Antibiotic Prophylaxis for Bacteremia in Patients with Joint Replacements

As an orthopedic surgeon, I have a large number of patients whose shoulders and knees I have replaced.   I also have many more patients who have metal implants related to fracture repair and metal or plastic anchor implantation from rotator cuff surgery.  The question of prophylactic antibiotics always comes up.  Dentists are apparently under the impression that antibiotics may only be needed for the first 2 years after a joint replacement.  This, I assume, was based on a study by dentists not orthopedic surgeons.

If I put a joint replacement in your body, you will always need prophylactic antibiotics for dental work and other procedures as written by the AAOS below.  Always means always and forever, for the rest of your life.

From the AAOS as of 2009…

More than 1,000,000 total joint arthroplasties are performed annually in the United States, of which approximately 7 percent are revision procedures.¹ Deep infections of total joint replacements usually result in failure of the initial operation and the need for extensive revision, treatment and cost. Due to the use of perioperative antibiotic prophylaxis and other technical advances, deep infection occurring in the immediate postoperative period resulting from intraoperative contamination has been markedly reduced in the past 20 years.

Bacteremia from a variety of sources can cause hematogenous seeding of bacteria onto joint implants, both in the early postoperative period and for many years following implantation.² In addition, bacteremia may occur in the course of normal daily life^3-5 and concurrently with dental, urologic and other surgical and medical procedures.⁵ The analogy of late prosthetic joint infections with infective endocarditis is invalid as the anatomy, blood supply, microorganisms and mechanisms of infection are all different.⁶

It is likely that bacteremia associated with acute infection in the oral cavity,^7,8 skin, respiratory, gastrointestinal and urogenital systems and/or other sites can and do cause late implant infection.⁸ Practitioners should maintain a high index of suspicion for any change or unusual signs and symptoms (e.g. pain, swelling, fever, joint warm to touch) in patients with total joint prostheses. Any patient with an acute prosthetic joint infection should be vigorously treated with elimination of the source of the infection and appropriate therapeutic antibiotics.^8,9

Patients with joint replacements who are having invasive procedures or who have other infections are at increased risk of hematogenous seeding of their prosthesis. Antibiotic prophylaxis may be considered, for those patients who have had previous prosthetic joint infections, and for those with other conditions that may predispose the patient to infection (Table 1). ^8,10-16 There is evidence that some immunocompromised patients with total joint replacements may be at higher risk for hematogenous infections.^10-18

However, patients with pins, plates and screws, or other orthopaedic hardware that is not within a synovial joint are not at increased risk for hematogenous seeding by microorganisms.

Prophylactic antibiotics prior to any procedure that may cause bacteremia are chosen on the basis of its activity against endogenous flora that would likely to be encountered from any secondary other source of bacteremia, its toxicity, and its cost. In order to prevent bacteremia, an appropriate dose of a prophylactic antibiotic should be given prior to the procedure so that an effective tissue concentration is present at the time of instrumentation or incision in order to protect the patient’s prosthetic joint from a bacteremia induced periprosthetic sepsis. Current prophylactic antibiotic recommendations for these different procedures are listed in Table 2. ¹⁹

Occasionally, a patient with a joint prosthesis may present to a given clinician with a recommendation from his/her orthopaedic surgeon that is not consistent with these recommendations. This could be due to lack of familiarity with the recommendations or to special considerations about the patient’s medical condition which are not known to either the clinician or orthopaedic surgeon. In this situation, the clinician is encouraged to consult with the orthopaedic surgeon to determine if there are any special considerations that might affect the clinician’s decision on whether or not to pre-medicate, and may wish to share a copy of these recommendations with the physician, if appropriate. After this consultation, the clinician may decide to follow the orthopaedic surgeon’s recommendation, or, if in the clinician’s professional judgment, antibiotic prophylaxis is not indicated, may decide to proceed without antibiotic prophylaxis.

This statement provides recommendations to supplement practitioners in their clinical judgment regarding antibiotic prophylaxis for patients with a joint prosthesis. It is not intended as the standard of care nor as a substitute for clinical judgment as it is impossible to make recommendations for all conceivable clinical situations in which bacteremias may occur. The treating clinician is ultimately responsible for making treatment recommendations for his/her patients based on the clinician’s professional judgment.