The Journal of Arthroplasty 30 (2015) 543–546
Contents lists available at ScienceDirect
The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org
Is Routine Antibiotic Prophylaxis Cost Effective for Total Joint Replacement Patients? James D. Slover, MD, MS a, Michael S. Phillips, MD b, Richard Iorio, MD a, Joseph Bosco, MD a a b
Department of Orthopaedic Surgery, NYU Langone Medical Center, New York, New York Department of Epidemiology, NYU Langone Medical Center, New York, New York
a r t i c l e
i n f o
Article history: Received 19 September 2014 Accepted 1 November 2014 Keywords: antibiotic prophylaxis dental procedures total hip replacement total knee replacement infections
a b s t r a c t The routine use of amoxicillin antibiotic prophylaxis prior to dental procedures for patients with total joint prostheses in place remains controversial. This analysis shows that the practice may not be cost-effective for patients in whom the risk of infection with dental work is low. However, specific data quantifying the risk and the impact prophylactic antibiotics can have is needed. Patients and physicians will need to continue to consider their use on an individual basis and should consider the risk of infection as well as the risk of adverse drug reaction when making treatment decisions. © 2014 Elsevier Inc. All rights reserved.
The need for antibiotic prophylaxis prior to dental procedures for patients with existing total joint replacements remains controversial. Currently, over a million hip and knee replacement procedures are done each year in the United States, resulting in a substantial number of patients who have joint replacements in place today [1–3]. Late hematogenous infection of a total joint replacement is postulated, but not definitively proven, to occur when bacteremia, caused by dental procedures, results in bacterial seeding of the prosthesis [4]. It is estimated that 6–13% of prosthetic joint infections involve organisms that could be from the oral cavity [5], and some hematogenous infections may occur through this transmission mechanism. Antibiotic prophylaxis can reduce the incidence of bacteremia with dental procedures, thus theoretically, decreasing the likelihood of late hematogenous infections of a total joint prosthesis [4]. However, the true risk associated with dental procedures is unknown, the ability of prophylaxis to decrease the risk of these infections is not clearly established, and significant adverse drug reactions associated with antibiotic use can occur. These include allergic reactions as well as the development of Clostridium difficile infection (CDI), both of which also can have significant costs and clinical consequences for patients. As a result, it is difficult for clinicians and patients to weight the risks, benefits and relative costs of performing routine antibiotic prophylaxis for dental procedures. The purpose of this study is to use a decision analysis model and the currently available data to quantify the cost-effectiveness of antibiotic prophylaxis prior to dental procedures in patients with total joint replacements and to determine the associated conditions for which it The Conflict of Interest statement associated with this article can be found at http:// dx.doi.org/10.1016/j.arth.2014.11.001. Reprint requests: James Slover, MD, MS, NYU Langone Medical Center, 301 East 17th Street Suite 213, New York, NY 10003. http://dx.doi.org/10.1016/j.arth.2014.11.001 0883-5403/© 2014 Elsevier Inc. All rights reserved.
would be cost-effective in order to help clinicians consider their treatment choice in the absence of this definitive data and to help guide future research efforts intended to determine the scenarios where antibiotic prophylaxis is indicated. Methods Model Design We used a decision model [6] to evaluate the cost-effectiveness of routine antibiotic prophylaxis prior to dental work in patients with total joint replacement. The decision model depicting the pathway followed by patients in the screening program is shown in Fig. 1. Patients transition along the appropriate arm of the decision tree according to the likelihood of each event determined by the probability of each event as detailed below. In addition, we assigned a utility value, measured in quality-adjusted life-years, and a cost to every health state, which results from the sequence of events depicted in each terminal branch of the tree. The specific probabilities, utility values and costs used are discussed in detail below. The model is designed to analyze the cost-effectiveness from the payer perspective. Model Probabilities Health State Values The methodology for determining the utility and disutility values was described in a previous publication and is shown again here given their importance for the reader [7]. Utilities used in the model were based on scores for joint arthroplasty reported in the literature [8,9]. The utility value after total joint arthroplasty, was set at 0.75, which is
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J.D. Slover et al. / The Journal of Arthroplasty 30 (2015) 543–546
Fig. 1. The figure represents the decision model used to model patients with total joint replacement undergoing a dental procedure. Each patient either receives prophylactic antibiotics or does not. Those that receive antibiotics either have an antibiotic reaction or do not. Both groups then either have a prosthetic infection or do not.
consistent with the average utility values found in the Swedish Registry after hip arthroplasty (0.73) [10]. The utility value for an infected total joint replacement was assigned an initial value of 0.4 to be consistent with the utility value associated with this state in the literature [11]. Disutilities represent the negative preference patients have for a particular health state or outcome, such as primary or revision knee arthroplasty. These negative utility values, or disutilities, account for the decreased mobility, increased pain, and potential complications, which are incurred during the post-operative and post-acute care recovery period. The disutility of having an adverse drug reaction was set at −0.05, or roughly loss of 3 weeks of perfect health [7]. Costs We set the average cost of a septic joint revision at $90,000 for the base case to be consistent with previous studies of resource utilization
for revisions of infected joint replacements [12,13]. The β-lactam class of antibiotics (such as amoxicillin) are most frequently used for dental prophylaxis and are the most frequent cause of severe drug related anaphylaxis [14], occurring in 0.015–0.004% [15] of treatments at a cost of $7600 [16] per episode. Clostridium difficile infection is another severe consequence of β-lactam use, occurring in 6.7 of 100,000, or 0.0000067% [17], of outpatient treatments at a cost of $13,000–16,400 [18] per episode. Amoxicillin, the most frequently used antibiotic for prophylaxis is associated with rash in 5.1% of patients [19] treated at a cost of $200 per episode requiring an outpatient evaluation. Amoxicillin causes an adverse event severe enough to require emergency department evaluation (ED) in 0.15% [20] of outpatient treatments, at a cost of $1200 [21] per ED visit. Using these data, the average cost of an antibiotic complication per prophylactic prescription is $14.30 (0.0015 × $7600 + 0.0000067 * $15000 + 0.05 × $200 + 0.0015 × $1200).
Fig. 2. Results of sensitivity analysis demonstrating the relationship between the probability of sustaining an infected prosthesis after dental work and the reduction in this risk provided by the use of prophylactic antibiotics. For example, if the risk of peri-prosthetic infection for a given patient with dental work is 0.012, or 1.2%, then the relative risk with prophylactic antibiotics would have to be 0.58, or 42% less, for the use of antibiotic prophylaxis to be cost-effective (blue areas).
J.D. Slover et al. / The Journal of Arthroplasty 30 (2015) 543–546
The overall risk of a complication is equal to the sum of probabilities of each of these antibiotic reactions and is 5.30067%. (0.15 + 0.0000067 + 0.05 + 0.15) [4,22,23]. Analysis After completion of the model, the total tabulated costs are used to evaluate the overall cost of the screening program. Sensitivity analysis is a test of the stability of conclusions conducted by varying a variable, or variables, over a stated range and evaluating the effect of this variation on the outcome, in this study the total cost of the patient's treatment [6]. Two-way sensitivity analysis was used to examine the relationship between the probability of an infected total joint secondary to dental work and the probability of an adverse drug reaction from antibiotic prophylaxis. A threshold of Willingness to Pay was set at $50,000 per quality-adjusted life-year to be consistent with cost-effectiveness studies. The model was constructed using decision analysis software (TreeAge Pro 2008, Williamstown, MA). Results Fig. 2 demonstrates the cost benefit analysis for different infection risk profiles. It demonstrates that if the risk of an infected prosthesis is less than 0.75 %, then antibiotic prophylaxis will not be cost-effective no matter how much the risk is reduced by the administration of prophylactic antibiotics (red areas). However, there are scenarios where it would be cost-effective. For example, if the risk of getting an infected prosthesis was 0.0012 or 1.2%, then it would be cost-effective to administer prophylactic antibiotics if they reduced that risk by 42% (creating relative risk of 0.58) or more. If the risk of an infected prosthesis was 0.021 or 2.1%, then prophylactic antibiotics would only have to reduce the risk by 25 % (creating relative risk of 0.75) or more to be cost effective. Discussion The routine use of antibiotic prophylaxis for patients with total joint implants remains a topic of continued debate [24]. Despite a lack of evidence demonstrating a significant risk for prosthetic infection with dental procedures and insufficient data demonstrating that the use of antibiotic prophylaxis prior to dental procedures can reduce the risk of prosthesis infection [4], many surgeons continue to support their use [25]. However, the risk of routine antibiotic prophylaxis in this situation is not benign, and poses significant risks for patients and is associated with significant potential costs to the health care system [26–28]. Recent updates by the American Heart Association restricted the use of prophylactic antibiotic prophylaxis for endocarditis prevention and to date, no increase in the incidence of endocarditis with dental procedures has been detected [29]. Recent American Academy of Orthopaedic Surgeon Guideline Recommendations have asked clinicians to consider changing the practice of routine antibiotic prophylaxis for patients with orthopedic implants undergoing dental procedures, but have not strongly advised against it due to insufficient data at this time [4]. In our report, decision analysis was used to examine this practice from a cost-effectiveness standpoint. The results show that because of the costs associated with adverse antibiotic reactions, prophylactic antibiotics would need to reduce the infection risk substantially to be cost effective. If the risk of infection with a dental procedure is greater than 0.7% (probability of 0.007), which no study has demonstrated, prophylactic antibiotics may be cost effective (Fig. 2). However, this risk of prosthesis infection directly from dental work has not been clearly quantified, but available evidence suggests it is very low [4,30]. If the risk is less than 0.7%, then the use of prophylactic antibiotics would not be a cost-effective practice. If the risk of prosthesis infection is greater than 0.7%, then it may be cost-effective to use prophylactic antibiotics, provided this risk can be reduced by an appropriate amount.
545
Studies to determine the true risk and the degree it can be reduced with the use of antibiotic prophylaxis are needed. Although specific data are lacking, the apparent low rate of prosthesis infection associated with dental procedures, and the lack of quantification of the amount that risk can be reduced with the use of prophylactic antibiotics, make it difficult to establish the advisability of routine prophylaxis. We tend to focus on our own areas of responsibility in today's age of specialized medicine, but orthopedic surgeons should consider the clinical impact and cost associated with adverse reactions when we are advising our patients with joint replacements who are undergoing dental procedures about antibiotic prophylaxis. This includes severe allergic reactions and infections caused by C. difficile, which have substantial clinical and financial consequences, as well as more mild, but much more common, reactions to antibiotic use [27,26]. These must be considered by clinicians and patients when making treatment decisions, and further work is needed to determine which patients, if any, would benefit from antibiotic prophylaxis prior to a dental procedure. There are limitations of this analysis. This includes the limited data quantifying the risk of infection of a prosthetic joint with dental work, and the magnitude that risk is decreased with the use prophylactic antibiotics. Additionally, the data determining the cost of treating adverse reactions to antibiotics may vary for different patients or groups of patients. A variety of antibiotic reactions in terms of type and cost are possible, and this is true of prosthetic infections as well. Further studies providing data to quantify these parameters, would enhance the applicability of the analysis. Finally, clinicians can choose in certain circumstances to recommend interventions, despite potential lack of cost-effectiveness, and these decisions should continue to be valid on a patient by patient basis in consultation with the patient about risks and benefits of both prophylaxis and lack of prophylaxis with dental work. Certain patient populations may have higher risk of infection due to dental work induced bacteremia (immunosuppressed, diabetics, HIV etc.) and may benefit from antibiotic prophylaxis if the incidence of infection after dental work is high enough. Identifying the risk in these higher risk populations is necessary to make evidence based recommendations.
Conclusion The routine use of antibiotic prophylaxis prior to dental procedures for patients with total joint prostheses remains controversial. This analysis shows that the practice may not be cost-effective for patients in whom the risk of infection with dental work is low. However, antibiotic prophylaxis can still be considered, especially for higher risk populations with immunosuppression who may be more likely to benefit. This analysis provides guidelines for the probabilities that would be needed to make this practice cost-effective, in order to help clinicians consider this issue more specifically and to provide guidelines for future research efforts. Studies quantifying the risk of infection with dental work and the amount that risk can be modified with amoxicillin prophylaxis are needed. Until these data are obtained, patients and physicians will need to continue to consider their use on an individual basis and should consider the risk of infection and the risk of adverse drug reaction when making treatment decisions, especially for higher risk populations with immunosuppression who may be more likely to benefit from prophylaxis.
References 1. Kurtz SM, Ong KL, Schmier J, et al. Future clinical and economic impact of revision total hip and knee arthroplasty. J Bone Joint Surg Am Oct 2007;89(Suppl 3):144. 2. Kurtz SM, Ong KL, Schmier J, et al. Primary and revision arthroplasty surgery caseloads in the United States from 1990 to 2004. J Arthroplasty Feb 2009;24(2):195. 3. Maradit-Kremers H, B.D. Prevalence of total hip (THA) and total knee (TKA) Arthroplasty in the United States. Poster No. P057. AAOS Annual Meeting; 2014. 4. Watters 3rd W, Rethman MP, Hanson NB, et al. Prevention of orthopaedic implant infection in patients undergoing dental procedures. The Journal of the American Academy of Orthopaedic Surgeons. Mar 2013;21(3):180.
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5. Young H, Hirsh J, Hammerberg EM, Price CS. Dental disease and periprosthetic joint infection. J Bone Joint Surg Am. Jan 15 2014;96(2):162. 6. Hunink M. Decision Making in Health and Medicine. Edited: Cambridge University Press; 2003. 2003. 7. Slover JD, Tosteson AN, Bozic KJ, et al. Impact of hospital volume on the economic value of computer navigation for total knee replacement. J Bone Joint Surg Am. Jul 2008;90(7):1492. 8. Laupacis A, Bourne R, Rorabeck C, et al. The effect of elective total hip replacement on health-related quality of life. J Bone Joint Surg Am. Nov 1993;75(11):1619. 9. Heck DA, Robinson RL, Partridge CM, et al. Patient outcomes after knee replacement. Clin Orthop Nov 1998;356:93. 10. Swedish National Hip Registry AAOS Exhibition; 2007. 11. Bozic KJ, Chiu VW, Slover JD, et al. Health state utility in patients with osteoarthritis of the hip and total hip arthroplasty. J Arthroplasty. Sep 2011;26(6 Suppl):129 e121-122. 12. Bozic KJ, Ries MD. The impact of infection after total hip arthroplasty on hospital and surgeon resource utilization. J Bone Joint Surg Am. Aug 2005;87(8):1746. 13. Lalani T, Chu VH, Grussemeyer CA, et al. Clinical outcomes and costs among patients with Staphylococcus aureus bacteremia and orthopedic device infections. Scandinavian journal of infectious diseases 2008;40(11–12):973. 14. Renaudin JM, Beaudouin E, Ponvert C, et al. Severe drug-induced anaphylaxis: analysis of 333 cases recorded by the Allergy Vigilance Network from 2002 to 2010. Allergy. Jul 2013;68(7):929. 15. Idsoe O, Guthe T, Willcox RR, et al. Nature and extent of penicillin side-reactions with particular reference to fatalities from anaphylactic shock. Bull World Health Organ 1968;38(2):159. 16. Flabbee J, Petit N, Jay N, et al. The economic costs of severe anaphylaxis in France: an inquiry carried out by the Allergy Vigilance Network. Allergy Mar 2008;63(3):360–5. 17. Hirschhorn LR, Trnka Y, Onderdonk A, et al. Epidemiology of community-acquired Clostridium difficile-associated diarrhea. The Journal of infectious diseases. Jan 1994;169(1):127. 18. McGlone SM, Bailey RR, Zimmer SM, et al. The economic burden of Clostridium difficile. Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases. Mar 2012;18(3):282. 19. Bigby M, Jick S, Jick H, et al. Drug-induced cutaneous reactions. A report from the Boston Collaborative Drug Surveillance Program on 15,438 consecutive inpatients, 1975 to 1982. JAMA : the journal of the American Medical Association. Dec 26 1986; 256(24):3358.
20. Shehab N, Patel PR, Srinivasan A, et al. Emergency department visits for antibiotic-associated adverse events. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. Sep 15 2008;47(6):735. 21. Caldwell N, Srebotnjak T, Wang T, Hsia R. How much will I get charged for this? Patient charges for top ten diagnoses in the emergency department. PLoS One 2013;8(2):e55491. 22. Osmon DR, Berbari EF, Berendt AR, et al. Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. Jan 2013;56(1):e1. 23. Murdoch DR, Roberts SA, Fowler Jr VG, et al. Infection of orthopedic prostheses after Staphylococcus aureus bacteremia. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. Feb 15 2001;32(4):647–9. 24. Legout L, Beltrand E, Migaud H, et al. Antibiotic prophylaxis to reduce the risk of joint implant contamination during dental surgery seems unnecessary. Orthopaedics & traumatology, surgery & research : OTSR. Dec 2012;98(8):910. 25. Colterjohn T, de Beer J, Petruccelli D, et al. 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. J Arthroplasty. Dec 2 2013;21(3):180. 26. Dubberke ER, Wertheimer AI. Review of current literature on the economic burden of Clostridium difficile infection. Infect Control Hosp Epidemiol. Jan 2009; 30(1):57. 27. Ghantoji SS, Sail K, Lairson DR, et al. Economic healthcare costs of Clostridium difficile infection: a systematic review. The Journal of hospital infection. Apr 2010; 74(4):309. 28. Lockhart PB, Blizzard J, Maslow AL, et al. Drug cost implications for antibiotic prophylaxis for dental procedures. Oral surgery, oral medicine, oral pathology and oral radiology. Mar 2013;115(3):345. 29. Desimone DC, Tleyjeh IM, Correa de Sa DD, et al. Incidence of infective endocarditis caused by viridans group streptococci before and after publication of the 2007 American Heart Association's endocarditis prevention guidelines. Circulation. Jul 3 2012;126(1):60. 30. 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. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. Jan 1 2010;50(1):8.
Contents lists available at ScienceDirect
The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org
Is Routine Antibiotic Prophylaxis Cost Effective for Total Joint Replacement Patients? James D. Slover, MD, MS a, Michael S. Phillips, MD b, Richard Iorio, MD a, Joseph Bosco, MD a a b
Department of Orthopaedic Surgery, NYU Langone Medical Center, New York, New York Department of Epidemiology, NYU Langone Medical Center, New York, New York
a r t i c l e
i n f o
Article history: Received 19 September 2014 Accepted 1 November 2014 Keywords: antibiotic prophylaxis dental procedures total hip replacement total knee replacement infections
a b s t r a c t The routine use of amoxicillin antibiotic prophylaxis prior to dental procedures for patients with total joint prostheses in place remains controversial. This analysis shows that the practice may not be cost-effective for patients in whom the risk of infection with dental work is low. However, specific data quantifying the risk and the impact prophylactic antibiotics can have is needed. Patients and physicians will need to continue to consider their use on an individual basis and should consider the risk of infection as well as the risk of adverse drug reaction when making treatment decisions. © 2014 Elsevier Inc. All rights reserved.
The need for antibiotic prophylaxis prior to dental procedures for patients with existing total joint replacements remains controversial. Currently, over a million hip and knee replacement procedures are done each year in the United States, resulting in a substantial number of patients who have joint replacements in place today [1–3]. Late hematogenous infection of a total joint replacement is postulated, but not definitively proven, to occur when bacteremia, caused by dental procedures, results in bacterial seeding of the prosthesis [4]. It is estimated that 6–13% of prosthetic joint infections involve organisms that could be from the oral cavity [5], and some hematogenous infections may occur through this transmission mechanism. Antibiotic prophylaxis can reduce the incidence of bacteremia with dental procedures, thus theoretically, decreasing the likelihood of late hematogenous infections of a total joint prosthesis [4]. However, the true risk associated with dental procedures is unknown, the ability of prophylaxis to decrease the risk of these infections is not clearly established, and significant adverse drug reactions associated with antibiotic use can occur. These include allergic reactions as well as the development of Clostridium difficile infection (CDI), both of which also can have significant costs and clinical consequences for patients. As a result, it is difficult for clinicians and patients to weight the risks, benefits and relative costs of performing routine antibiotic prophylaxis for dental procedures. The purpose of this study is to use a decision analysis model and the currently available data to quantify the cost-effectiveness of antibiotic prophylaxis prior to dental procedures in patients with total joint replacements and to determine the associated conditions for which it The Conflict of Interest statement associated with this article can be found at http:// dx.doi.org/10.1016/j.arth.2014.11.001. Reprint requests: James Slover, MD, MS, NYU Langone Medical Center, 301 East 17th Street Suite 213, New York, NY 10003. http://dx.doi.org/10.1016/j.arth.2014.11.001 0883-5403/© 2014 Elsevier Inc. All rights reserved.
would be cost-effective in order to help clinicians consider their treatment choice in the absence of this definitive data and to help guide future research efforts intended to determine the scenarios where antibiotic prophylaxis is indicated. Methods Model Design We used a decision model [6] to evaluate the cost-effectiveness of routine antibiotic prophylaxis prior to dental work in patients with total joint replacement. The decision model depicting the pathway followed by patients in the screening program is shown in Fig. 1. Patients transition along the appropriate arm of the decision tree according to the likelihood of each event determined by the probability of each event as detailed below. In addition, we assigned a utility value, measured in quality-adjusted life-years, and a cost to every health state, which results from the sequence of events depicted in each terminal branch of the tree. The specific probabilities, utility values and costs used are discussed in detail below. The model is designed to analyze the cost-effectiveness from the payer perspective. Model Probabilities Health State Values The methodology for determining the utility and disutility values was described in a previous publication and is shown again here given their importance for the reader [7]. Utilities used in the model were based on scores for joint arthroplasty reported in the literature [8,9]. The utility value after total joint arthroplasty, was set at 0.75, which is
544
J.D. Slover et al. / The Journal of Arthroplasty 30 (2015) 543–546
Fig. 1. The figure represents the decision model used to model patients with total joint replacement undergoing a dental procedure. Each patient either receives prophylactic antibiotics or does not. Those that receive antibiotics either have an antibiotic reaction or do not. Both groups then either have a prosthetic infection or do not.
consistent with the average utility values found in the Swedish Registry after hip arthroplasty (0.73) [10]. The utility value for an infected total joint replacement was assigned an initial value of 0.4 to be consistent with the utility value associated with this state in the literature [11]. Disutilities represent the negative preference patients have for a particular health state or outcome, such as primary or revision knee arthroplasty. These negative utility values, or disutilities, account for the decreased mobility, increased pain, and potential complications, which are incurred during the post-operative and post-acute care recovery period. The disutility of having an adverse drug reaction was set at −0.05, or roughly loss of 3 weeks of perfect health [7]. Costs We set the average cost of a septic joint revision at $90,000 for the base case to be consistent with previous studies of resource utilization
for revisions of infected joint replacements [12,13]. The β-lactam class of antibiotics (such as amoxicillin) are most frequently used for dental prophylaxis and are the most frequent cause of severe drug related anaphylaxis [14], occurring in 0.015–0.004% [15] of treatments at a cost of $7600 [16] per episode. Clostridium difficile infection is another severe consequence of β-lactam use, occurring in 6.7 of 100,000, or 0.0000067% [17], of outpatient treatments at a cost of $13,000–16,400 [18] per episode. Amoxicillin, the most frequently used antibiotic for prophylaxis is associated with rash in 5.1% of patients [19] treated at a cost of $200 per episode requiring an outpatient evaluation. Amoxicillin causes an adverse event severe enough to require emergency department evaluation (ED) in 0.15% [20] of outpatient treatments, at a cost of $1200 [21] per ED visit. Using these data, the average cost of an antibiotic complication per prophylactic prescription is $14.30 (0.0015 × $7600 + 0.0000067 * $15000 + 0.05 × $200 + 0.0015 × $1200).
Fig. 2. Results of sensitivity analysis demonstrating the relationship between the probability of sustaining an infected prosthesis after dental work and the reduction in this risk provided by the use of prophylactic antibiotics. For example, if the risk of peri-prosthetic infection for a given patient with dental work is 0.012, or 1.2%, then the relative risk with prophylactic antibiotics would have to be 0.58, or 42% less, for the use of antibiotic prophylaxis to be cost-effective (blue areas).
J.D. Slover et al. / The Journal of Arthroplasty 30 (2015) 543–546
The overall risk of a complication is equal to the sum of probabilities of each of these antibiotic reactions and is 5.30067%. (0.15 + 0.0000067 + 0.05 + 0.15) [4,22,23]. Analysis After completion of the model, the total tabulated costs are used to evaluate the overall cost of the screening program. Sensitivity analysis is a test of the stability of conclusions conducted by varying a variable, or variables, over a stated range and evaluating the effect of this variation on the outcome, in this study the total cost of the patient's treatment [6]. Two-way sensitivity analysis was used to examine the relationship between the probability of an infected total joint secondary to dental work and the probability of an adverse drug reaction from antibiotic prophylaxis. A threshold of Willingness to Pay was set at $50,000 per quality-adjusted life-year to be consistent with cost-effectiveness studies. The model was constructed using decision analysis software (TreeAge Pro 2008, Williamstown, MA). Results Fig. 2 demonstrates the cost benefit analysis for different infection risk profiles. It demonstrates that if the risk of an infected prosthesis is less than 0.75 %, then antibiotic prophylaxis will not be cost-effective no matter how much the risk is reduced by the administration of prophylactic antibiotics (red areas). However, there are scenarios where it would be cost-effective. For example, if the risk of getting an infected prosthesis was 0.0012 or 1.2%, then it would be cost-effective to administer prophylactic antibiotics if they reduced that risk by 42% (creating relative risk of 0.58) or more. If the risk of an infected prosthesis was 0.021 or 2.1%, then prophylactic antibiotics would only have to reduce the risk by 25 % (creating relative risk of 0.75) or more to be cost effective. Discussion The routine use of antibiotic prophylaxis for patients with total joint implants remains a topic of continued debate [24]. Despite a lack of evidence demonstrating a significant risk for prosthetic infection with dental procedures and insufficient data demonstrating that the use of antibiotic prophylaxis prior to dental procedures can reduce the risk of prosthesis infection [4], many surgeons continue to support their use [25]. However, the risk of routine antibiotic prophylaxis in this situation is not benign, and poses significant risks for patients and is associated with significant potential costs to the health care system [26–28]. Recent updates by the American Heart Association restricted the use of prophylactic antibiotic prophylaxis for endocarditis prevention and to date, no increase in the incidence of endocarditis with dental procedures has been detected [29]. Recent American Academy of Orthopaedic Surgeon Guideline Recommendations have asked clinicians to consider changing the practice of routine antibiotic prophylaxis for patients with orthopedic implants undergoing dental procedures, but have not strongly advised against it due to insufficient data at this time [4]. In our report, decision analysis was used to examine this practice from a cost-effectiveness standpoint. The results show that because of the costs associated with adverse antibiotic reactions, prophylactic antibiotics would need to reduce the infection risk substantially to be cost effective. If the risk of infection with a dental procedure is greater than 0.7% (probability of 0.007), which no study has demonstrated, prophylactic antibiotics may be cost effective (Fig. 2). However, this risk of prosthesis infection directly from dental work has not been clearly quantified, but available evidence suggests it is very low [4,30]. If the risk is less than 0.7%, then the use of prophylactic antibiotics would not be a cost-effective practice. If the risk of prosthesis infection is greater than 0.7%, then it may be cost-effective to use prophylactic antibiotics, provided this risk can be reduced by an appropriate amount.
545
Studies to determine the true risk and the degree it can be reduced with the use of antibiotic prophylaxis are needed. Although specific data are lacking, the apparent low rate of prosthesis infection associated with dental procedures, and the lack of quantification of the amount that risk can be reduced with the use of prophylactic antibiotics, make it difficult to establish the advisability of routine prophylaxis. We tend to focus on our own areas of responsibility in today's age of specialized medicine, but orthopedic surgeons should consider the clinical impact and cost associated with adverse reactions when we are advising our patients with joint replacements who are undergoing dental procedures about antibiotic prophylaxis. This includes severe allergic reactions and infections caused by C. difficile, which have substantial clinical and financial consequences, as well as more mild, but much more common, reactions to antibiotic use [27,26]. These must be considered by clinicians and patients when making treatment decisions, and further work is needed to determine which patients, if any, would benefit from antibiotic prophylaxis prior to a dental procedure. There are limitations of this analysis. This includes the limited data quantifying the risk of infection of a prosthetic joint with dental work, and the magnitude that risk is decreased with the use prophylactic antibiotics. Additionally, the data determining the cost of treating adverse reactions to antibiotics may vary for different patients or groups of patients. A variety of antibiotic reactions in terms of type and cost are possible, and this is true of prosthetic infections as well. Further studies providing data to quantify these parameters, would enhance the applicability of the analysis. Finally, clinicians can choose in certain circumstances to recommend interventions, despite potential lack of cost-effectiveness, and these decisions should continue to be valid on a patient by patient basis in consultation with the patient about risks and benefits of both prophylaxis and lack of prophylaxis with dental work. Certain patient populations may have higher risk of infection due to dental work induced bacteremia (immunosuppressed, diabetics, HIV etc.) and may benefit from antibiotic prophylaxis if the incidence of infection after dental work is high enough. Identifying the risk in these higher risk populations is necessary to make evidence based recommendations.
Conclusion The routine use of antibiotic prophylaxis prior to dental procedures for patients with total joint prostheses remains controversial. This analysis shows that the practice may not be cost-effective for patients in whom the risk of infection with dental work is low. However, antibiotic prophylaxis can still be considered, especially for higher risk populations with immunosuppression who may be more likely to benefit. This analysis provides guidelines for the probabilities that would be needed to make this practice cost-effective, in order to help clinicians consider this issue more specifically and to provide guidelines for future research efforts. Studies quantifying the risk of infection with dental work and the amount that risk can be modified with amoxicillin prophylaxis are needed. Until these data are obtained, patients and physicians will need to continue to consider their use on an individual basis and should consider the risk of infection and the risk of adverse drug reaction when making treatment decisions, especially for higher risk populations with immunosuppression who may be more likely to benefit from prophylaxis.
References 1. Kurtz SM, Ong KL, Schmier J, et al. Future clinical and economic impact of revision total hip and knee arthroplasty. J Bone Joint Surg Am Oct 2007;89(Suppl 3):144. 2. Kurtz SM, Ong KL, Schmier J, et al. Primary and revision arthroplasty surgery caseloads in the United States from 1990 to 2004. J Arthroplasty Feb 2009;24(2):195. 3. Maradit-Kremers H, B.D. Prevalence of total hip (THA) and total knee (TKA) Arthroplasty in the United States. Poster No. P057. AAOS Annual Meeting; 2014. 4. Watters 3rd W, Rethman MP, Hanson NB, et al. Prevention of orthopaedic implant infection in patients undergoing dental procedures. The Journal of the American Academy of Orthopaedic Surgeons. Mar 2013;21(3):180.
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