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What are recommendations for antibiotic prophylaxis prior to dental surgery in patients with hip replacement?

Comment by InpharmD Researcher

The American Dental Association (ADA) does not recommend the use of prophylactic antibiotics in patients with prosthetic joints who are undergoing dental procedures. Numerous reviews and clinical studies have analyzed prosthetic joint infection (PJI) in patients undergoing dental procedures, with consistent findings, that prophylactic antibiotics are unnecessary in most patients who have undergone hip replacement.
Background

The American Dental Association does not recommend the use of prophylactic antibiotics in patients with prosthetic joints who are undergoing dental procedures, as clinical evidence fails to demonstrate an association between dental procedures and prosthetic joint infection (PJI) or any effectiveness for antibiotic prophylaxis. This recommendation is due to case-control studies that did not show any association between dental procedures and the risk of PJI. One of four studies, however, did support antibiotic prophylaxis. Although only a few studies exist, the panel believes further studies would not result in changes to the conclusion made. Furthermore, this evidence can be extrapolated to all joints due to the physiological characteristics of the tissues involved. Other considerations for this recommendation include the risk of antibiotic resistance, anaphylaxis, potential drug interactions, and opportunistic infections such as C. difficile. [1]

A 2019 review of guidelines confirms previous recommendations regarding antibiotic prophylaxis in the prevention of prosthetic joint infections and endocarditis following dental surgery. While most evidence is based on older case-control studies, a large 2017 retrospective study also showed no difference between PJI after dental work with or without antimicrobial prophylaxis [See Table 2]. The authors concede that PJI post-dental procedures, although rare (<0.5%), can see patients suffer significant morbidity. However, this must be balanced against adverse effects of unnecessary antibiotics, such as adverse drug reactions, contribution to antimicrobial resistance, and disruption of the gut microbiome. [2]

A 2021 review found 44 PJIs after dental procedures (22 in primary in total hip arthroplasty, 20 in primary total knee arthroplasty, one in revision hip repacement, 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. The authors conclude lower extremity PJI associated with dental procedures is often caused by organisms unlikely to be prevented with amoxicillin. [3]

In a 2016 review on the use of antimicrobial prophylaxis for dental procedures in patients with prosthetic joints, the authors suggest that proof of a causative relation with dental procedures is not possible because the responsible bacteremia can originate from the oral cavity at any time regardless of when the dental procedure occurs. Large cohort studies have shown a PJI incidence of less than 1% in the first year after implantation. The overall low incidence, the low proportion of microorganisms belonging to oral flora found in prosthetic joint infection the low risk of hematogenous seeding, and the low virulence of these bacteria are arguments against antimicrobial prophylaxis during dental procedures in patients with artificial joints. Although some experts may consider the use of antimicrobial prophylaxis in rare cases (e.g. immunosuppressed transplant patients), the authors do support the generalized use of antibiotic prophylaxis for dental procedures in patients with prosthetic joints. [4]

A 2020 systematic review sought to reassess clinical literature to determine if there is evidence to support antibiotic prophylaxis in patients with periodontal disease as a means to decrease the risk of PJI. The authors concluded, "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." [5]

References:

1. Sollecito TP, Abt E, Lockhart PB, et al. The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints: Evidence-based clinical practice guideline for dental practitioners--a report of the American Dental Association Council on Scientific Affairs. J Am Dent Assoc. 2015;146(1):11-16.e8.
2. Goff DA, Mangino JE, Glassman AH, Goff D, Larsen P, Scheetz R. Review of Guidelines for Dental Antibiotic Prophylaxis for Prevention of Endocarditis and Prosthetic Joint Infections and Need for Dental Stewardship. Clin Infect Dis. 2020;71(2):455-462. doi:10.1093/cid/ciz1118
3. Danilkowicz RM, Lachiewicz AM, Lorenzana DJ, Barton KD, Lachiewicz PF. Prosthetic joint infection after dental work: is the correct prophylaxis being prescribed? A systematic review. Arthroplasty Today. 2021;7:69-75.
4. Sendi P, Uçkay I, Suvà D, Vogt M, Borens O, Clauss M. Antibiotic Prophylaxis During Dental Procedures in Patients with Prosthetic Joints. J Bone Jt Infect. 2016;1:42-49.
5. Moreira AI, Mendes L, Pereira JA. 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. Int Orthop. 2020;44(2):231-236. doi:10.1007/s00264-019-04433-8

Literature Review

A search of the published medical literature revealed 2 studies investigating the researchable question:

What are recommendations for antibiotic prophylaxis prior to dental surgery in patients with hip replacement?

Level of evidence

A - Consistent, well-formed evidence in the form of randomized, controlled trials; multiples systematic reviews and/or meta-analyses that corroborate evidence; multiple high-quality studies with consistent results  Read more→



Please see Tables 1-2 for your response.


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

Design

Retrospective, population-based, cohort study

N=255,568

Objective

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

Study Groups

Dental surgery (n=13,026)

Use of prophylactic antibiotics (n=6,513)

Methods

Inclusion criteria: all patients who underwent total hip arthroplasty (THA) or total knee arthroplasty (TKA) and received dental procedures (including periodontal treatment and surgical or nonsurgical tooth extraction) within the first 2 years after arthroplasty

Exclusion criteria: none described

This was a large retrospective database analysis based on Taiwanese health insurance data. Patients who underwent dental surgery after TKA/THA were compared to TKA/THA patients who had no dental surgery. The cohort of patients who underwent dental surgery was further subdivided into patients who received antibiotic prophylaxis or not.

Each of these cohorts was propensity-score matched based on age, sex, and index date for 1:1 comparisons. 

Duration

January 1997 to November 2009

Outcome Measures

Prosthetic joint infection incidence

Baseline Characteristics

 

No antibiotic (n=6,513)

Antibiotic (n=6,513)

P-value

Age, years

50.17 ± 18.46 50.17 ± 18.46 0.995

Male

4,078 (62.6%) 4,078 (62.6%) 1

Results

  No antibiotic (n=6,513)

Antibiotic (n=6,513)

 

PJI within 1 year

12 (0.18%) 13 (0.2%) 0.83

At 1 year after the index date, 328 patients (0.57%) in the dental subcohort and 348 patients (0.61%) in the nondental subcohort
developed PJI (P=0.30). 

The adjusted hazard ratio for antibiotic use as a risk factor for PJI after dental surgery was 1.03 (95% CI 0.47 to 2.27; P=0.94).

Study Author Conclusions

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

InpharmD Researcher Critique

This study provides real-world evidence that using antibiotic prophylaxis for dental procedures does not affect prosthetic joint infection. The authors did well to propensity-score match the variables. 

Limitations include the retrospective, database design which can allow for confounders and relies on billing. The specific agents for microbial prophylaxis were not discussed and may not be consistent. This study was also only consisted of Taiwanese patients which may not reflect the U.S. population.

References:

Kao FC, Hsu YC, Chen WH, Lin JN, Lo YY, Tu YK. Prosthetic joint infection following invasive dental procedures and antibiotic prophylaxis in patients with hip or knee arthroplasty. Infect Control Hosp Epidemiol. 2017;38(2):154-161.

Dental Procedures as Risk Factors for Prosthetic Hip or Knee Infection: A Hospital-Based Prospective Case-Control Study

Design

Prospective, single-center, case-control study

N=678

Objective

To examine the association between dental procedures with or without antibiotic prophylaxis and prosthetic hip or knee infection

Study Groups

Case (n=339)

Control (n=339)

Methods

Inclusion criteria: patients who underwent a total hip or knee arthroplasty but without a prosthetic joint infection who were hospitalized during the same period on the same orthopedic floor

Exclusion criteria: none described

Patients hospitalized with a prosthetic hip or knee infection at the Mayo Clinic were matched with control subjects hospitalized on an orthopedic service. The pared matching was not performed on any variable, but frequency matching was used on the location of joint arthroplasty.

A dental propensity score was calculated for each patient that took into account covariates that would predict the propensity of each patient to visit a dentist. The primary risk factors of interest in this study were whether a patient had a high-risk or low-risk dental procedure and whether the patient had antibiotic prophylaxis.

Duration

2001 to 2006

Outcome Measures

Impact of dental surgery on prosthetic joint infection

Baseline Characteristics

 

Case (n=339)

Control (n=339)

Age, years (interquartile range)

69.5 (25.7 - 91.2) 71.4 (36.0 - 94.8) 

Female

168 (50%) 180 (53%)

Total hip arthroplasty (THA)

Total knee arthroplasty (TKA)

164 (48%)

175 (52%)

164 (48%)

175 (52%)

Time from implant to initial dental procedure

Low-risk dental procedure

None

<12 months

1-2 years

>2 to 5 years

>5 to 10 years

>10 years

High-risk dental procedure 

None

<12 months

1-2 years

>2 to 5 years

>5 to 10 years

>10 years

 

 

192 

41 (41%)

13 (13%)

24 (24%)

10 (10%)

12 (12%)

 

164

58 (43%)

13 (10%)

25 (20%)

17 (13%)

15 (12%) 

 

 

161

37 (24%)

15 (10%)

31 (20%)

37 (24%)

32 (21%)

 

116

63 (32%)

19 (10%)

36 (18%)

43 (22%)

36 (18%)

Results

 

Case (n=339)

Control (n=339)

Low-risk dental procedure

Without antibiotic prophylaxis

With antibiotic prophylaxis

 

41 (12%)

59 (17%)

 

65 (19%)

87 (26%)

High-risk dental procedure

Without antibiotic prophylaxis

With antibiotic prophylaxis 

 

33 (10%)

95 (28%)

 

49 (14%)

148 (44%)

There was no increased risk of prosthetic hip or knee infection for patients undergoing a high-risk or low-risk dental procedure who were not administered antibiotic prophylaxis (adjusted odds ratio [OR] 0.8; 95% confidence interval [CI] 0.4 to 1.6), compared with the risk for patients not undergoing a dental procedure (adjusted OR 0.6; 95% CI 0.4 to 1.1) respectively.

Antibiotic prophylaxis in high-risk or low-risk dental procedures did not decrease the risk of subsequent total hip or knee infection (adjusted OR, 0.9 [95% CI 0.5 to 1.6] and 1.2 [95% CI 0.7 to 2.2], respectively).

Adverse Events

N/A

Study Author Conclusions

Dental procedures were not risk factors for subsequent total hip or knee infection. The use of antibiotic prophylaxis prior to dental procedures did not decrease the risk of subsequent total hip or knee infection.

InpharmD Researcher Critique

The power to detect a statistically significant association between prosthetic hip or knee infections and infection originated from dental or oral origin was limited in this study. Referral bias was minimized by choosing control patients from the same institution, and classification bias was minimized by blinding the reviewer to dental records.

References:

Berbari EF, Osmon DR, Carr A, et al. Dental procedures as risk factors for prosthetic hip or knee infection: a hospital-based prospective case-control study. Clin Infect Dis. 2010;50(1):8-16.