The Journal of Arthroplasty 29 (2014) 1091–1097

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Antibiotic Prophylaxis for Dental Procedures at Risk of Causing Bacteremia Among Post-Total Joint Arthroplasty Patients: A Survey of Canadian Orthopaedic Surgeons and Dental Surgeons Tristan Colterjohn, BAS a, b, Justin de Beer, MD, FRCSC a, b, c, Danielle Petruccelli, MLIS, MSc c, Nazar Zabtia, MD, FRCSC a, b, Mitch Winemaker, MD, FRCSC a, b, c a b c

Department of Surgery, Hamilton Health Sciences, Hamilton, Ontario, Canada Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada Hamilton Arthroplasty Group; Hamilton Health Sciences Juravinski Hospital, Hamilton, Ontario, Canada

a r t i c l e

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Article history: Received 14 August 2013 Accepted 26 November 2013 Keywords: total joint arthroplasty antibiotic prophylaxis dental survey orthopedic surgeons dental surgeons bacteremia

a b s t r a c t To elicit current practice and attitudes toward use of antibiotic-prophylaxis among TJA patients prior to dental procedures, a cross-sectional survey of practicing Canadian orthopaedic (OS) and dental surgeons (DS) was undertaken. Of respondents, 77% of OS and 71% of DS routinely prescribe antibiotic-prophylaxis, but while 63% of OS advocate lifelong use, only 22% of DS choose to do so (P b 0.0001). Both groups nonetheless recognize the importance of treatment within 2-years post-TJA as per AAOS/ADA guidelines. However, greater duration of practice pointed to potential inadequacy of these guidelines based on reported experience with late-hematogenous infection post-TJA. While discrepancies in attitude toward antibiotic-prophylaxis between surgeon groups remain, both groups agreed that the evidence to support decision making regarding antibiotic-prophylaxis for TJA patients undergoing dental procedures remains inadequate. © 2014 Elsevier Inc. All rights reserved.

The use of antibiotics to prevent infections of prosthetic joints after dental procedures has remained a controversial topic for decades, with frequent but often inconclusive advisory statements from different medical associations, most notably the American Academy of Orthopaedic Surgeons (AAOS). In their most recent clinical practice guideline, produced in conjunction with the American Dental Association (ADA) in December 2012, the recommendations consisted of two major points; first, “the practitioner might consider discontinuing the practice of routinely prescribing prophylactic antibiotics for patients with hip and knee prosthetic joint implants undergoing dental procedures”, and secondly that “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” [1]. Moving away from their previous information statements largely derived from professional opinion, the 2012 evidence-based clinical practice guidelines came as a reversal of their 2009 information statement, which advised that given the potential adverse outcomes and cost of treating an infected joint arthroplasty, the AAOS recommends that

The Conflict of Interest statement associated with this article can be found at http://dx.doi.org/10.1016/j.arth.2013.11.024. Reprint requests: Danielle Petruccelli, MLIS, MSc, Hamilton Arthroplasty Group, Hamilton Health Sciences Juravinski Hospital, Hamilton, Ontario, Canada. http://dx.doi.org/10.1016/j.arth.2013.11.024 0883-5403/© 2014 Elsevier Inc. All rights reserved.

clinicians consider antibiotic prophylaxis for all total joint arthroplasty (TJA) patients prior to any invasive procedure that may cause bacteremia [2]. The 2009 statement by the AAOS was itself an abrupt departure from its previous guidelines. In 1997 the AAOS partnered with the ADA to create an expert panel on the issue which released an advisory statement that cautioned against routine antibiotic prophylaxis for most artificial joint recipients undergoing dental procedures. They supported antibiotic prophylaxis indefinitely for patients with immune-compromising comorbidities, including diabetes, inflammatory joint disease, and chemotherapy or irradiation-induced immune suppression, as well as for a defined list of invasive procedures including dental extractions and periodontal procedures [3]. In addition they only recommended antibiotic prophylaxis for TJA patients during the first two years post-surgery, citing the timeframe as the most critical period for seeding of bacteremia to a TJA [3]. This recommendation was based on results of a single study which showed that the rate of deep periprosthetic infection was highest in the first 2 years postoperative occurring at a rate of 0.14 cases per 1000 jointyears (confidence interval 0.07–0.25), and that the annual infection rate thereafter was much lower dropping to 0.03 cases per 1000 joint years (confidence interval 0.01–0.07) [4,5]. While seemingly convincing, these results were based on unpublished data and had thus not been subjected to critical peer review. Hanssen et al [4] further indicated that these rates were similar to those for infective

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endocarditis in the general population, a patient group for which the American Heart Association did not recommend antimicrobial prophylaxis citing that toxicity outweighed potential benefit. While the updated 2003 advisory statement was relatively in keeping with the 1997 version, the 2009 information statement both removed the two-year post-surgery limit advising that precautions be continued indefinitely, and chose not to define the meaning of “invasive procedure”[2,6]. This contradictory set of subsequent guidelines and the continuing controversy regarding the use of antibiotic prophylaxis for hip and knee TJA patients undergoing dental procedures prompted us to conduct a cross-sectional survey of both Canadian Orthopaedic Surgeons and Dental Surgeons in an effort to determine current practice and attitude toward the use of antibiotic prophylaxis among TJA patients prior to dental procedures. Of particular interest were the potential discrepancies in practice between Orthopaedic and Dental Surgeons.

Method To elicit current practice and attitude toward use of antibiotic prophylaxis among TJA patients prior to dental procedures, a crosssectional self-administered survey of practicing Canadian Orthopaedic Surgeon (OS) and Dental Surgeons (DS) was conducted. Two separate but very similar surveys specific to practicing OS and DS were developed by an expert orthopaedic and dental surgeon panel comprised of three Orthopaedic Surgeons, two Dental Surgeons, one Orthopaedic Research Nurse and one Orthopaedic Research Coordinator/Measurement and Evaluation Specialist. The expert panel generated survey items, reviewed multiple iterations, and determined content and face validity of the surveys. The OS and DS specific surveys were comprised of 16-items each, which tapped prevalence, duration, and restrictions in prescribing and advising of antibiotics prior to dental treatment, incidence of late hematogenous infection in TJA attributed to dental origin in own

Fig. 1. Canadian orthopaedic surgeon survey of antibiotic prophylaxis for dental procedures at risk of causing bacteremia among post-total joint arthroplasty patients.

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Fig. 1. (continued)

practice, rating of support from OS/DS colleagues in respective prophylactic antibiotic treatment regiments, and perception of evidence-based research and treatment plans in support of decision making with regard to TJA and antibiotic prophylaxis. The OS and DS surveys are provided as Figs. 1 and 2. The OS survey was developed in SurveyMonkey® and sent via email to OS identified as members of the Canadian Orthopaedic Association with inclusion of responses restricted to practicing hip and/or knee arthroplasty surgeons. The DS survey was mailed to practicing general practitioner DS identified as members of the Ontario Dental Association and sent via mail with return via fax or self-addressed stamped envelope. The survey was resent to nonresponders at three months after the first mail out. Survey responses were analysed using descriptive statistics and the chi-square test for proportions. All analyses were performed using IBM SPSS Statistics version 20. A value of P b 0.05 was considered statistically significant.

Results A total of 956 surgeons were surveyed and 329 completed and returned the survey giving an overall response rate of 34.4%, including 30.9% (172/556) among OS and 39.3% (157/400) among DS (P = 0.008). The final sample of respondents comprised of 153 OS identified as practicing hip and/or knee arthroplasty surgeons, and 157 practicing DS. Of the sample, 52.3% of OS (80/153) and 77.1% of DS (121/157) reported being in practice for more than 15 years (P b 0.0001). Longer duration of practice was significantly associated with a greater likelihood of prescribing antibiotic prophylaxis for OS (r = 0.482, P b 0.0001) as compared to DS (r = 0.035, P = 0.663). Of respondents, 76.5% of OS (117/153) and 70.7% of DS (111/157) routinely prescribe antibiotic prophylaxis (P = 0.250). However, while 63.4% of OS (97/ 153) advocate lifelong antibiotic prophylaxis, only 21.7% of DS (34/157) choose to do so (P b 0.0001). Likewise 52.9% of surveyed DS (83/157)

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Fig. 2. Ontario dental surgeon survey of antibiotic prophylaxis for dental procedures at risk of causing bacteremia among post-total joint arthroplasty patients.

opt to prescribe/advise antibiotics for only the first two years post-TJA versus 28.1% (43/153) of OS (P b 0.0001). Among surveyed OS, 33.9% (52/153) restrict prophylactic antibiotics to specific dental procedures, as compared to 61.8% of DS (97/157) (P b 0.0001). Of surgeons that restrict antibiotic prophylaxis to certain procedures, 96.1% of OS indicate they restrict to invasive dental procedures, while 67.7% of DS indicate prophylactic antibiotics for both routine cleaning and invasive procedures, noting that antibiotics should be prescribed for any treatment that may cause bleeding. A total of 89.5% of OS (137/153) versus 56.7% of DS (89/157) indicated that they advise lifelong antibiotic prophylaxis for immune compromised “at risk” patients (P b 0.0001). Of these, significantly more OS (89.1%) prescribe lifelong antibiotics for immune compromised patients, as compared to DS (67.1%) (P b 0.0001). Thirty-five percent (54/153) of OS reported a total of 85 cases of late hematogenous infection in TJA patients, occurring within the last five years of the survey date, which they had attributed to dental origin, compared to only 7 cases identified by 1.3% (2/157) of surveyed DS. Among OS, increased number of years in practice significantly correlated with number of identified late hematoge-

nous infections attributed to dental origin within own practice (r = 0.635, P b 0.0001). In fact all 85 cases were reported by OS who had been in practice for more than 15 years. Likewise the one dental surgeon who reported 6 of the 7 identified cases had been in practice for more than 15 years. Duration of OS practice N 15 years was also significantly correlated with advising/prescribing lifelong prophylactic antibiotics prior to dental treatment (r = 0.581, P b 0.0001). Considering identified bacteremia cases, OS further indicated that 40% (34/85) of these late hematogenous infection cases were treated with a two-stage TJA revision, and attributed 32.9% (28/85) of infected cases to a streptococcus species organism. Within their own practice, Dental Surgeons felt that patient disregard of hip or knee TJA as constituting a change in medical health and subsequent failure to volunteer this information to the Dentist and/or Dental Hygienist occur at a rate of 33%, as identified on a 10-point VAS. OS rated support from DS regarding their antibiotic prophylaxis practice as a mean of 7.2/10 (±2.2) on a 10-point VAS where 0 = poor and 10 = excellent. On the contrary DS mean rating of like support from OS was rated significantly lower at 6.5/10 (±3.2), (P = 0.020).

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Fig. 2. (continued)

Both surgeon groups, including 82.4% of OS (126/153) and 65.6% of DS (103/157) felt that existing evidence-based research and treatment plans in the literature to support decision making regarding antibiotic prophylaxis for TJA patients undergoing dental procedures remain inadequate. Discussion The survey results indicate a strong trend toward the use of antibiotic prophylaxis to prevent bacteremia among post-TJA patients as being more widely held among orthopaedic surgeons compared to dental surgeons. Orthopaedic surgeon preference for a proactive approach is understandable given their higher exposure to the severe consequences of TJA infection. Of surveyed orthopaedic surgeons, those with the most experience (15 years or more in practice) reported all of the identified cases of late hematogenous infection attributed to dental origin and for that

reason routinely recommend lifelong prophylactic antibiotic treatment. In their 2009 information statement the AAOS itself justified their support of antibiotic prophylaxis prior to any invasive procedure that may produce bacteremia regardless of length of time after TJA surgery, citing the potential adverse outcomes and cost of treating an infected TJA [7]. In a recent prospective review of the economic impact of periprosthetic joint infections requiring a two-stage total knee revision as compared to non-infected total knees, Kapadia et al [8] reported a significantly higher mean annual cost of $116,383 USD in the infected cohort as compared to $28,249 in the matched group. On the other hand, dental surgeons are instead more likely to be exposed to the consequences of excessive application of prophylactic antibiotics. As a comparison, a 2012 meta-analysis by Legout et al [9] concluded that when the costs of antibiotic-related complications were taken into account, the cost of preventing one case of prosthetic infection directly related to a dental procedure was

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$480,000 in 1990. Additional consequences of liberal antibiotic use include hypersensitivity reactions such as anaphylaxis, suppression of natural oral flora, and development of antibiotic-resistant strains of bacteria [7,9–11]. This divide between surgical groups has been well documented in similar past studies. In a 2002 survey conducted by Kingston et al [12] orthopaedic surgeons and dentists were polled along with urologists on the use of antibiotic prophylaxis. When asked about the relationship between dental procedures and TJA infection, orthopaedic surgeons answered that infection could probably result from dental procedures, while dentists preferred to answer “don’t know”. Orthopaedic surgeons also believed that patients with hip or knee arthroplasties should probably be given antibiotics for both routine and lengthy dental procedures, while dentists responded “probably not” and “don’t know” respectively [12]. A postal survey conducted by Sandhu et al in 1997 [13] produced similar results where nearly 80% of responding surgeons claimed to always recommend the prophylactic use of antibiotics, compared to 30% of oral surgeons. Results of our study indicated that while 77% of OS and 71% of DS routinely prescribe antibiotic prophylaxis, 34% of surveyed OS restrict prophylaxis to specific dental procedures compared to 62% of DS. Of OS that restrict treatment, 96% prescribe for invasive dental procedures only, while 68% of DS indicate treatment for any dental procedure that may cause bleeding. That such inconsistency persists indicates that guidelines are insufficient due to the lack of level 1 evidence in this regard. Since the possibility of remote infection of oral bacteremia from prosthetic joints was first raised, orthopedic surgeons seem to have strongly favoured the use of antibiotic prophylaxis prior to dental procedures, despite a lack of supporting evidence and the vocal disagreement of a portion of the surgical community. Opinion surveys as far back as the 1970s and early 1980s indicated that more than 90% of orthopaedic surgeons favoured antibiotic treatment before dental procedures for TJA patients [14]. Amidst this popular opinion, some practitioners had a growing concern over the lack of support for antibiotic prophylaxis in the literature, and in 1988 the ADA sponsored a workshop in Chicago to address this issue. The results of the meeting were published in 1990, and stated that the data supporting the use of antibiotics for dental patients with prosthetic joints were limited [15]. These findings were followed up in 1997 by a joint advisory statement by the AAOS and ADA which recommended that antibiotic prophylaxis only be considered for high-risk patients and for those who had received their prosthesis within two years. This position was held consistently until February 2009 when the AAOS independently published an information statement advising that antibiotic prophylaxis be considered for all TJA patients prior to any invasive procedure that may cause bacteremia [2]. With the December 2012 clinical practice guideline, the AAOS has once again collaborated with the ADA and returned to a position somewhat similar to its pre-2009 stance, this time employing robust systematic, evidence-based health research methodology to arrive at their recommendations. Despite their efforts to arrive at consensus, the AAOS Clinical Practice Guideline Unit states “the grades of recommendation in this clinical practice guideline are limited at best due to the lack of evidence in some cases and conflicting evidence in others”[1]. Given the sheer lack of level 1 evidence in this regard, the complexities of developing such a consensus guideline to date are appreciated. What is of concern though is whether these recommendations will actually have any effect on the contrasting attitudes between dentists and orthopaedic surgeons. With the results of survey studies consistently pointing to this discrepancy of opinion across multiple iterations, a solution in the form of another similarly constructed guideline seems unlikely. One 2008 study by Tong and Theis [16] concluded that more than

90% of practicing orthopaedic surgeons in New Zealand did not follow the contemporary AAOS guidelines regarding the use of prophylactic antibiotics. In our cross-sectional survey both surgeon groups agreed there is a lack of available evidence for decision-making, and the authors of the 2009 and 2012 guidelines admit this weakness. In a 2009 interview, Dr. Terry Clyburn, a member of the Patient Safety Committee that developed the 2009 AAOS statement, declared: “Although it is true that no medical evidence exists to support an increased risk of total joint infection in patients undergoing either oral or urologic procedures, neither is there evidence that these patients are not at risk for bacteremia that could result in total joint infection” [17]. The 2012 update is much the same, describing its two major recommendations as “limited” and “inconclusive”, meaning that the quality of supporting evidence is either unconvincing or absent [1]. A 2010 study by Berbari et al [18] is the only prospective case–control study in the field, and it found no increased risk of prosthetic infection for patients undergoing either high or low-risk dental procedures when they were not administered antibiotic prophylaxis. The lack of evidence to support guidelines in either direction prevents a consensus from being reached. Results of the current study confirm that discrepancies in attitude toward antibiotic prophylaxis between Canadian orthopaedic surgeons and dental surgeons remain. Both surgeon groups nonetheless recognize the importance of antibiotic prophylaxis in at least the first two years following TJA in accordance with the original AAOS and ADA practice guidelines. However, greater duration of practice and hence greater experience pointed to the potential inadequacy of these guidelines based on reported experience with late hematogenous infection among TJA patients. It is very clear that orthopaedic and dental surgeons agree the evidence and current practice guidelines to support decision making regarding antibiotic prophylaxis for TJA patients undergoing dental procedures remain inadequate. References 1. American Dental Association; American Academy of Orthopaedic Surgeons. (2012, December 7). Summary of recommendations of prevention of orthopaedic implant infection in patients undergoing dental procedures guideline. Available at: http://www.aaos.org/research/guidelines/PUDP/dental_guideline.asp. Accessed 11 June, 2013. 2. American Academy of Orthopedic Surgeons. (2009, February). Information statement: antibiotic prophylaxis for bacteremia in patients with joint replacements. Available at: http://orthodoc.aaos.org/davidgrimmmd/Antibiotic% 20Prophylaxis%20for%20Patients%20after%20Total%20Joint%20Replacement.pdf. Accessed 15 June, 2013. 3. American Dental Association, American Academy of Orthopaedic Surgeons. Antibiotic prophylaxis for dental patients with total joint replacements. J Am Dent Assoc 1997;128:1004. 4. Hanssen AD, Osmon DR, Nelson CL. Prevention of deep periprosthetic joint infection. Am J Bone Joint Surg 1996;78-A(3):458. 5. Osmon DR, Steckelberg JM, Hanssen AD. Incidence of prosthetic joint infection due to viridians streptococci. Read at the Annual Meeting of the Musculoskeletal Infection Society. Colorado: Snowmass; 1993. 6. American Dental Association. American Academy of Orthopedic Surgeons. Antibiotic prophylaxis for dental patients with total joint replacements. J Am Dent Assoc 2003;134:895. 7. Napeñas JJ, Lockhart PB, Epstein JB. Comment on the 2009 American Academy of Orthopaedic Surgeons’ information statement on antibiotic prophylaxis for bacteremia in patients with joint replacements. J Can Dent Assoc 2009; 75(6):447. 8. Kapadia BH, McElroy MJ, Issa K, Johnson AJ, Bozic KJ, Mont MA. The economic impact of periprosthetic infections following total knee arthroplasty at a specialized tertiary-care center. J Arthroplasty. 2013 Oct 17. doi:pii:S0883-5403 (13)00698-0. 10.1016/j.arth.2013.09.017. [Epub ahead of print] 9. Legout L, Beltrand E, Migaud H, et al. Antibiotic prophylaxis to reduce the risk of joint implant contamination during dental surgery seems unnecessary. Orthop Traumatol Surg Res 2012;98:910. 10. Little JW. Patients with prosthetic joints: are they at risk when receiving invasive dental procedures? SCD Spec Care Dent 1997;17(5):153. 11. Garg A, Guez G. Debate rages over antibiotic prophylaxis in patients with total joint replacements. Dent Implant Update 2011;22(5):33. 12. Kingston R, Kiely P, McElwain JP. Antibiotic prophylaxis for dental or urological procedures following hip or knee replacement. J Infect 2002;45:243.

T. Colterjohn et al. / The Journal of Arthroplasty 29 (2014) 1091–1097 13. Sandhu SS, Reuben SF, Lowry JC, et al. Who decides on the need for antibiotic prophylaxis in patients with major arthroplasties requiring dental treatment: is it a joint responsibility? Ann R Coll Surg Engl 1997;79:143. 14. Little JW, Jacobson JJ, Lockhart PB. The dental treatment of patients with joint replacements: a position paper from the American Academy of Oral Medicine. J Am Dent Assoc 2010;141(6):667. 15. American Dental Association Council on Dental Therapeutics. Management of dental patients with prosthetic joints. JADA 1990;121(4):537.

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16. Tong D, Theis J. Antibiotic prophylaxis and invasive dental treatment in prosthetic joint patients. J New Zealand Med Assoc 2008;121:45. 17. Porucznik MA. AAOS releases new statement on antibiotics after arthroplasty. Available at http://www.aaos.org/news/aaosnow/may09/cover2.asp; 2009, May. Accessed June 11, 2013. 18. Berbari EF, Osmon DR, Carr A, et al. Dental procedures as risk factors for prosthetic hip or knee infection: a hospital-based prospective case-control study. Clin Infect Dis 2010;1(50):8.

Antibiotic prophylaxis for dental procedures at risk of causing bacteremia among post-total joint arthroplasty patients: a survey of Canadian orthopaedic surgeons and dental surgeons.

To elicit current practice and attitudes toward use of antibiotic-prophylaxis among TJA patients prior to dental procedures, a cross-sectional survey ...
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