site infection following elective spinal surgery

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

To describe oral health and hygiene as a risk factor for surgical site infection (SSI).

METHODS

This cross-sectional study was conducted on patients over 18 years of age who were candidates for elective spinal surgery. The exclusion criteria were immunodeficiency, history of cancer, history of previous infection at the surgical site, cutaneous diseases and long-term use of corticosteroids. Questionnaires were filled out for patients via an interview in order to collect the demographic data of patients. Oral and dental examinations were performed using DMFT (D: decayed, M: missing, F: filled, T: total) and PUFA (P: pulp, U: ulcer, F: fistula, A: abscess) indices. Data were analyzed using Fisher's exact test and Mann-Whitney test.

RESULTS

A total of 78 patients were evaluated. There were 59 females (75.6%) and 19 males (24.6%). Eight patients were positive for SSI. Teeth caries (P = 0.016) and periodontal disease (P = 0.049) were significantly correlated with SSI. No significant association was noted between PUFA and SSI (P > 0.05). Sixty-five patients (83.3%) had a history of dental infection before surgery. Fifty% of patients being positive for SSI had a history of dental abscess (P = 0.023).

CONCLUSIONS

A significant association exists between SSI and caries, gingivitis/periodontitis and history of dental abscess.

Risk of Periprosthetic Joint Infection in Patients With Multiple Arthroplasties

BACKGROUND

Risk of subsequent periprosthetic joint infection (PJI) in a second prosthetic joint following initial PJI has been shown to be 19%-20%. We sought to identify (1) the risk of developing a second PJI for our patients with multiple prosthetic joints and (2) the effect of bacteremia on development of a subsequent PJI.

METHODS

We retrospectively reviewed all patients treated surgically for PJI by a single surgeon from 2003 to 2014. Time between initial and subsequent infection, bacteremia, and risk factors for PJI were identified.

RESULTS

Of 167 patients treated for PJI, 76 had multiple prosthetic joints. Thirteen percent (10/76) developed a PJI in a second location. Excluding simultaneous infections, the rate was 8.3% (6/72), despite having a 57% incidence of immunosuppression, diabetes, renal failure, smoking, or steroid use. Average follow-up for patients with 1 PJI was 4.6 years (range 0.03-13.6). Seventy percent (7/10) of patients with multiple infections were bacteremic at the time of initial infection compared to 18.1% (12/66) of patients with a single infection (P = .0004). Excluding the 4 simultaneous infections (all bacteremic), the risk of developing an infection in a second joint was 20% if bacteremic and 5.2% if not bacteremic.

CONCLUSION

Our study identified the risk of developing a subsequent PJI to be one half of previous studies. Bacteremia at the time of PJI is an important factor for developing subsequent PJI. Multiple prosthetic joints may be less hazardous than previously thought for patients with PJI suggesting that suppressive antibiotics may only be necessary in cases with bacteremia.

Sepsis Within 30 Days of Geriatric Hip Fracture Surgery

BACKGROUND

Sepsis after hip fracture typically develops from one of the 3 potential infectious sources: urinary tract infection (UTI), pneumonia, and surgical site infection (SSI). The purpose of this investigation is to determine (1) the proportion of cases of sepsis that arises from each of these potential infectious sources; (2) baseline risk factors for developing each of the potential infectious sources; and (3) baseline risk factors for developing sepsis.

METHODS

The National Surgical Quality Improvement Program database was searched for geriatric patients (aged >65 years) who underwent surgery for hip fracture during 2005-2013. Patients subsequently diagnosed with sepsis were categorized according to concomitant diagnosis with UTI, SSI, and/or pneumonia. Multivariate regression was used to test for associations while adjusting for baseline characteristics.

RESULTS

Among the 466 patients who developed sepsis (2.4% of all patients), 157 (33.7%) also had a UTI, 135 (29.0%) also had pneumonia, and 36 (7.7%) also had SSI. The rate of sepsis was elevated in patients who developed UTI (13.0% vs 1.7%; P < .001), pneumonia (18.2% vs 1.8%; P < .001), or SSI (14.8% vs 2.3%; P < .001). The mortality rate was elevated among those who developed sepsis (21.0% vs 3.8%; P < .001).

CONCLUSION

Sepsis occurs in about 1 in 40 patients after geriatric hip fracture surgery. Of these septic cases, 1 in 3 is associated with UTI, 1 in 3 with pneumonia, and 1 in 15 with SSI. The cause of sepsis is often unknown on clinical diagnosis, and this distribution of potential infectious sources allows clinicians for direct identification and treatment.

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.

Prosthetic Joint Infection Following Invasive Dental Procedures and Antibiotic Prophylaxis in Patients With Hip or Knee Arthroplasty

OBJECTIVES

We aimed to clarify whether invasive dental treatment is associated with increased risk of prosthetic joint infection (PJI) and whether prophylactic antibiotics may lower the infection risk remain unclear.

DESIGN

Retrospective cohort study.

PARTICIPANTS

All Taiwanese residents (N=255,568) who underwent total knee or hip arthroplasty between January 1, 1997, and November 30, 2009, were screened.

METHODS

The dental cohort consisted of 57,066 patients who received dental treatment and were individually matched 1:1 with the nondental cohort by age, sex, propensity score, and index date. The dental cohort was further divided by the use or nonuse of prophylactic antibiotics. The antibiotic and nonantibiotic subcohorts comprised 6,513 matched pairs.

RESULTS

PJI occurred in 328 patients (0.57%) in the dental subcohort and 348 patients (0.61%) in the nondental subcohort, with no between-cohort difference in the 1-year cumulative incidence (0.6% in both, P=.3). Multivariate-adjusted Cox regression revealed no association between dental procedures and PJI. Furthermore, PJI occurred in 13 patients (0.2%) in the antibiotic subcohort and 12 patients (0.18%) in the nonantibiotic subcohorts (P=.8). Multivariate-adjusted analyses confirmed that there was no association between the incidence of PJI and prophylactic antibiotics.

CONCLUSIONS

The risk of PJI is not increased following dental procedure in patients with hip or knee replacement and is unaffected by antibiotic prophylaxis.

Infect Control Hosp Epidemiol. 2017;38:154–161

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.

Antibiotic prophylaxis for dental treatment after prosthetic joint replacement: exploring the orthopaedic surgeon's opinion

Background

Antibiotic prophylaxis before dental treatment is routinely recommended by orthopaedic surgeons to prevent prosthetic joint infection (PJI). This recommendation is at odds with current guidelines.

Methods

A postal survey of 9 checkbox or short-answer questions was completed by 633 orthopaedic surgeons.

Results

The majority of respondents (n = 186 of 260, 72%) believe that antibiotic prophylaxis is required indefinitely for dental treatment. A small number (n = 43, 15%) seek a dentist's opinion before elective joint replacement. The surgeons reported low numbers of PJIs, although 24% (n = 68 of 280) believed that they were associated with dental treatment.

Conclusions

Australian orthopaedic surgeons continue to recommend antibiotic prophylaxis for dental treatment. The recording of PJI in relation to dental procedures into clinical registries would enable the development of consistent guidelines between professional groups responsible for the care of this patient group.

Antimicrobial prophylaxis in dentistry

Use of antibiotics both in humans and animals runs along with effects that can contribute to the spread of antibiotic resistance. Although several available guidelines for antibiotic treatment have been published to date, clinical practice in dentistry and particularly in oral surgery is not free from controversies regarding antibiotic prophylaxis. Antibiotic coverage to prevent infectious endocarditis, joint prostheses infections or local infections requires a careful evaluation of the patient condition, associated risks and other aspects that could influence the decision. It is of great relevancy for oral surgeons and for dentists in general to know exactly what they are up against. Here we review the literature regarding prophylactic use of antimicrobials in dentistry.

Antibiotic prophylaxis during dental procedures in patients with in situ lower limb prosthetic joints

The average age of patients presenting for total joint arthroplasty is decreasing. The number of primary and revision arthroplasty procedures performed in the UK, Europe and USA is increasing annually. As number of procedures performed increases, the life expectancy of our patients and therefore the in vivo duration of prosthetic joints increase, and the potential for complications such as infection increases. One potential source for this is bacterial dissemination during dental surgery. Many attempts have been made to address this issue in the form of national guidelines, but there is no clear consensus on antibiotic prophylaxis before these procedures in order to decrease the risk of prosthetic joint infection. This continues to be an area of indecision and uncertainty resulting in patients having delays in their treatment while decisions are made by oral and orthopaedic surgeons about prophylactic antibiotic use. This article reviews the existing national guidelines, highlighting the current views and issues surrounding this subject, and a critical appraisal of current evidence for the use of prophylactic antibiotics in this patient population is presented. We will also review the response in literature to the 2009 American Academy of Orthopaedic Surgeons information statement release on antibiotic prophylaxis in joint arthroplasty patients undergoing dental procedures.

Acute Hematogenous Infection of Revision Total Hip Arthroplasty by Oral Bacteria in a Patient without a History of Dental Procedures: Case Report

The risk of periprosthetic joint infection from hematogenous bacterial seeding is increased in patients undergoing dental procedures that facilitate the development of bacteremia.

We herein report the case of a patient without a history of dental procedures who suffered from an acute metastatic infection of a hip prosthesis by the oral bacterium Streptococcus mutans 18 months after undergoing revision total hip arthroplasty. The patient was successfully treated by two-stage revision surgery.

It is important to realize that the efficacy of antibiotic prophylaxis against joint infections has not yet been convincingly proven. As a result, optimal dental hygiene and regular dental visits may be more important than antibiotic prophylaxis for maintaining joint health. Therefore, orthopedic surgeons should educate patients with joint prostheses about good oral health.

Periprosthetic joint infections: clinical and bench research

Prosthetic joint infection is a devastating complication with high morbidity and substantial cost. The incidence is low but probably underestimated. Despite a significant basic and clinical research in this field, many questions concerning the definition of prosthetic infection as well the diagnosis and the management of these infections remained unanswered. We review the current literature about the new diagnostic methods, the management and the prevention of prosthetic joint infections.

Health Technology Assessment Fireside: Antibiotic Prophylaxis and Dental Treatment in Canada

Objectives. This paper discusses the controversies surrounding the antibiotic prophylaxis preceding dental interventions within the following research question: how effective is dental antibiotic prophylaxis in preventing comorbidity and complications in those at risk? Methods. A synthesis of the available literature regarding antibiotic prophylaxis in dentistry was conducted under the lenses of Kazanjian's framework for health technology assessment with a focus on economic concerns, population impact, social context, population at risk, and the effectiveness of the evidence to support its use. Results. The papers reviewed show that we have been using antibiotic prophylaxis without a clear and full understanding of its benefits. Although the first guideline for antibiotic prophylaxis was introduced in 1990, it has been revised on several occasions, from 1991 to 2011. Evidence-based clinical guidelines are yet to be seen. Conclusions. Any perceived potential benefit from administering antibiotic prophylaxis before dental procedures must be weighed against the known risks of lethal toxicity, allergy, and development, selection, and transmission of microbial resistance. The implications of guideline changes and lack of evidence for the full use of antibiotic prophylaxis for the teaching of dentistry have to be further discussed.

Periprosthetic joint infection: are patients with multiple prosthetic joints at risk?

Patients who present with a periprosthetic joint infection in a single joint may have multiple prosthetic joints. The risk of these patients developing a subsequent infection in another prosthetic joint is unknown. Our purposes were (1) to identify the risk of developing a subsequent infection in another prosthetic joint and (2) to describe the time span and organism profile to the second prosthetic infection. We retrospectively identified 55 patients with periprosthetic joint infection who had another prosthetic joint in place at the time of presentation. Of the 55 patients, 11 (20%) developed a periprosthetic joint infection in a second joint. The type of organism was the same as the first infection in 4 (36%) of 11 patients. The time to developing a second infection averaged 2.0 years (range, 0-6.9 years).

Antimicrobial prophylaxis in noncardiac prosthetic device recipients

BACKGROUND

Secondary antimicrobial prophylaxis involves the use of ≥ 1 antimicrobial agent just prior to the time when a diagnostic/therapeutic procedure, which may induce infection, is to be performed. In the context of this article, antimicrobial agent(s) are administered to patients with ≥ 1 implanted prosthetic device in order to prevent metastatic seeding of the device(s) during bacteremia induced by a diagnostic/therapeutic procedure. Antimicrobial agents used in this context are only administered periprocedurally. Secondary antimicrobial prophylaxis of endocarditis in recipients of cardiac prosthetic materials (including valves, shunts, conduits, and patches) has been reasonably well established. However, secondary antimicrobial prophylaxis in recipients of other types of prosthetic devices has been the subject of much controversy, with a wide variety of recommendations being made.

OBJECTIVES

The purpose of this article was to conduct a narrative review of the published literature on the topic of secondary antimicrobial prophylaxis in recipients of noncardiac prosthetic devices and make evidence-based recommendations for each type of device, where possible.

METHODS

Medline/PubMed and EMBASE databases were searched for English-language articles published from 1950 to the present (January 2012). Search terms included "prophylaxis," "antibiotics," "antimicrobials," "prosthetic devices," "prosthesis-related infections," "bacteremia," the names of the individual types of prosthetic devices, and the names of the individual procedures potentially inducing bacteremia. Articles dealing with any aspect relevant to this topic were eligible for review. The bibliographies of retrieved articles were also carefully scanned to identify any articles not previously identified.

RESULTS

Based on review of the available literature, secondary antimicrobial prophylaxis is justified in only a few specific circumstances. For recipients of prosthetic vascular grafts/stents, hemodialysis arteriovenous shunts, and ventriculoatrial/ventriculovenous shunts, prophylaxis is warranted during the initial 6 months, initial 6 weeks, and at all times after implantation/revision, respectively, when dental procedures capable of inducing high-level bacteremia are planned. Prosthetic joint recipients should receive prophylaxis in the following 3 circumstances: 1) patient is to undergo dental procedure(s) capable of inducing high-level bacteremia plus either the patient is still within 2 years of device implantation/revision or the patient has ≥ 1 risk factor for hematogenous prosthetic joint infection; 2) patient is to undergo genitourinary tract procedure(s) capable of inducing high-level bacteremia plus the patient has ≥ 1 risk factor for high-risk bacteriuria; and 3) patient is to undergo perforating dermatologic surgery on the oral mucosa or at skin sites at increased risk for surgical site infection plus patient has ≥ 1 risk factor for hematogenous prosthetic joint infection. The data are inadequate to justify secondary antimicrobial prophylaxis for recipients of other types of prosthetic devices. On the basis of 9 surveys of prescriber behavior, it is apparent that there exists, over a wide geographic area, a wide disconnect between clinical practice and the secondary antimicrobial prophylaxis guidelines issued by the professional organizations representing these prescribers. Antimicrobial agent overuse was especially problematic among orthopedic and colorectal surgeons, urologists, and family practitioners. Dentists and maxillofacial surgeons followed guidelines more closely.

CONCLUSION

Device-, procedure-, and patient characteristic-dependent factors elicited over many years have narrowed down the secondary antimicrobial prophylaxis recommendations for noncardiac prosthetic devices to a small number. Despite this, physician prescribers frequently do not follow prophylaxis guidelines established by their own professional organizations. Risk-benefit and cost-effectiveness studies have found that no prophylaxis is actually superior to universal prophylaxis, likely due to known antimicrobial toxicities, such as anaphylactic/anaphylactoid reactions and Clostridium difficile-associated disease. Much work remains in establishing and extending the scientific basis for secondary antimicrobial prophylaxis and transforming this knowledge into appropriate action by the clinician.

Bacterial findings in infected hip joint replacements in patients with rheumatoid arthritis and osteoarthritis: a study of 318 revisions for infection reported to the norwegian arthroplasty register

High rates of Staphylococcus aureus are reported in prosthetic joint infection (PJI) in rheumatoid arthritis (RA). RA patients are considered to have a high risk of infection with bacteria of potentially oral or dental origin. One thousand four hundred forty-three revisions for infection were reported to the Norwegian Arthroplasty Register (NAR) from 1987 to 2007. For this study 269 infection episodes in 255 OA patients served as control group. In the NAR we identified 49 infection episodes in 37 RA patients from 1987 to 2009. The RA patients were, on average, 10 years younger than the OA patients and there were more females (70% versus 54%). We found no differences in the bacterial findings in RA and OA. A tendency towards a higher frequency of Staphylococcus aureus (18% versus 11%) causing PJI was found in the RA patients compared to OA. There were no bacteria of potential odontogenic origin found in the RA patients, while we found 4% in OA. The bacteria identified in revisions for infection in THRs in patients with RA did not significantly differ from those in OA. Bacteria of oral or dental origin were not found in infected hip joint replacements in RA.

Abiotrophia defectiva knee prosthesis infection: A case report

Background

Abiotrophia species have rarely been implicated in osteoarticular infections. We report one case of an A. defectiva knee prosthesis infection.

Case presentation

A 71-year-old man of Italian origin presented with pain and swelling of the knee four years after the implantation of a total knee replacement prosthesis. While standard culturing of the synovial fluid resulted in no isolation of microorganisms, the direct inoculation of the synovial fluid into a rich culture medium resulted in the identification of A. defectiva by polymerase chain reaction sequencing. Repeated attempts of culturing microorganisms from blood were negative, and echocardiograms and colonoscopies were unremarkable. High-dose amoxicillin for nine months and a two-stage replacement of the knee prosthesis led to full patient recovery by the time of the 12-month follow-up examination.

Conclusions

Because Abiotrophia spp. are fastidious microorganisms, it is likely that cases of Abiotrophia orthopedic infection are misdiagnosed as culture-negative infections. Direct inoculation of synovial fluids into rich broth medium and further polymerase chain reaction-based detection of culture-negative synovial fluids are key tests for accurate documentation and detection of these infections.

Antimicrobial prophylaxis in adults

Antimicrobial prophylaxis is commonly used by clinicians for the prevention of numerous infectious diseases, including herpes simplex infection, rheumatic fever, recurrent cellulitis, meningococcal disease, recurrent uncomplicated urinary tract infections in women, spontaneous bacterial peritonitis in patients with cirrhosis, influenza, infective endocarditis, pertussis, and acute necrotizing pancreatitis, as well as infections associated with open fractures, recent prosthetic joint placement, and bite wounds. Perioperative antimicrobial prophylaxis is recommended for various surgical procedures to prevent surgical site infections. Optimal antimicrobial agents for prophylaxis should be bactericidal, nontoxic, inexpensive, and active against the typical pathogens that can cause surgical site infection postoperatively. To maximize its effectiveness, intravenous perioperative prophylaxis should be administered within 30 to 60 minutes before the surgical incision. Antimicrobial prophylaxis should be of short duration to decrease toxicity and antimicrobial resistance and to reduce cost.

The dental treatment of patients with joint replacements: a position paper from the American Academy of Oral Medicine

BACKGROUND

In February 2009, the American Academy of Orthopaedic Surgeons (AAOS) published an information statement in which the organization "recommends that clinicians consider antibiotic prophylaxis [AP] for all total joint replacement patients prior to any invasive procedure that may cause bacteremia." The leadership of the American Academy of Oral Medicine (AAOM) thought that there was a need to respond to this new statement.

METHODS

The authors reviewed the literature on this subject as it relates to the AAOS's February 2009 information statement. The draft of the resulting report was reviewed and approved by the leadership of the AAOM and several dentists in North America who have expertise on this subject.

RESULTS

The risk of patients' experiencing drug reactions or drug-resistant bacterial infections and the cost of antibiotic medications alone do not justify the practice of using AP in patients with prosthetic joints.

CONCLUSIONS

The authors identified the major points of concern for a future multidisciplinary, systematic review of AP use in patients with prosthetic joints. In the meantime, they conclude that the new AAOS statement should not replace the 2003 joint consensus statement.

CLINICAL IMPLICATIONS

Until this issue is resolved, dentists have three options: inform their patients with prosthetic joints about the risks associated with AP use and let them decide; continue to follow the 2003 guidelines; or suggest to the orthopedic surgeon that they both follow the 2003 guidelines.

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.

Dental treatment and prosthetic joints: antibiotics are not the answer!

The routine administration of prophylactic antibiotics for dental interventions to prevent haematogenous spread of infections to prosthetic joints is a contentious issue. In this editorial we discuss the potentially harmful effects of this practice and propose an alternative solution.