So-called preventive use of antibiotics after hip replacement

Status
Not open for further replies.

FraidyCat

senior
Joined
May 31, 2013
Messages
261
Age
73
Country
United States United States
Gender
Female
Hi folks; I am back, after an approximately two-year hiatus that began when I cancelled my scheduled hip replacement in the spring of 2014. The main reason I chickened out was the emphatic mandate the surgeon and my dentist were both giving, that being that antibiotics would be required for my lifetime before any invasive dental procedure, including tooth-cleanings, which I'm told I need to have three times a year. With a not-that-distant history of C. difficile colitis, caused by clindamycin, one of the top antibiotics used by dentists (though I was given the drug following tear-duct surgery), I felt I was being forced to choose between hip surgery and a recurrence of C. diff.

Fast-forward to now. Since December, my hip pain has worsened. In addition, I've had an increase in low-back pain, which the surgeon thinks is probably related to the condition of the hip. Also, I no longer perceive my gait as normal (and others also comment on my "limp"). So I've been re-motivating myself to have hip replacement within the next few months. I'd thought that this time around I'd be spared some of the exhortations that antibiotics "must" be taken prior to routine dental cleanings, as the American Dental Association has recently issued new guidelines saying they no longer consider this necessary, especially in light of the rise of "superbugs" due to overuse of antibiotics. However, at two high-volume joint-replacement facilities in the Boston area (I'm planning to choose between them for the surgery), it's as though time has stood still, as the ortho departments at each still emphasize the "need" for prophylactic antibiotics for "lifetime" to avoid the "rare but catastrophic" potential for infection. I'm starting to feel the same stress as I did before I cancelled the hip op two years ago. And to wonder if I will need to choose between ending up, at a relatively young age, dependent on a walker or in a wheelchair due to no longer being able to walk due to hip pain, and subjecting myself to the risk of a potentially fatal (and definitely debilitating) dysenteric infection due to the "antibiotics" mandate.

My understanding is that in U.K. and Canada (to name the couple of countries I've read about) the "antibiotics" mandate is no longer favored by ortho doctors, whereas in the U.S. they are still clinging to it -- perhaps to cover themselves from the remote possibility of being sued should someone happen to get an infection after dental work, either causually or coincidentally -- and in the process, scaring the daylights out of anyone who doesn't go along with it.

Hoping to hear from others, whether in the U.S., U.K., or elsewhere, with regard to what you've been told about this issue and how you're handling it, if it's a concern that you share.
 
Last edited by a moderator:
Hi there Cat! Good to see you again. I'm so sorry to hear that you cancelled your op because of this.
American Dental Association has recently issued new guidelines
It's not actually that recent - my article on it in our Library gives the date of the announcement as December 18, 2012.

The other thing to remember is your freedom of choice. They can recommend their chosen path but they cannot force you to comply if you have good reason not to - and you do have a very good reason not to. It's entirely your choice. Just because they say so doesn't mean it's going to happen! You might also like to note that the UK followed close on the heels of the AAOS and the ADA by issuing their own statement to this effect. And the Mayo Clinic did too!

Dental antibiotics: Evidence insufficient to recommend prophylactic antibiotics for dental procedures
Periprosthetic infection: Mayo Clinic study shows that dental procedures are not a risk factor (Scientific Articles)
to avoid the "rare but catastrophic" potential for infection.
The fact is that they have it all wrong! The infection does not migrate from elsewhere in the body, it arises from something that each and everyone of us has which is biofilm. I've explained this in detail in this article so I suggest you read up on it, take it to heart and be reassured. I also suggest you go ahead with your op and when they tell you all this, just listen attentively and agree - and then do your own thing! I would imagine that about 88% of their patients do that anyway. It's the same with the oft told requirements that hip restrictions are for life - it would be so very interesting to discover how many of those patients actually complied with that beyond 10 months!

Peri-prosthetic infection - also known as late onset infection

The simple fact is that you need your hip done. Get it done and forget all their doom-laden prophetic warnings!
 
I've never taken antibiotics for dental work. From fifteen teeth pulled to root canal. I take that back.. I have taken them, however it was due to neglect. I've never heard of that being routine.
 
:phone:Oh yeah, also I agree whole heartily with Josephine .
 
I agree as well. I'm so sorry that you have gone all this time with a bad hip. The answer is as Jo says....just smile sweetly and do what is best for you. They won't send the Antibiotic Police out after you....promise! :heehee:

With both my knee replacements the direction from my surgeon was to take preventive antibiotics for two years. This was just as the change in policy was taking place and now I don't think he recommends taking them at all. I had a major tooth infection (undetected) when I got my second TKR and although the root canal and crown was a pretty big deal, the infection itself was not a problem at all for my knee. And I waited until 6 weeks after the TKR to get it taken care of because I didn't realize I even had the infection until then!
 
Thanks, @Josephine, both for the encouragement and the link to the article about biofilms; I wasn't familiar with this concept. I've read the Mayo study and the Canadian position statement as well. Though you're right that ortho doctors can't force compliance with the antibiotic mandate, they instead wield the weapon of scare stories. An excerpt from a reply I received from the ortho surgeon's nurse (after I asked for clarification of where the doctor stood re: this issue): "While we understand that our recommendations about dental prophylaxis for routine dental work ... are not 'evidenced based' we routinely care for patients with infected implants. Patients with bone infections around the implants require surgical removal of the implant, treatment with IV antibiotics for at minimum 6 weeks and another surgery to replant the implant once the infection seems to be managed. But we do recommend it given the enormity of treating the problem when it occurs. Most times we do NOT have a clear source for bone infections and ... they can occur at any point in the life of the implant."

On the one hand, it's hard not to feel apprehensive upon reading this graphic scenario. On the other hand, it seems like a bit of a non sequitur to state that, though there's no scientific evidence that links dental work to infection or that taking antibiotics prevents it, infection, when it does occur, is catastrophic so it's best just to take the antibiotic and thereby prevent it. Seems kind of like saying that, though Friday the 13th isn't really an unlucky date, one should still not leave the house that day in order to avoid accident.

Until the dental association revised its guidelines recently, dentists could, in effect, force compliance by refusing to work on patients who didn't premedicate (unless the patient lied and said they premedicated when they didn't). Post-change in dental guidelines I've had two ortho surgeons tell me that I can do as I wish but at my own peril.

@julesglass, wondering what you mean that your having taken antibiotics for dental work on occasion was "due to neglect"?
 
@Jamie, that's a very telling anecdote supporting the lack of necessity for "preventive" antibiotics. Per my reply to @Josephine, it's hard not to internalize the anxiety that the surgeons are trying to instill, as they are, after all, the "experts" and they do indeed see patients with infected hip implants. I've been able to delay having a hip op for the last few years as the pain was sporadic and mostly tolerable. But with lower-back and gait issues having worsened, as well as the hip pain, I'm afraid that if I delay much longer these effects might become permanent (though unsure to what extent the back pain is related to the hip).
 
For me, in Canada, my surgeon admits it's a controversial topic but says he prefers to err on the side of caution, and is recommending pre-dental antibiotics for 2 years from the surgery. My dentist commented that he no longer thinks it is necessary but that I should feel free to follow my surgeon's advice.
 
Well yes, but the thing is, peri-prosthetic infections don't arise from anything anywhere else on the body. It arises from the biofilm and the reason for that is unknown. Do read the article I posted above. And just in case you wonder, I got that information from an acknowledged expert in PPIs as I believe I have stated in the article.
 
@JayP, not so sure your doctor is on caution's side, as the risk of C. difficile colitis from dental antibiotics outweighs that of a remote hip infection. Though "for 2 years from the surgery" is preferable to "lifetime," which is what surgeons in U.S. are telling patients.

@Josephine, I spoke with an infectious disease doctor today and raised the topic of biofilms. He agreed that they can be the source of periprosthetic infection. However, he also said that infection could migrate from another area of the body, including the mouth -- though that possibility is unlikely.
 
I can assure you Dr Maale's information is sound on this as he's done so much unique research into this specific issue. His findings are that biofilm IS the cause of PPI and that so long as the immature bacteria in it don't mature, we are okay. But the big mystery is what causes these organisms to suddenly come out of stasis and start maturing. When we find that out, PPI will be much easier to deal with and we'll may even find a way of preventing it.

Your chap is also obviously hedging his bets by the use of 'can be' and 'could' and 'is unlikely'. With due respect to him, this is the language of someone who's not 'entirely' up to date with the subject! :wink: Dr Maale is dealing in much greater positives than that.
 
@FraidyCat I have had both knees and both hips replaced in the matter of less than three years. I went against my doctors wishes and have had several crowns, a root canal an many cleanings since my joint replacements. NO ANTIBIOTICS.

The only thing I did do was wait 6 months after each surgery before I went to have dental work done. I also had any work done that I had put off completed prior to my surgeries so I would not have to worry about going to the dentist for at least 6 months after surgery.

I was also very concerned about my doctor telling me to do the antibiotic treatments prior to each dental visit. I did my homework and decided that the antibiotic protocol was out dated and not current information.

If I can have had all the dental work I have had done since my surgeries and never had a problem using no antibiotics... I can say that you should just go ahead and have that surgery and do not worry about using antibiotics.
 
I was diagnosed with severe arthritis (both hips) in 2011, but have been delaying - now scheduled for July. I in the US, and my surgeon carefully explained that any time I have anything done to me that is even slightly invasive - not just dental and colonoscopy, but also skin biopsies I should take prophylactic antibiotics. Can't recall the lead time, etc. I did not realize there were regional differences in whether this advice was offered.

Having been trained as a molecular biologist, I am very aware of the dangers of over-prescribing antibiotics. We are near the time when bacterial infections become untreatable again. I'm going to have a very difficult time decidiing how I am going to handle this situation.
 
@Gazelle, that is certainly encouraging. Nonetheless, I'm sure the staunch advocates of premedication would maintain that one individual's experience can't be extrapolated to another and that the ultraconservative guidelines are aimed at protecting the tiny minority who, in absence of premedication, would (allegedly) have implant failure. Your suggestion of letting six months elapse prior to dental work post-surgery seems sensible. Thanks.

@wub, ironically, a new strain of bacterial infection that isn't treatable with any currently available antibiotic is a news item yesterday and today. Though the closest to a scientific background I have is having been a copy editor on a medical journal (with a subject-matter of orthopedics, coincidentally), my own layperson's logic would seem to suggest that, if one were to follow your surgeon's sweeping rules of prophylactic antibiotics for virtually everything, it could be just a matter of time before the cumulative dose would lead to C. difficile colitis, in which case you'd find yourself in the untenable position of having to cherrypick whether to use antibiotics even for major procedures or frank infection, as C. diff tends to recur and to become harder to eradicate with each recurrence.
 
Last edited by a moderator:
I'm going to have a very difficult time deciding how I am going to handle this situation.
@wub did you read my previous posts? There really is no to worry about it.
 
@wub did you read my previous posts? There really is no to worry about it.
@Josephine, I think the reason I and @wub (hope I'm not being presumptuous in what I'm about to attribute to you, @wub) remain concerned is that the clashing directives from the ortho surgeons on the one hand and the dentists and ID doctors on the other create a state of cognitive dissonance: i.e., the "experts" who are restoring our hip function, if all goes well, are basically saying that to safeguard the good results we *should* be doing something counter to what OTHER "experts" and our own common sense may be telling us. It's most patients' natural instinct to follow their doctors' instructions, whereas it takes a continual act of steeling oneself to defy the doctors' advice.
 
Actually, the message you got from the ID doctor actually admitted he was uncertain about this
He agreed that they can be the source of periprosthetic infection. However, he also said that infection could migrate from another area of the body, including the mouth -- though that possibility is unlikely.
Those three phrases I've emboldened are classic caveats people use when they don't really know and certainly don't know enough to risk being positive about something. In other words, his entire comment was of 'being on the safe side'. He was actually saying what I am saying but lacked the confidence to be clear about it. Therefore he is, by definition and by self declaration, NOT an expert in this particular aspect of infection. It's not his fault. PPIs are a very specialised area and not every ID doctor or orthopaedic surgeon has this expertise.
 
The information in my article I obtained from one of his lectures I attended in the UK in 2013. The link was just to his clinic. And the book you linked was published in 2012. I don't know of anything more recent. Perhaps I'll contact him and see what he has to suggest!
 
Status
Not open for further replies.

BoneSmart #1 Best Blog

Staff online

  • djklaugh
    Staff member since December 30, 2020
  • mendogal
    Staff member since November 10, 2023

Forum statistics

Threads
65,071
Messages
1,595,319
BoneSmarties
39,299
Latest member
mexicaliaguilas
Recent bookmarks
0
Back
Top Bottom