Evidence insufficient to recommend prophylactic antibiotics for dental procedures

[Josephine]

Evidence Insufficient to Recommend Routine Antibiotics for Joint Replacement Patients Who Undergo Dental Procedures
LINK
December 18, 2012

New, collaborative evidence-based guideline proposes

The American Academy of Orthopaedic Surgeons (AAOS), and the American Dental Association (ADA) found that there is insufficient evidence to recommend the routine use of antibiotics for patients with orthopaedic implants to prevent infections prior to having dental procedures because there is no direct evidence that routine dental procedures cause prosthetic joint infections.

The AAOS and ADA’s recommendations are based on a collaborative evidence-based clinical practice guideline that focuses on the possible linkage between orthopaedic implant infection and patients undergoing dental procedures.

“As clinicians, we want what is in the best interest of our patients, so this clinical practice guideline is not meant to be a stand-alone document. Instead it should be used as an educational tool to guide clinicians through treatment decisions with their patients in an effort to improve quality and effectiveness of care,” said David Jevsevar, MD, MBA, chair of the AAOS Evidence Based Practice Committee which oversees the development of clinical practice guidelines.

“It has been long debated that patients with orthopaedic implants, primarily hip and knee replacements, are prone to implant infections from routine dental procedures,” added Dr. Jevsevar who also is an orthopaedic surgeon in St. George, Utah. “What we found in this analysis is that there is no conclusive evidence that demonstrates a need to routinely administer antibiotics to patients with an orthopaedic implant, who undergo dental procedures.

· In 2010, there were more than 302,000 hip replacement and 658,000 knee replacement procedures performed in the United States.

· Infections can occur when foreign organisms enter the wound during or at any point following joint replacement, and can lead to additional surgery and prolonged antibiotic treatment.

· For studies of hip and knee included in this guideline, the mean rate of infection was 2%

Elliot Abt, DDS, MS, MSc, who served as member of the AAOS-ADA work group on behalf of the ADA, pointed out that the review committee conducted a thorough review of existing clinical research published in the peer-reviewed literature.

“This guideline was based primarily on clinical research which examined a large group of patients, all having a prosthetic hip or knee and half with an infected prosthetic joint,” said Dr. Abt, a general dentist in Skokie, Ill., and a member of the ADA Council on Scientific Affairs. “The research showed that invasive dental procedures, with or without antibiotics, did not increase the odds of developing a prosthetic joint infection.”

This clinical practice guideline, with three recommendations, is based on a systematic review of the correlation between dental procedures and prosthetic joint infection (PJI).

· Recommendation 1 which is based on limited evidence, supports that practitioners consider changing their longstanding practice of prescribing prophylactic antibiotics for patients who undergo dental procedures.
Limited evidence shows that dental procedures are unrelated to PJI.

· Recommendation 2 addresses the use of oral topical antimicrobials (topical antibiotic administered by a dentist) in the prevention of PJI in patients undergoing dental procedures.
There is no direct evidence that the use of oral topical antimicrobials before dental procedures will prevent PJI

· Recommendation 3 is the only consensus recommendation in the guideline, and it supports the maintenance of good oral hygiene.

 

[Josephine]

The UK position:

In 2012, the British Society for Antimicrobial Chemotherapy issued this statement in the British National Formulary (the bible on drugs)

"Advice of a Working Party of the British Society for Antimicrobial Chemotherapy is that patients with prosthetic joint implants (including total hip replacements) do not require antibiotic prophylaxis for dental treatment. The Working Party considers that it is unacceptable to expose patients to the adverse effects of antibiotics when there is no evidence that such prophylaxis is of any benefit, but that those who develop any intercurrent infection require prompt treatment with antibiotics to which the infecting organisms are sensitive*

The Working Party has commented that joint infections have rarely been shown to follow dental procedures and are even more rarely caused by oral streptococci"
*This means that it does not imply that oral infections should not themselves be appropriately treated with antibiotics

 

[Josephine]

Antibiotic Prophylaxis Prior to Dental Procedures
Prepared by: Center for Science Information, ADA Science Institute
Last Updated: February 18, 2016

In patients with prosthetic joint implants, a January 2015 ADA clinical practice guideline, based on a 2014 systematic review states, “In general, for patients with prosthetic joint implants, prophylactic antibiotics are not recommended prior to dental procedures to prevent prosthetic joint infection.”

In 2014, the ADA Council on Scientific Affairs assembled an expert panel to update and clarify the clinical recommendations found in the 2012 evidence report and 2013 guideline, Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures.1, 2

As was found in 2012, the updated systematic review undertaken in 2014 and published in 2015 found no association between dental procedures and prosthetic joint infections.3 Based on this evidence review, the 2015 ADA clinical practice guideline states,3 "In general, for patients with prosthetic joint implants, prophylactic antibiotics are not recommended prior to dental procedures to prevent prosthetic joint infection.”

A co-published editorial by Meyer4 also states:
"The new CSA guideline clearly states that for most patients, prophylactic antibiotics are not indicated before dental procedures to prevent [prosthetic joint infections]. The new guideline also takes into consideration that patients who have previous medical conditions or complications associated with their joint replacement surgery may have specific needs calling for premedication. In medically compromised patients who are undergoing dental procedures that include gingival manipulation or mucosal inclusion, prophylactic antibiotics should be considered only after consultation with the patient and orthopedic surgeon. For patients with serious health conditions, such as immunocompromising diseases, it may be appropriate for the orthopedic surgeon to recommend an antibiotic regimen when medically indicated, as footnoted in the new chair-side guide."

The ADA encourages dental professionals to review the full 2015 guideline3 and take this recommendation into account, consult with the patient's orthopedic surgeon as needed, and consider the patient's specific needs and preferences when planning treatment. According to the ADA Chairside Guide, in cases where antibiotics are deemed necessary, it is most appropriate that the orthopedic surgeon recommend the appropriate antibiotic regimen and, when reasonable, write the prescription.

 

[Josephine]

Mayo Clinic study shows that dental procedures are not a risk factor in prosthetic hip or knee infections. Authors call for reconsideration of administering antibiotics to all patients with prosthetic hip or knee joints who undergo dental treatment.

A report from the Mayo Clinic, published in January 2010, described a large case-control study which examined the association between dental procedures - with or without antibiotic prophylaxis - and prosthetic joint infections. The study found no increased risk of prosthetic joint infections after dental procedures. And to top that, the study found that antibiotic prophylaxis was not associated with any reduction in risk of infection. The study data indicated that there is no need for antibiotic prophylaxis in patients with total hip or knee replacements undergoing dental procedures.

This report comes on the heels of the recent information statement by the American Association of Orthopaedic Surgeons (AAOS) that advocated using antibiotic prophylaxis in all patients with a joint prosthesis.* The Mayo Clinic study was designed to determine whether dental procedures, with and without antibiotic prophylaxis, are risk factors for prosthetic hip or knee infection. It was designed as a prospective study, case controlled, in a single-institution and conducted between 2001-2006. The full report can be found in Clinical Infectious Diseases, January 1, 2010 issue. The lead author was E.F. Berbari from the Mayo Clinic College of Medicine, along with a bevy of authors, some of which were from the Department of Periodontics, Burnsville, Minnesota, and the Department of Endodontics, Virginia Commonwealth University.

There were 339 case patients and 339 control patients evaluated between December 2001 and May 2006. Case patients were those diagnosed with prosthetic hip or knee infections who were hospitalized at the Mayo Clinic. The control subjects were patients with prosthetic hips or knees with no infections, but who were hospitalized for:
(1) an arthroplasty of a different site or side of the index total hip or knee arthroplasty,
(2) for aseptic revision of the index arthroplasty, or
(3) for other orthopedic procedures.

Dental records were obtained from each patient's dentist. Dental procedures were categorized into low-risk and high-risk procedures. Low-risk procedures included restorative dentistry, dental filling, endodontic treatment, and fluoride treatment. High-risk procedures included dental hygiene, mouth surgery, periodontal treatment, dental extraction, and therapy for dental abscess. Hip or knee infections were determined using routine microbiological techniques that isolated the bacterial flora. In addition, a dental propensity score was calculated for each patient that predicted the propensity of each patient to visit a dentist.

The primary risk factor was whether a patient had a high risk or low risk dental procedure and whether, at the time of the procedure closest to the study date, the patient had antibiotic prophylaxis. The risk factor was defined at 4 levels:
(1) patient did not have dental procedure in the observation period (reference level),
(2) was an edentulous patient, none of whom had a dental visit ,
(3) patient had a dental procedure without antibiotic prophylaxis, and
(4) patient had a dental procedure with antibiotic prophylaxis.

Results

The total numbers of patients enrolled in the study were 339 case patients with prosthetic hip or knee infections and 339 control patients with prosthetic hip or knee replacement but no infections. 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.

Of the case patients, 292 were dentate individuals and 47 were edentulous. Of the control patients, 313 were dentate individuals and 26 were edentulous. Among the dentate case patients, 192 (66%) had undergone a low-risk dental procedure over a 2-year observation period. Among the dentate control patients, 161 (51%) had undergone a low-risk dental procedure over the same 2-year observation period. In addition, 164 of the case patients and 146 of the control patients had undergone a high-risk dental procedure over the 2-year period.

The status of oral health was then compared between case patients and control patients during the 24 months that preceded the enrolment date. Among dentate case patients, the mean number of tooth brushings per week (mean + standard deviation) was 11.7 + 5.7 for case patients and 11.9 + 5.5 for control patients. Eighty-eight of the dentate case patients had >1 dental hygiene visit; 152 of the dentate control patients had >1 dental hygiene visit.

Statistically, it was determined that there was no difference in the risk of developing prosthetic hip or knee infection between a patient with at least 1 dental hygiene visit relative to a patient with no visits.

Among the 339 case patients, 259 (76%) had a diagnosis of prosthetic hip or knee infection established within 10 days before or after the study date. Staphylococci were the most commonly encountered organisms isolated from the infection sites. Thirty-five (13.5%) of the prosthetic hip or knee infection cases were associated with bacterial flora of potential oral or dental origin.

Low-risk and high-risk dental procedures performed within 6 months or 2 years of the hospital admission of infected prosthetic joints were not significantly associated with an increased risk of prosthetic hip or knee infection, compared with no dental procedure.

Odds ratio (OR) estimates were used to assess the effect of antibiotic prophylaxis on the risk of prosthetic joint infections. Low-risk and high-risk dental procedures with antibiotic prophylaxis were compared with the same risk procedure without prophylaxis. The OR estimate was 0.7 (95% CI 0.3-1.5) for low-risk procedures and 0.7 (95% CI 0.3-1.4) for high-risk procedures performed within 6 months of hospital admission. The OR estimate was 1.2 (95% CL 0.7-2.2) for low-risk procedures and 0.9 (95% CI 0.5-1.6) for high-risk procedures performed within 2 years before hospital admission date. These odd ratios and 95% confidence limit values indicated no significant differences between the risk of prosthetic joint infections with and without antibiotic prophylaxis.

The 35 patients with prosthetic hip or knee infection associated with dental flora pathogens were compared to a randomly selected group of 35 control patients. The data showed no increased risk of total hip or knee infection regardless of the use of antibiotic prophylaxis.

The study also addressed whether dental procedures were a risk factor for subsequent prosthetic hip or knee infections in patients who were immunocompromised, had diabetes, had a prior arthroplasty, had duration of prosthetic joint infection symptoms of <8 days, or were within a year of joint arthroplasty. It was found that high-risk and low-risk dental procedures were not risk factors for prosthetic hip or knee infections in any of these subgroups.

Results Summary

1. 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 compared with the risk for patients not undergoing a dental procedure.
2. Antibiotic prophylaxis in high-risk or low-risk dental procedures did not decrease the risk of subsequent total hip or knee infection.

Discussion Points

1. The results of this large, prospective, case-controlled study at the Mayo Clinic showed that the use of antibiotic prophylaxis prior to dental procedures did not alter the subsequent risk of prosthetic hip or knee infection.
2. The ADA/AAOS 2003* advisory panel recommends that antibiotic prophylaxis be considered in those patients who are believed to be at increased risk and that prophylaxis is not needed in otherwise healthy patients after two years of implant surgery.
3. The recent information statement by the AAOS (see May 2009 Clinical Perspective) has advocated using antibiotic prophylaxis in all patients with a joint prosthesis.
4. This Mayo Clinic study suggests that the risk of prosthetic hip or knee infection following dental procedures is not increased in those groups previously identified as being at risk.
5. The majority of prosthetic hip or knee infections are due to staphylococci. Bacterial species from dental procedures include viridians group streptococci, beta-hemolytic streptococci, and gram-positive anaerobes, species not ordinarily associated with prosthetic hip or knee infections.

Oral Hygiene and Risk of Joint Infection

Poor dental hygiene, periodontal, and periapical infections probably produce bacteremia in the absence of dental procedures. In the Mayo Clinic study, the authors indicated that patients with >1 dental hygiene visit were 30% less likely to develop prosthetic hip or knee infection. The authors' suggested that the reported prosthetic joint infections attributed to dental procedures were more likely to have been caused by bacteremia related to routine daily activities than by bacteremia related to dental procedures.

In view of the previous statement, the authors emphasize that it is inconsistent to recommend prophylaxis of prosthetic hip or knee infection for dental procedures but not to recommend prophylaxis for the same patients during routine daily activities. Of course, a recommendation for universal prophylaxis for routine daily activities is impractical and impossible. However, it is important to emphasize that maintaining good oral hygiene and eradicating dental disease is a key to decreasing the frequency of bacteremia from routine daily activities.

Accompanying Editorial to the Mayo Clinic Report

In the same issue of Clinical Infectious Diseases, there is an editorial entitled "Antibiotics for Prevention of Periprosthetic Joint Infection Following Dentistry: Time to Focus on Data," by W. Zimmerli and P. Sendi. This editorial made the following points:

1. Prosthetic joint infections occur in 0.3% to 1% of patients undergoing total hip arthroplasty and in 1% to 2% in patients after knee arthroplasty. Most of episodes are sequalea of Staphylococcus aureus sepsis, skin infection, or infections of the urinary tract.
2. Although it is conceivable that a small portion of the infections are caused by transient bacteremia during dental procedures, clinical experience does not favor this hypothesis.
3. The present statement by the AAOS* recommends that clinicians consider antibiotic prophylaxis for all total joint replacement patients prior to any invasive procedure that may cause bacteremia. Physicians and dentists will follow these latest recommendations. But here are the consequences: general prophylaxis increases the unjustified use of antibiotics, the risk of adverse effects (toxicity and allergy) will probably outweigh any prevention of prosthetic joint infection, and the dentist could be sued for not giving antibiotics according to the AAOS guidelines.
4. Clear conclusive data obtained from clinical studies can help in resolving the question of whom to premedicate with antibiotics.
5. This editorial reminds the physicians and the dental community that the Mayo Clinic study has the potential to reassure the responsible physicians and dentists that antibiotic prophylaxis is not needed for all patients with total joint replacement prior to any dental procedure and to convince individuals with joint replacement that meticulous dental hygiene is important.

* these comments should be taken with caution as this article preceded the AAOS/ADA statement issued on December 18, 2012 which can be found in the first post of this thread.