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Antibiotic Prophylaxis

for the Prevention of Joint Infections

Other Methods to Decrease Bacteremia

  • Oral antimicrobial rinses (e.g., chlorhexidine, povidone-iodine) to reduce the frequency of bacteremia associated with dental procedures.

    •  Evidence shows that there is no clear benefit associated with its use.

  • The establishment and maintenance of optimal oral hygiene is the most effective way to decrease daily bacteremia

  • The antibiotic was inadvertantly not administered before the procedure

    • The dosage may be administered up to 2 hours after the procedure is completed

  • The patient is already taking penicillin or amoxicillin for eradication of an infection.  Resistance to these medications is likely.  

    • Clindamycin, azithromycin or clarithromycin should be used if prophylaxis is immediately necessary.  Cephalosporins exhibit cross-resistance and so should be avoided.

    • Or, wait at least 10 days after completion of antibiotic therapy.  The usual regimen can then be used.

  • The duration of the dental appointment is longer than 6 hours.

    • A second dose of the antibiotic should be administered.

  • How often can a patient requiring antibiotic prophylaxis be seen?

    • Every 10 days if the same antibiotic is to be used.  

  • What if a patient needs to be seen before this interval is up?

    • Use an alternate antibiotic

Special Conditions

 

References

Dental Management of the Medically Compromised Patient.  Little, Falace, Miller and Rhodus. 8th Edition

J Andrade, E. Stadnick, A Mohamed. Infective endocarditis practice: An update for clinical practice. BCMJ 2008 50:8, 451-455.

 

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

 

 

 

 

Conditions for Which Antibiotic Prophylaxis is NOT Recommended

Antibiotic prophylaxis has been advocated for the patients with the following conditions when they undergo dental treatment.  However, no evidence of need or efficacy to prevent infections has been documented.

 

The following conditions/devices have NOT been found to be susceptible to distant site infection from bacteremia secondary to invasive dental treatment.  Antibiotic prophylaxis is NOT recommended

  • Chronic indwelling catheters of any kind

  • Renal dialysis arteriovenous shunt

  • Cerebrospinal fluid shunts

  • Vascular grafts

  • Orthopedic screws, plates or pins

  • Implanted pacemaker or defibrillator

  • Coronary artery stents

  • Breast implants

  • Penile implants

  • Valvular dysfunction due to:

    • Previous use of fenfluramine and/or dexfenfluramine

    • IV drug use

    • Kawasaki disease

    • Hypertrophic cardiomyopathy

    • Systemic lupus erythematosus

 

The following conditions have NOT been found to cause increased susceptibility to dental/orofacial infection. Antibiotic prophylaxis is NOT recommended 

  • Immunosuppressive drugs (e.g., steroid therapy, chemotherapy, DMARDs)

  • Autoimmune disease (e.g., systemic lupus erythematosus, rheumatoid arthritis)

  • Insulin-dependent diabetes

  • HIV infection/AIDS

  • Splenectomy

  • Severe neutropenia

  • Sickle cell anemia

  • Head and neck radiotherapy

  • Solid organ transplants

  • Stem cell and bone marrow transplants

Assumptions behind the practice of antibiotic prophylaxis

  • Dental manipulation of oral tissues causes an abrupt increase of oral bacteria in the blood, lasting minutes to hours.

    • Dental procedures CAN cause bacteremias.  However, so can normal daily activities such as eating and oral hygiene procedures which could cause multiple bacteremias each day.  

  • This increase in bacterial loading can cause devastating infections systemically or to specific structures or devices.

    • No studies prove that the magnitude of bacteremia caused by dental procedures is higher than for daily activities. 

  • A large dose of antibiotics shortly before the dental procedure will counter the effects of this increase, and decrease the numbers of infections cause by this "transient bacteremia".

    • While studies have shown that amoxicillin reduces the bacteremia associated with dental procedures, there have been no studies that show the efficacy of antibiotic prophylaxis to prevent infective endocarditis or other distant infections in dental patients.

Clinical Practice Guideline

ADA & AAOS (2012)

In 2012, the American Dental Association and the American Academy of Orthopaedic Surgeons (AAOS) released the first co-developed evidence-based guideline on the Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures. The clinical practice guideline, with three recommendations, is based on a systematic review of the literature. The review found no direct evidence that dental procedures cause orthopaedic implant infections.

 

The following is a summary of the recommendations of the AAOS-ADA clinical practice guideline, Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures. This summary does not contain rationales that explain how and why these recommendations were developed, nor does it contain the evidence supporting these recommendations. All readers of this summary are strongly urged to consult the full guideline and evidence report for this information (see link below). We are confident that those who read the full guideline and evidence report will see that the recommendations were developed using systematic evidence-based processes designed to combat bias, enhance transparency, and promote reproducibility.

 

This summary of recommendations is not intended to stand alone. Treatment decisions should be made in light of all circumstances presented by the patient. Treatments and procedures applicable to the individual patient rely on mutual communication between patient, physician, dentist and other healthcare practitioners.

 

The Guideline Recommendations:

 

1. The practitioner might consider discontinuing the practice of routinely prescribing prophylactic antibiotics for patients with hip and knee prosthetic joint implants undergoing dental procedures.

Strength of Recommendation: Limited

 

A Limited Recommendation means the quality of the supporting evidence that exists is unconvincing, or that well-conducted studies show little clear advantage to one approach versus another.

Practitioners should be cautious in deciding whether to follow a recommendation classified as Limited, and should exercise judgment and be alert to emerging publications that report evidence. Patient preference should have a substantial influencing role.

 

2. We are unable to recommend for or against the use of topical oral antimicrobials in patients with prosthetic joint implants or other orthopaedic implants undergoing dental procedures.

Strength of Recommendation: Inconclusive

 

An Inconclusive Recommendation means that there is a lack of compelling evidence resulting in an unclear balance between benefits and potential harm.

 

Practitioners should feel little constraint in deciding whether to follow a recommendation labeled as Inconclusive and should exercise judgment and be alert to future publications that clarify existing evidence for determining balance of benefits versus potential harm. Patient preference should have a substantial influencing role.

 

3. In the absence of reliable evidence linking poor oral health to prosthetic joint infection, it is the opinion of the work group that patients with prosthetic joint implants or other orthopaedic implants maintain appropriate oral hygiene.

Strength of Recommendation: Consensus

 

A Consensus Recommendation means that expert opinion supports the guideline recommendation even though there is no available empirical evidence that meets the inclusion criteria.

 

Practitioners should be flexible in deciding whether to follow a recommendation classified as Consensus, although they may set boundaries on alternatives. Patient preference should have a substantial influencing role.

 

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