From the HealthPartners Medical Group and Clinics




October 2007 - The Prevention of Prosthetic Joint Infections Associated with Dental Procedures.





Editors Note:
A recent IME Pearl summarized the new American Heart Association guideline for the prevention of infective endocarditis associated with dental procedures. Since the publication of this Pearl, readers have requested re-publication of a previous IME Pearl addressing the use of prophylactic antibiotics to prevent prosthetic joint infections associated with dental procedures. The following is an updated version of that Pearl.

In 2003, the American Academy of Orthopaedic Surgeons and the American Dental Association published an advisory statement regarding the use of prophylactic antibiotics to prevent infection in persons with total joint replacements who are undergoing dental procedures (1).

Most prosthetic joint infections are caused by staphylococci (i.e., Staphylococcus aureus, Staphylococcus epidermidis, and other coagulase-negative staphylococci), not viridans group streptococci, the predominant oral bacterial species (one study found that viridans group streptococci comprised only 4.9% of microbial isolates from infected prosthetic joints).

Transient bacteremia due to viridans group streptococci commonly occurs when the teeth and periodontal tissues are manipulated during dental procedures and during routine daily activities such as tooth brushing and flossing, use of wooden toothpicks, use of water irrigation devices, and chewing food (2).

The infrequent prosthetic joint infection caused by viridans group streptococci is far more likely to have resulted from a random bacteremia due to routine daily activities than from dental-induced bacteremia. It is probable that few, if any, cases of prosthetic joint infection are prevented by prophylactic antibiotics prior to dental procedures.

The advisory statement makes the following recommendations:

* Antibiotic prophylaxis is not indicated for dental patients with pins, plates, and screws.
* Antibiotic prophylaxis is not routinely indicated for most dental patients with prosthetic joints.
* Certain high-risk patients (see Table I below) with joint prostheses undergoing higher-risk dental procedures (see Table II below) may benefit from antibiotic prophylaxis.
* High-risk patients with a prosthetic joint undergoing a higher-risk dental procedure should receive one of the following prophylactic regimens:

1) If not allergic to penicillin: <>/I>Amoxicillin or cephalexin, 2 g orally one hour prior to the dental procedure. If unable to take oral medications: cefazolin 1 g or ampicillin 2 g intramuscularly or intravenously 1 hour prior to the dental procedure.

2) If allergic to penicillin: Clindamycin 600 mg orally 1 hour prior to the dental procedure. If unable to take oral medications: clindamycin 600 mg intravenously 1 hour prior to the dental procedure.

Table I: Patients at Increased Risk for Prosthetic Joint Infection
1) All patients during the first two years following joint replacement.
<L/B>2) Immunocompromised/immunosuppressed patients including:

a) Patients with inflammatory arthropathies such as rheumatoid arthritis and systemic lupus erythematosus

b) Drug- or radiation-induced immunosuppression

3) Patients with co-morbidities such as:

a) Previous prosthetic joint infections
b) Malnourishment
c) Hemophilia
d) HIV infection
e) Type 1 diabetes mellitus
f) Malignancy


Table II: Dental Procedures Associated with a Higher Incidence of Bacteremia
1) Dental extractions
2) Prophylactic cleaning of teeth or implants where bleeding is anticipated
3) Periodontal procedures
4) Root canal (endodontic) instrumentation only beyond the apex
5) Dental implant placement and reimplantation of avulsed teeth
6) Intraligamentary and intraosseous local anesthetic injections


CONCLUSIONS
* Most prosthetic joint infections are caused by staphylococci, not viridans group streptococci, the predominant oral bacterial species.

* Transient bacteremia due to viridans group streptococci commonly occurs when the teeth and periodontal tissues are manipulated during dental procedures and during routine daily activities such as tooth brushing and flossing, use of wooden toothpicks, use of water irrigation devices, and chewing food.

* The infrequent prosthetic joint infection caused by viridans group streptococci is far more likely to have resulted from a random bacteremia due to routine daily activities than from dental-induced bacteremia.

* Antibiotic prophylaxis is not indicated for dental patients with pins, plates, or screws.

* Antibiotic prophylaxis is not indicated for most dental patients with prosthetic joints.

* Certain high-risk patients with joint prostheses undergoing higher-risk dental procedures may benefit from antibiotic prophylaxis.

* Amoxicillin and cephalexin are the prophylactic antibiotics of choice for high-risk patients with a joint prosthesis undergoing a higher-risk dental procedure. Clindamycin is preferred for penicillin-allergic individuals.

1) The American Urologic Association and the American Academy of Orthopaedic Surgeons have developed a similar advisory statement for patients with prosthetic joint replacements undergoing urologic procedures. The entire advisory statement can be viewed at www.aaos.org/about/papers/advistmt/1023.asp. The expert panel concluded that antibiotic prophylaxis is indicated for certain high-risk patients with joint prostheses (see Table I above) undergoing higher-risk urological procedures including:

* Any stone manipulation
1 Any procedure with transmural incision of the urinary tract
2 Any endoscopic procedures of upper tract (ureter and kidneys)
3 Transrectal prostate biopsy
4 Any procedure that includes bowel segments
5 Any procedure with entry into the urinary tract (except for transurethral catheterization) in individuals with higher risk of bacterial colonization including those individuals with 1) an indwelling catheter or performing intermittent catheterization, 2) indwelling ureteral stent, 3) urinary retention, 4) a history or recent/recurrent urinary tract infection or prostatitis, 5) urinary diversion.

Recommended antibiotics for prophylaxis in high-risk patients with prosthetic joints undergoing higher-risk urologic procedures include:

* A single dose of a quinolone one to two hours preoperatively (e.g., ciprofloxacin 500 mg; levofloxacin 500 mg, ofloxacin 400 mg).
or
* Ampicillin 2 gm IV plus gentamicin 1.5 mg/kg IV 30-60 minutes preoperatively (if allergic to penicillin, vancomycin 1 gm IV over 1-2 hours).

2) The risk of bacteremia associated with dental procedures and daily activities is lessened in individuals who are in good dental health. Patients who are anticipating joint replacement should be in good dental health prior to surgery and should seek professional dental care, if necessary. Patients who had already had a joint replacement should perform effective daily oral hygiene procedures to remove plaque (i.e., brushing and flossing).

References
American Dental Association; American Academy of Orthopaedic Surgeons. Antibiotic Prophylaxis for Dental Patients with Total Joint Replacements (Advisory Statement). JADA 2003; 134: 895-899.

American Urologic Association; American Academy of Orthopaedic Surgeons. Antibiotic Prophylaxis for Urological Patients with Total Joint Replacements (Advisory Statement 2002).

Portnoff JE, Israel HA, Brause BD, Behrman DA. Dental Premedication Protocols for Patients with Knee and Hip Prostheses: A Review of Current Recommendations. N Y State Dent J 2006; 72(3): 20-25.

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