Antibiotics and Hip Surgery
Guidelines by the American Dental Association and Academy of Orthopaedic Surgeons
Antibiotic Prophylaxis for Dental Patients with Total Joint Replacements
American Dental Association; American Academy of Orthopaedic Surgeons
An expert panel of dentists, orthopaedic surgeons and infectious disease specialists, convened by the American Dental Association (ADA) and the American Academy of Orthopaedic Surgeons (AAOS) performed a thorough review of all available data to determine the need for antibiotic prophylaxis to prevent hematogenous prosthetic joint infections in dental patients who have undergone total joint arthroplasties. The result is this report, which has been adopted by both organizations as an advisory statement. The panel’s conclusion: Antibiotic prophylaxis is not indicated for dental patients with pins, plates and screws, nor is it routinely indicated for most dental patients with total joint replacements. However, it is advisable to consider premedication in a small number of patients (Table 1) who may be at potential increased risk of hematogenous total joint infection.
Approximately 450,000 total joint arthroplasties are performed annually in the United States. Deep infections of these total joint replacements usually result in failure of the initial operation and the need for extensive revision. Due to the use of perioperative antibiotic prophylaxis and other technical advances, deep infection occurring in the immediate postoperative period resulting from intraoperative contamination has been markedly reduced in the past 20 years.
Patients who are about to have a total joint arthroplasty should be in good dental health prior to surgery and should be encouraged to seek professional dental care if necessary. Patients who already have had a total joint arthroplasty should perform effective daily oral hygiene procedures to remove plaque (e.g. manual or powered toothbrushes, interdental cleaners, oral irrigators) to establish and maintain good oral health. The risk of bacteremia is far more substantial in a mouth with ongoing inflammation than in one that is healthy and employing these home-oral hygiene devices.1
Bacteremias can cause hematogenous seeding of total joint implants, both in the early postoperative period and for many years following implantation.2 It appears that the most critical period is up to two years after joint placement.3 In addition, bacteremias may occur in the course of normal daily life4-6 and concurrently with dental and medical procedures.6 It is likely that many more oral bacteremias are spontaneously induced by daily events than are dental treatment-induced.6 Presently, no scientific evidence supports the position that antibiotic prophylaxis to prevent hematogenous infections is required prior to dental treatment in patients with total joint prostheses.1 The risk/benefit7,8 and cost/effectiveness7,9 ratios fail to justify the administration of routine antibiotic prophylaxis. The analogy of late prosthetic joint infections with infective endocarditis is invalid as the anatomy, blood supply, microorganisms and mechanisms of infection are all different.10