Prophylactic Systemic Antibiotic Use Before Dental Procedure (Hip/Knee Patients)

Four low quality studies were included (Kao, 2017; Berbari, 2010; Thornhill, 2023; Sax, 2023) as the best available evidence. In 255,568 patients, Kao et al. reported no difference in risk of periprosthetic joint infection (PJI) between total knee arthroplasty (TKA) and total hip arthroplasty (THA) patients who had a dental procedure within 2 years after arthroplasty and those that did not. Of those who had a dental procedure, there was no difference in PJI risk between those that received antibiotics and those that did not. Berbari et al. found no association with low-risk and high-risk dental procedures with TKA and THA PJI in 339 matched patients. In addition, they found that antibiotic prophylaxis prior to dental procedures did not decrease the risk of PJI. In a database analysis of over 1,952,917, Sax et al. similarly found no association between a dental procedure, defined as any procedure involving gingival manipulation, and risk of PJI. In addition, comparing patients who undergo a dental procedure, the rates of PJI and revision were not different between patients who received antibiotic prophylaxis and those who did not.

Benefits/Harms of Implementation
Periprosthetic joint infection is a devastating complication after TJA associated with increased morbidity and mortality. While the data reviewed does not support this, it is possible that rates of PJI after dental procedures may increase without antibiotic prophylaxis. Importantly, however, rates of PJI are reported as low as 1%. The direct societal cost of providing antibiotic prophylaxis prior to dental procedures in patients with TJA is significant, and it is expected that wider adoption of the recommendation will decrease these societal costs. In addition, antibiotic prophylaxis may promote the selection of antibiotic-resistant bacteria and increase the risk of Clostridioides difficile infection. Thus, limiting the use of dental antibiotic prophylaxis in TJA may lead to significant cost savings, reduce the risk of developing antibiotic resistance, and incidence of Clostridioides difficile infection.

Outcome Importance
Antibiotic prophylaxis prior to dental procedures after THA and TKA is a widely utilized practice. For many, this recommendation will be a shift in practice, which may limit wide acceptability. Some stakeholders may have concerns regarding the risks of not providing antibiotic prophylaxis in higher risk patients such as revision TJA patients, patients with prior PJI, or patients with certain medical comorbidities. Importantly, the evidence in this recommendation is mostly derived from patients with primary arthroplasty, particularly THA and TKA. The number of patients with revision arthroplasty and other high-risk populations was too small in the studies included to draw meaningful conclusions. However, it could be argued that the predominance of staphylococci and relative infrequency of viridans group streptococci and other mouth bacterial flora as a causative microbiologic etiology of PJI makes antibiotic prophylaxis prior to dental procedures less intuitive as a prevention strategy even in high-risk populations.

Cost Effectiveness/Resource Utilization
It is estimated that the annual cost of dental antibiotic prophylaxis for patients undergoing TJA in the United States is $59 million, which will only continue to increase as the rates of arthroplasty increase (Thornhill, 2022). Implementing this recommendation could result in significant cost savings for the healthcare system. Moreover, it would reduce antibiotic usage and support antibiotic stewardship, along with its associated benefits.

Acceptability
Periprosthetic joint infections are among the most common causes of failure after TJA. As the number of patients undergoing THA and TKA increases annually, the number of PJIs will increase as well as the costs and secondary adverse effects of antibiotic prophylaxis prior to dental procedures. With increased emphasis on value-based care, this recommendation will reduce costs to the healthcare system without impacting the risk of PJI. In addition, antimicrobial stewardship will prevent the selection of antibiotic-resistant bacteria and protect patients from adverse events associated with unnecessary antibiotic use. A recent large case-control study demonstrated that clindamycin and amoxicillin-clavulanate, commonly used antibiotics for dental prophylaxis, are associated with some of the highest risks of C. difficile infection among all the examined oral antibiotics (Miller, 2023).

Feasibility
Fortunately, adopting the guidelines is not resource-intensive or reliant on special needs. Therefore, it would be highly feasible to implement the guidelines with greater clinician acceptance.

Future Research
There is a need for higher-quality evidence, investigations into specific patient subgroups, and economic analyses. Future studies should aim to address the existing gaps in evidence, particularly regarding the efficacy of prophylaxis in high-risk groups (e.g. immunosuppressed and revision TJA) and the cost-benefit analysis of such practices. In particular, future research should focus on patients with revision or megaprostheses as well as patients with medical comorbidities that already place them at a heightened risk of infection (e.g. immunocompromised). Additionally, exploring patient-centered outcomes and preferences could enrich the evidence base and inform more nuanced recommendations.