Prophylaxis Against Total Joint Replacement Infection
Patients who have- undergone total replacement of a joint with a prosthetic joint may be at risk for hematogenous spread of bacteria and subsequent infection. These late. prosthetic joint infections result in severe morbidity,
because the implant is usually lost when infections occur. There has been great concern that the bacteremia caused by ‘.tooth extraction may result in such infection·s. However the recent literature suggests that bacteremias from . oral procedures do not cause prosthetic joint infections.
It appears that the bacteremia after oral surgery is of a transient nature and does not expose the implant and periimplant tissues to bacteria long enough to cause infection. Instead it appears that the hematogenous spread of prosthetic joint infections. is caused by chronic infections elsewhere in the body that result in chronic septicemias. These infections are typically urinary tract infections, pulmonary infections, and skin infections, hut established odontogenic infections may also cause a septicemia of sufficient magnitude to cause a total joint infection. In July of 1997 the American Dental Association (ADA) and the American Academy of Orthopedic Surgeons (AAOS) issued a joint recommendation concerning the
management of patients with prosthetic total [oints. The recommendations of the ADA and MOS recognize that most patients with a prosthetic joint are not at risk for joint infection after a dental surgical procedure. Instead
the guidelines identify the high-risk patients who are ‘potentially usceptible to such infections (Box 15-14). Likewise, it Identtfles those procedures that are most likely to cause joint infections and therefore require prophylaxis
(Box IS-IS). Finally, the joint statement recommends a specific antibiotic recommendation to help prevent infection in the susceptible patient who is undergoing one of the procedures that require prophylaxis (Table 15-5).
When the dentist decides to provide antibiotic prophylaxis for a patienf, the recommended antibiotics are first-generation cephalosporin: and ampicillin. For patients who are allergic to penicillin, clindamycin is recommended, ‘As with bacterial endocarditis prophylaxis, only a single preoperative dose is recommended, with no follow-up doses. If patients are unable to take oral rnedication, a parenteral regimen is also sugge-sted (Box 15-16). If a patient who has a total joint replacement needs treatment of an infection, aggressive therapy for’ the. infection is necessary to prevent seeding of the bacteria, causing odontogenic infection to the prosthetic joint . This aggressive treatment should include extraction, I&D, – and the use of high-dose bactericidal antibiotics, probably given IV. The clinician should strongly consider performing C&S testing, because if a prosthetic joint infection does occur, it would. be useful to know which bacteria is likely the culprit and its antibiotic sensitivity.
Antihiotic Reginal Prophylaxis of Total joint Rcplaccrncat Infection
Standard oral prophylaxis
f II \ I’ 111< I:;
First generation cephalosporin
2 G 1 hr before procedure’
Penicillin allergic oral prophylaxis
2 G 1 hr before procedure
600 mg 1 hr before procedure
1 G IV within 1 hr of procedure
600 mg IV within 1 hr of procedure
Indication for Parenteral Regimen
• Patient to have general anesthetic and NPO
• Unable to take oral medications
• High-risk patients, such as those with history of previous