Routine antibiotic prophylaxis and preoperative dental screening may not reduce the risk of periprosthetic joint infection in patients undergoing total hip or knee arthroplasty, according to an updated clinical practice guideline.
Charles P. Hannon, MD, of the Department of Orthopedic Surgery at the Mayo Clinic, and colleagues from the American Academy of Orthopaedic Surgeons and the American Association of Hip and Knee Surgeons led the multidisciplinary workgroup that developed the guideline. The update—endorsed by the American Dental Association, Infectious Diseases Society of America, and Musculoskeletal Infection Society—was based on a systematic review of 1,251 abstracts and 203 full-text articles, of which eight met inclusion criteria.
The guideline issued five recommendations—two supported by limited evidence and three based on expert consensus—to guide clinicians managing dental care in patients with total joint arthroplasty. The limited-strength recommendations advised that systemic antibiotic prophylaxis prior to dental procedures didn't reduce periprosthetic joint infection (PJI) risk and that preoperative dental screening before total hip or knee arthroplasty didn't lower postoperative infection rates. Four low-quality studies found no evidence supporting antibiotic use in this context. However, the guideline authors acknowledged that certain subgroups such as patients who are immunocompromised, have prior PJIs, or have undergone revision or megaprosthesis procedures may require individualized management.
Three consensus recommendations were developed where direct evidence was lacking. The panel concluded that oral antiseptic rinses prior to dental procedures are unnecessary and that the timing of dental procedures should depend on invasiveness and the risk of transient bacteremia. Suggested intervals included a minimum of 3 weeks between invasive dental surgery and arthroplasty and at least 3 months between total joint arthroplasty and most dental procedures.
The guideline applies specifically to total hip and knee arthroplasty, excluding other orthopedic implants as a result of insufficient data. With approximately 500,000 hip replacements performed annually in the United States—projected to increase by 71% and 85% in total knee replacement by 2030—and PJIs affecting 1% to 2% of cases, the guideline authors underscored the growing clinical and economic impact of infection prevention. The estimated annual cost of managing these infections is projected to reach $1.85 billion by 2030.
“Medical care should be based on evidence, a physician's expert judgment, and the patient's circumstances, values, preferences, and rights,” wrote the guideline authors. “Treatment decisions should be made after [a] comprehensive individualized shared decision-making discussion between the patient and physician,” they concluded.
The authors reported no relevant financial relationships or conflicts of interest.
Source: Journal of the American Academy of Orthopaedic Surgeons
