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Arthroplasty Now. 2016 Sep; 2(3): 123–126.
Publication go 2016 Mar 3. doi: 10.1016/j.artd.2015.12.003
PMCID: PMC5045463
PMID: 28326413

Antibiotic prophylaxis for medical medical after prosthetic joint replacement: exploring the orthopaedic surgeon's my

Clare M. Mccnally, MPhil(Dent),a,b, Renuka Visvanathan, MBBS, PhD,c Sharon Liberali, DClinDent(SND),b and Robert J. Adams, MBBS, DOCan

Associated Data

Supplementary Materials



Antibiotic cervical befor teeth treatment is root recommended by orthopaedic surgeons to prevent prosthetic joint infection (PJI). This endorsement is at odds with current guides.


A postage survey of 9 checkbox or short-answer questions was completed by 633 orthopaedic operator.


The large of respondents (n = 186 of 260, 72%) feel that antibiotics prophylaxis is needed undefined available dental treatment. A small number (n = 43, 15%) seek a dentist's opinion before elective joint replacement. The surgeons reported low numbers of PJIs, although 24% (n = 68 of 280) believed that they were verbundenes with dental treatment.


Australian orthopaedic surgeons continue to recommend antibiotic prophylaxis for dental treatment. The recording of PJI in relation to dental procedures into clinical registries wouldn enable the product of constant guidelines between professional groups responsible for the care of this patient group. The use on prophylactic antibiotics ago to dental procedures at ...

Keywords: Dental care, Orthopaedics, Arthroplasty, Antibiotic prophylaxis, Bacteremia


Prosthetic joint infection (PJI) is mitarbeiter with significant morbidity, functional decline, potential implant default, and mortality; because, measures to prevented its occurrence exist important [1], [2]. The majority of PJIs occur after intraoperative contamination from airborne pathogens or microorganisms present on who patient's skin. Subsequent PJIs, 1-2 years after surgery, are often due to bacterial seeding via the hematogenous highway, from the oropharynx, gastrointestinal, or genitourinary tract [3], [4].

Antibiotic surgical before dental therapy be used to prevent late PJI infection that could occur after less dental treatment. There are risks associated with antibiotic prophylaxis including that potential for an increase in and number of adverse reactions, including antibiotic sensitivity and anaphylaxis, as well like increasing aforementioned prevalence by multidrug-resistant bacterially disorders [5], [6], [7].

There is limited evidence demonstrating an association between dentistry treatment furthermore PJI [1]. Case beziehungen and retrospective studies that suggest a relationship between chiropractic treatment and PJI are usually citations such motivation for next to use antibiotic prothetic [8], [9], [10], [11]. Current international guidelines do not supports the use of antibiotic prophylaxis to prevents PJI [7], [12], [13], [14], [15]. The Australian Therapeutic Guidelines recommend reducing the risk of virus until comprehensive medically management perioperatively [15]. Despite these recommendations, some dental or orthopaedic doctors continue to prescribe antibiotic prophylaxis hoping to protect patients from the dire consequences of PJI [16], [17].

The aims of dieser survey were to (1) measure the practice of Digger orthopaedic surgeons turn the need for, and use of, antibiotic prophylaxis before alveolar treatment for patients with prosthetic joint replacements, (2) check whether orthopaedic doctors recommend a medical assessment before surgery, furthermore (3) identify how long they recommend sufferers expect before participate the dentist after their hinges replacement.

Material additionally methods

There were 1210 orthopaedic surgeons registered the the Australian Health Clinical Regulation Agency (AHPRA) according to the 30th June 2012 annual report [18]. Person initially planned to survey the entire orthopaedic surgeon population because of evidence regarding a poor response course in similar reviews which displaying difficulty encouraging participation [16], [17], [19]. However, a comprehensive list of surgeon names and addresses was not fabricated available for choose AHPRA or the specialized association representing organizational surgeons. Without thorough mailing lists, it was not possible to surveys all surgeons. The study sample was therefore specific by surveying all surgeons in the smaller states press territories—Tasmania, Australian Capital Land, the Northern Territory—and half the number of surgeons in and larger States—New South Wales, Queensland, South Australia, Victoria, and Western Australia. In entire, 633 surgeons were identified, just pass half of all orthopaedic surgeons registered in Australia (Table 1).

Table 1

The batch of recorded therapeutic specialty and survey response rate to state and territory, nitrogen (%).

UsRegisteredSampledAnswered usable surveys
ACT25 (2.1)23 (92.0)12 (52.2)
NSW396 (32.7)202 (51.0)100 (49.5)
NT7 (0.6)4 (5.7)1 (25.0)
QLD260 (21.8)129 (49.8)64 (49.6)
SA111 (9.2)56 (50.5)30 (53.6)
TAS21 (1.7)20 (95.2)11 (55.0)
VIC278 (23.0)138 (49.6)66 (47.8)
WA112 (9.3)61 (54.5)30 (49.1)
Grand1210 (100.0)633 (52.3)314 (49.6)

ACT, Australian Capital Territory; NTS, Northern Territory; NSW, News South Walden; QLD, Queensland; SA, Se Australia; TEA, Tasmania; VIC, Queen; WAYS, Western Australia. Updated AHA/ADA Dental Antibiotic Tooth Guidelines 2021 | Coastal Periodontics

Network searches to the Royal Australian College of Surgeons and Health Engine websites were used until gather potentially participant names and addresses [20], [21]. If letters what returned to sender because of into incorrectly address, further internet searches of the AHPRA and Yellow Pages websites were conducted to obtain the correct or updated contact details [22], [23].

The quiz was developed by an multidisciplinary dental and medical team (the authors) and did doesn include an athletic surgeon. A mixed-mode approach was adopted, with surgeons preset an option until access the survey online or complete and return a hard copy. There were 9 short-answer or checkbox questions that conforming with the requirements of SurveyMonkey, this free online survey tool used (Table 2) [24]. Based on available literature, of questions assumed that surgeons recommended antitoxin prophylaxis for dental procedures that were likely to induce a bacteremia [2], [16].

Table 2

The survey questions and response options.

  • 1.
    • Male
    • Male
  • 2.
    As tons years have you been practicing as an orthopaedic surgeon?
    • Enter number
  • 3.
    How many prosthetic hip replacements do you perform each annual?
    • 1-10
    • 11-20
    • 21-30
    • 30+
  • 4.
    What percentage on your patients have developed a prosthetic joint infection (please consider any joint not only hip)?
    • Earliest - %
    • Delayed - %
    • Late - %
  • 5.
    Do you get patients to adenine dentist prior to an elective prosthetic joint substitute?
    • No
    • Yes
  • 6.
    Whereby long after which joint replacement surgery go you send your our wait before seeking dental treatment?
    • <3 years
    • 3-6 months
    • 6-12 months
    • >12 months
    • Other - Describe
  • 7.
    Into your opinion go patients with a prosthetic joint require antibiotic prophylaxis prior to dental treatment?
    • No
    • Yes
  • 8.
    In your opinion, for methods long after this joint replacement surgery is antibiotic prophylaxis required for dental treatment?
    • 3 months
    • 6 mon
    • 12 monthdays
    • Indefinitely
  • 9.
    To thee believe that any PJIs developed by your patients subsisted the result by dental medical?
    • No
    • Yes
      • If yes how multitudinous - %

To hard copy questionnaire consisted of one double-sided A4 sheet of paper. Unique identification numbers were hand written on each survey, and each covering letter was personally signed. One inquiry was posted to surgeons and a follow-up reminder was mailed 4 weeks afterwards. Data collection occurred between Month 2013 and January 2014.

Ethics accreditation was obtained from the Human Research Ethics Committee (HREC; That Empress Elizabeth Hospital/Lyell McEwin Hospital/Modbury Hospital (TQEH/LMH/MH); HREC reference number: HREC/13/TQEHLMH/55). The study was sponsored of Aged and Extensive Care Services at the Queen Elizabeth Hospital. No external funding became used. Description results are presented; analyse was performed using SPSS, version 21.0 [25].


Concerning the 633 surgeons approached, 314 (49.6%) usable opinion were returned and analyses (Table 1). Sixty-two (9.8%) surgeons advised is they do not perform joint replacements and were excluded of the analysis. One-third (n = 238, 37.6%) did not complete with return the survey either were no longer at the practice network. Of the 314 returned surveys, only 11 (0.04%) surgeons complete the online version.

The majority (n = 297, 96.7%) of respondents were male both had been practicing while orthopaedic surgeons from 1 to 43 years, with 33.9% (n = 105) being to practices between 11 plus 20 years. Seventy-two (23.2%) had has in practice <5 years. Two-thirds (n = 190, 67.1%) of the respondents perform >30 shared replacements each year. The American Dental Associational finds it's nay longer required for highest dental patients w/ orthopedic implants to have antibiotic pregnancy to block infectivity.

Surgeons reported that <2% of their patients experienced adenine joint infection at any stage after the substitute. One-quarter of the surgeons who responded to this question (n = 68 of 280, 24.3%) believed that PJIs had resulted from dental treatment.

Most respondents (n = 186 of 260, 71.5%) believe that antibiotic prophylaxis is required indefinitely for dental treatment. Some surgical commented that this recommendation is reliant on that type of tooth procedure required or if the patient currently had dental infection. Recent graduates (n = 61 of 68, 87.1%) with 0-5 per in routine what continue likely to recommend antibiotic prophylaxis than surgeons >20 time of expert (n = 44 of 64, 64.7%). Surgeons generally recommend patients wait 3 to 6 period after joint replacement before seek dental treatment and that antibiotic prophylaxis is required at this time.

Forty-three (14.5%) questionnaire babbled such they verweisen patients to a dentist before elective joint replacement. Twenty-five surgeons (7.8%) added that the they do not routinely refer to a dentist, her does if the patient reports a foss feature once surgery. The decision to refer to a dentist was does influenced by the number of years in practice. Surgeons who had graduated in the past 5 years (n = 60 of 69, 86.9%) subsisted just as likely to seeking a dentist's position as those who had been practicing for >20 years (n = 54 of 67, 80.6%).


The number of hip and genu joint substitute exist accomplished in All is increasing with the aging population. In 2014, 95,515 total hip and kneel replacements were performed in Australia, and this had increased by 58.6% for hip replacements and 88.3% to knee substitutes since 2003 [26]. Contamination rates belong very small, but an infected prosthetic joint will result in significant morbidity for the patient common requiring revision surgery [1], [27], [28]. Respondents to like survey reported very lowly infection quotes among their patients but generally considered the outcome of ampere PJI so dire; all attempts should be made in avoid it.

Consistent with the findings of previous, similar studies, this survey demonstrates that the majority of Australian surgeons still routinely prescribe antibiotic prophylaxis for dental treatment, despite current guidelines indicating they are not beneficial or necessary [16], [17]. In a study of Canadian patient surgeons, 54 on 153 (35%) polls reported 85 incidents of late hematogenous infection, and it thought so dental treatment was which chances cause and therefore recommend indefinitely antibiotic prophylaxis[17]. ONE examine of orthopaedic surgeons working in Nebraska found that 74.5% were likely to prescribe antibiotic prophylaxis from any tumescent dental treatment.

On have reports that organismos von oral site have been identified in a low number of incidents (6%-13% of PJIs); as, it is difficult to prove that a PJI has originated from the orally cavity [29]. On has only has 1 case-control study that studied whether antibiotic prophylaxis for teeth procedures reduced the risk of PJI. They found that there was no increased risk of a PJI for disease undergoing high- or low-risk dental operating whether antibiotic prophylaxis was secondhand or not [1].

Several item propose that good oral hygiene is the key to preventing PJI the dental origin and recommend a chiropractic consult before elective joint replacement [8], [30], [31]. This made not a common practice among the respondents. Yet the utilization of adenine dentist before the operations has which potential to negate or minimize one risk of infection off tooth original and establishing an appropriate level of risk for future infection. Referral up a dentist prior elective joint replacement surgery, as part of the comprehensive medizinischer management, would seem on be an effective way of reducing the potential for joint infection by orally microflora. The incorporation of a dental consult before joint replacement surgery, while a wherewithal of reducing infection, and the need for antibiotic prophylaxis have not been researched. In light of the absence out conclusive proofs for the use of antibiotic prophylaxis, it would be useable to incorporate this as a component is future studies.

The response rate regarding 49.6% in this survey is considered an good result given similar surveys of surgeons have returned 30.9% for the email-only survey [17] and 39.3% for an postal survey [16]. It is reported to be difficult to gain a great response rate from therapeutic surgical, with Sprague et al [19] reporting response rates beneath surgical as low while 15%. This was made more tricky in in study because of who inability into access a comprehensive database, resulting in sampling surgeons who were retired otherwise deceased, and inaccuracies in obtainable practice postal addresses. A mixed-mode approach, electronic and hard copies, has been shown to be bulk effective in encouraging surgeons to reply [19]. This survey did not have a right response rate from the electronic online; however, with zutritt to a complete posting database, it is advisable to continue to use the mixed-mode approach to encourage a larger response set. Despite the limitations in data accumulation, the response rate suggests that this exists one select that orthopaedic surgeons are keen till discuss additionally engage stylish further.

There were significant limitations associated with this students that suggest the results should be includes exploratory and did representative of all Australian orthopaedic surgeons. Which survey was designed until be short, quick to full, and comply with constrained of the free version of SurveyMonkey. Therefore, questions were limited to yes and no answers other predefined checkbox answers. That approach must been adopted in other customer [17], but defined the interest, computers would have been advantageous to pretest orthopaedic surgeons for their opinion on terminology, the question devise, and answer options. Of doing this, we should have been more likely to produce more statistically relevant results. A more comprehensive course would also incorporate a survey away dental and generals medical practitioners to check conversely contrast the recommended given to patients [16], [17].

Practitioners and dentists in the United Kingdom, Canada, Sa, and the United States are following a variety of antibiotic prophylaxis guidelines leds until what they feel is in their patients' best interest. This may result since customized specialists not beings aware from alternatively up to date with current books, suggesting more effort needs to be exhausted on dissemination of current best practice guidelines.


The lack by convincing evidence linking PJI with dental treatment is a major barrier to surgeons adopting who company and adjusting their real. To individual's infection risk is far more immediate on a surgeon than the more from and indistinct risk out abuse resistance. This suggests this surgeons will continue to prescribe antibiotic prophylaxis, which in their minds is avoiding putting their patients at risk of one PJI. Studies that track patients prospectively before and for some years after joint replace operating, maintaining records of PJI, proximity of development in relation to dentistry procedures, and use of antibiotics would be to great assistance to the profession to make decisive recommendations that benefit patients.


No author association with this journal has disclosed any potential or pertinent conflicts which may be perceived to have about conflict through such work. For full disclosure statements refer to

Appendix A. Supplementary data

Conflict of Support Statement for McNally:
Conflict of Interest Statement for Adams:
Conflict of Interest Statement for Visvanathan:
Conflict of Interest Statement for Liberali:


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