What is the current guideline on antibiotic prophylaxis for patients with total joint replacement ?
In 2016, an inter-professional consensus statement was developed through collaboration between three organizations – the Canadian Dental Association (CDA), the Canadian Orthopedic Association (COA) and the Association of Medical Microbiology and Infectious Disease (AMMI). At the November 2017 meeting, Council approved a recommendation to support this consensus statement, in which the following conclusions were advanced:
- Most transient bacteremia of oral origin occurs outside of dental procedures.
- The significant majority of prosthetic joint infections are not due to organisms found in the mouth.
- Few prosthetic joint infections have a clearly defined relationship with dental procedures.
There is no reliable evidence that antibiotic prophylaxis prior to dental procedures prevents prosthetic joint infections.
- Patients should not be exposed to the adverse effects of antibiotics when there is no evidence that such prophylaxis is of any benefit.
- Routine antibiotic prophylaxis is not indicated for dental patients with total joint replacements, nor for patients with orthopedic pins, plates and screws.
- Patients should be in optimal oral health prior to having total joint replacement and should maintain good oral hygiene and oral health following surgery. Orofacial infections in all patients, including those with total joint prostheses, should be treated to eliminate the source of infection and prevent its spread.
Council supports the COA/CDA/AMMI Consensus Statement on Patients with Total Joint Replacements having Dental Procedures.
Members should review the Canadian Consensus Statement On Dental Patients with Total Joint Replacement and implement it in their practice.
Patients may present with a recommendation from the orthopedic surgeon or primary family health care provider that is inconsistent with the consensus statement. This may reflect a lack of familiarity with the consensus statement or special considerations about the patient’s medical condition of which the dentist is unaware. In such circumstances, members are encouraged to discuss the current evidence with the patient and consult with the orthopedic surgeon or primary family health care provider regarding the reason for the recommendation and the specific procedures for which antibiotic prophylaxis is suggested.
Each provider is ultimately responsible for his or her own treatment decisions. Following a consultation, the dentist may decide to follow the recommendation of the orthopedic surgeon or the primary family health care provider or, if professional judgement dictates that antibiotic prophylaxis is not indicated, decline to provide it. In the latter circumstance, the dentist may suggest that the orthopedic surgeon or primary family health care provider should prescribe for the patient as he or she deems appropriate.
- Prosthetic cardiac valve or prosthetic material used for cardiac valve repair.
- Previous, relapse or recurrent infective endocarditis.
- Specific conditions related to congenital heart disease (CHD):
- a) Unrepaired cyanotic CHD, including palliative shunts and conduits
- b) Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure
- c) Repaired CHD with residual defects at the site of or adjacent to the site of a prosthetic patch or prosthetic device (which inhibits endothelialization).
- d) Surgical or transcatheter pulmonary artery valve or conduit placement such as Melody valve and Contegra conduit
- Cardiac transplantation recipients who develop cardiac valvulopathy.
Patients who have had surgery for placement of prosthetic heart valves or prosthetic intravascular or intracardiac materials are at risk for the development of an infection and should be given premedication according to the 2021 AHA scientific statement.
There is no evidence that patients who have had coronary artery bypass graft surgery are at increased risk of infective endocarditis (IE) and therefore, these patients do not need antibiotic prophylaxis.
There are insufficient data to support specific recommendations for patients who have undergone heart transplantation. The guideline advises that the use of antibiotic prophylaxis for heart transplant recipients who develop cardiac valvulopathy is reasonable.
Consultation with the patient’s physician and/or cardiologist is strongly recommended to determine the severity and stability of any heart condition, as well as the possible need for AP.
For further information on dental management of patients with cardiovascular diseases, you may wish to review the following articles: Dental management of patients with recent MI and/or cardiovascular surgery (rcdso.org) and Dental treatment for patients with cardiac implantable electronic devices (rcdso.org).
The drug of choice is Amoxicillin 2 grams taken orally 30-60 minutes before the dental procedure.
The following antibiotics should be considered:
- Doxycycline 100 mg
- Azithromycin or Clarithromycin 500mg
- Cephalexin 2 g*
*Cephalosporins should not be used in individuals with immediate-type hypersensitivity reactions (such urticaria, angioedema or anaphylaxis) to penicillins or ampicillin.
Antibiotic prophylaxis should be taken in a single dose 30-60 minutes before dental treatment. This time period is recommended so that there will be high blood levels of antibiotic at the time bacteremia occurs.
If the patient has not taken the antibiotic as required, the dentist should administer it and then allow sufficient time to elapse prior to commencing treatment.
If the antibiotic is inadvertently not administered, it may be given up to 2 hours after the procedure. However, it is important to note that the post-exposure protocol is intended to be used rarely, and not routinely as a means of managing patients who neglect to take their antibiotics as required.
If a patient is already receiving antibiotic therapy with an antibiotic that is also recommended for antibiotic prophylaxis, then it is prudent to select an antibiotic from another class, rather than increase the dose of the currently administered antibiotic. For example, if a patient is already taking amoxicillin, the dentist should select doxycycline, azithromycin or clarithromycin for antibiotic prophylaxis.
