Antibiotic Prophylaxis for Joint Replacement Patients

2012 Guidelines From AAOS and ADA

dentist
Photo by Marcin Balcerzak (iStockphoto)

I had my first joint replacement in 1980. I was a 24 year old with rheumatoid arthritis, a bit overwhelmed, but trying hard to take it in stride. As I left the hospital I was handed an identification card that had my name on it, as well as the date of my surgery and the joint that had been replaced. I was told to refer to the back of the card, if I was to have any dental work or invasive diagnostic procedures performed (e.g., colonscopy).

It referred to an antibiotic prophylaxis regimen that needed to be followed.

Over the years, I learned from personal experience that some doctors and dentists strictly adhered to the antibiotic protocol and others less so.  There became some question with regard to the necessity of the regimen. In 2012, the American Dental Association (ADA) and the American Academy of Orthopaedic Surgeons (AAOS) released the first co-developed evidence-based guidelines on the Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures. The guideline which was released was based on a systematic review of literature. It should also be noted that the review found no direct evidence that dental procedures cause joint implant infections. The ADA/AAOS guideline put forth 3 recommendations:

1 - The co-developed guidelines suggested that practitioners may consider discontinuing the practice of routinely prescribing prophylactic antibiotics for patients with hip and knee replacements who are undergoing a dental procedure.

The strength of this recommendation was "limited", meaning quality evidence was lacking, or well-conducted studies showed little advantage of one approach over the other. Practitioners should use their judgment and patient preference should be considered.

2 - Guideline authors were unable to recommend for or against the use of topical oral antimicrobials in patients with joint implants who were undergoing dental procedures.

This recommendation or guideline was classified as "inconclusive", meaning there was a lack of evidence and an unclear balance between benefit and harm to the patient.

3 - Without evidence that would link poor oral health to a prosthetic joint infection, patients with joint implants should maintain appropriate oral hygiene. This recommendation was classified as "consensus", meaning the expert opinion supports the conclusion although evidence does not exist which would meet inclusion criteria.

Previous Recommendations

Long ago, it was recommended that antibiotics for dental procedures were only necessary for two years after a joint replacement surgery. In 2009, the recommendation changed to antibiotics should be taken prior to dental procedures by joint replacement patients, not just for two years, but rather for life.

It has been my personal experience that doctors and dentists are still unsure of what to do about antibiotic prophylaxis in joint replacement patients. My dentist is sticking to the antibiotic protocol.

I believe he doesn't want to change what seems to be working -- at least in my case.  He may be considering each patient's individual case, which would seem reasonable. If the patient is immunocompromised, has an autoimmune condition, or a higher risk of infection for any reason, it would seem to make sense to go forward with antibiotic use prior to dental procedures.

I had a colonoscopy recently and the gastroenterologist brought up the possibility of antibiotic prophylaxis. The doctor asked me what my dentist does about it. When I said we pre-treat with amoxicillin prior to dental procedures, the gastroenterologist said "then we will do the same."

The Bottom Line

While guidelines seem to have relaxed a bit regarding antibiotic prophylaxis for joint replacement patients, it seems reasonable that the patient's medical condition, risk of infection, history of antibiotic pre-treatment, and the patient's wishes be considered.

Source:

AAOS and ADA. Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures. Evidence-Based Guideline and Evidence Report. December 7, 2012.
http://www.aaos.org/Research/guidelines/PUDP/PUDP_guideline.pdf

Guideline. Antibiotic prophylaxis for GI endoscopy. American Society for Gastrointestinal Endoscopy.

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