Quality Resource Guide l Contemporary Approaches to Antibiotic Prophylaxis 3rd Edition 4 www.metdental.com In 2014, the ADA Council on Scientific Affairs produced an evidence-based clinical practice guideline for dental practitioners regarding the use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints. 26 Given a moderate grade of evidence, they concluded: In general, for patients with prosthetic joint implants, prophylactic antibiotics are not recommended prior to dental procedures to prevent prosthetic joint infection. • Evidence fails to demonstrate: - An association between dental procedures and prosthetic joint infections - Effectiveness of antibiotic prophylaxis • Mindful of the potential harm from antibiotic use, using antibiotics before dental procedures is not recommended to prevent prosthetic joint infection • Additional case control studies are needed to increase the level of certainty in the evidence to a level higher than moderate Furthermore, antibiotic resistance, adverse drug reactions and cost must also be considered when deciding for or against antibiotic prophylaxis. Repeated exposure to antibiotics is a risk factor for the development of resistant bacteria. Emergence of resistant bacteria poses a serious risk to society. Prolonged treatment with antibiotics is also associated with candidasis. Although a single dose of antibiotics for prophylaxis of prosthetic joint infection is unlikely to cause a Clostridioides (formerly Clostridium) difficile infection, comprehensive dental care often involves multiple appointments. This additional exposure to patients who may have taken antibiotics for other medical conditions will increase the risk of experiencing changes in the gastrointestinal flora, leading to pseudomembranous colitis. A recent study estimated that in a single year there were approximately 462,000 people with C. difficile infections (slightly decreased from 2012 to 2017), 27 while the CDC estimates those infections result in nearly 12,800 deaths in 2017 and costing approximately over 1 billion dollars in healthcare costs. 28,29 Investigators have identified clindamycin and cephalosporins (both considered useful in antibiotic prophylaxis) as possible C. difficile infection-inducing medications. 30 Lastly, the annual cost of amoxicillin administered to patients with hip and knee prostheses before dental procedures in the United States may exceed $50 million. 31 Berbari and colleagues, 32 identified prosthetic joint infection risk factors independent of dental procedures, including: • Post-arthroplasty wound dehiscence • Post-arthroplasty wound hematoma • Post-arthroplasty wound infection There were also some additional preoperative factors/conditions with significant odds ratios for prosthetic joint infections independent of dental procedures, including prior operation/ arthroplasty on the index joint, diabetes mellitus, and/or being immunocompromised (defined as rheumatoid arthritis or current use of systemic steroids/immunosuppressive drugs or diabetes mellitus or presence of a malignancy or a history of chronic kidney disease). Because the available evidence is not detailed enough to apply to the full range of patients in everyday practice, the AAOS completed work on an Appropriate Use Criteria (AUC) www.orthoguidelines.org/go/auc in the fall of 2016. 18,33 The AUC is a decision-support tool to help clinicians in their judgment regarding antibiotic prophylaxis for patients with a prosthetic joint. The AUC was generated to provide further input as to when/if there are some SPECIAL circumstances, in higher risk populations, when there may be some rationale in using antibiotic prophylaxis. It is based on expert opinion. The AUC takes into consideration various scenarios including: • Planned dental procedure • Immunocompromised status • Glycemic control • History of peri-prosthetic or deep prosthetic joint infection of the hip or knee that required an operation • Time since hip or knee joint replacement procedure By applying various different scenarios, the AUC can help a clinician determine when antibiotic prophylaxis is rarely appropriate, may be appropriate or is appropriate in special patient circumstances. It is important to understand that these scenarios may indeed have some added risk of developing prosthetic joint infections in a small number of patients, but they are independent of dental treatment, since there is no evidence to support an association between dental procedures and risk of experiencing prosthetic joint infections. 18,34 Discussion of available treatment options applicable to each individual patient relies on obtaining a proper medical history, open communication between the patient, dentist, and orthopedic surgeon, and weighing the potential risks and benefits for that specific patient. It is appropriate for the dentist to make the final judgment to use antibiotic prophylaxis for patients potentially at higher risk of experiencing prosthetic joint infection using the AUC as a guide, without consulting the orthopedic surgeon. 19