Perhaps due to the ongoing misprescribing of appropriate antibiotic prophylaxis for cardiac patients at risk, the American Heart Association released a recent Scientific Statement with the purpose of examining interval evidence of the acceptance and impact of the 2007 recommendations and, if needed, to make revisions based on this evidence. The conclusion from this expert panel was, “no recommended changes to the 2007 guidelines” (Wilson, et al., 2021). The group did, however, make some suggestions for additions to the existing guidelines which could have significant ramifications on contemporary dental practice: 1) reinforce the 2007 recommendation for allergy screening of patients who describe a history of penicillin allergy; 2) consider doxycycline as an alternative to clindamycin in those patients with a history of penicillin allergy; and 3) no longer recommended clindamycin for antibiotic prophylaxis for dental procedures. While the first suggestion is evidence-based and is in line with the 2007 recommendations, the other two considerations are off the mark. Doxycycline may be an alternative in patients who are unable to tolerate a penicillin, cephalosporin, or macrolide, however, there is no scientific evidence to support its effectiveness for endocarditis prophylaxis following dentistry in humans. In fact, one of the most referenced studies on this topic published by Glauser & Francioli in 1982, actually concluded that, "While significant protection for infective endocarditis in rats was achieved with all three antibiotics [clindamycin, erythromycin and doxycycline], only clindamycin was fully Antibiotic prophylaxis for orthopedic patients The latest joint guidelines published by the American Dental Association (ADA) and American Academy of Orthopedic Surgeons (AAOS) for the dental management of orthopedic populations at risk for infection and the dental procedures that put these patients at risk was published in 2013 (Rethman et al., 2013). Unfortunately, these guidelines fall short in clearly delineating those specific patient populations who may be at highest risk or those dental procedures that may carry a higher risk of bacteremia as outlined in the 2003 guidelines (Tables 7 and 8; American Dental Association, 2003). These 2013 guidelines state that, “Treatments and procedures applicable to the individual patient rely on mutual communication between patient, physician, dentist and other healthcare practitioners.” They propose a shared decision-making tool designed to help the patient who has undergone an orthopedic procedure to determine, with the assistance of his or her dentist or physician, whether taking an antibiotic prior to a dental procedure is prudent or necessary (Jevsevar, 2013). The final recommendations state that the practitioner might consider
effective against all three species at doses that simulated serum levels achievable in humans after oral administration" (Glauser & Francioli, 1982). Furthermore, doxycycline, as a bacteriostatic antibiotic, has not been a recommended choice in any dental guidelines, and certainly not at the low, one-time dose of 100mg being suggested in this publication. There were no additional comments or references in support of this suggestion in the Scientific Statement. The other suggestion, that clindamycin no longer be recommended for antibiotic prophylaxis for dental procedures, is also unsupported universally by peer-reviewed evidence in the Scientific Statement. If this were to be adopted within new guidelines, it would result in the loss of an excellent tool in our toolkit (clindamycin), and the replacement of therapy with an inferior option at a potentially inferior dose (doxycycline). The authors reasoning for this new position quotes their own published work from a study in England six years earlier in which they found antibiotic prophylaxis with clindamycin to have thirteen more fatal adverse drug reactions than amoxicillin per one million patients treated (Thornhill, et al. 2015). Original evidence from the peer reviewed literature as well as more contemporary reviews on the utility and safety of clindamycin directly refute these suggestions (Bignardi, 1998; Donaldson & Goodchild, 2017). At this time clindamycin remains a viable option for infective endocarditis prophylaxis for those patients at risk. discontinuing the custom of routinely prescribing prophylactic antibiotics for patients with hip and knee prosthetic joint implants undergoing dental procedures because the evidence in support of this practice is limited. Given this lack of clear and distinct recommendations in consistently managing these patients, a panel of experts convened by the American Dental Association Council on Scientific Affairs developed an evidence-based clinical practice guideline on the use of prophylactic antibiotics in patients with prosthetic joints who are undergoing dental procedures (Sollecito et al., 2015). The 2014 Panel concluded that, in general, for patients with prosthetic joint implants, prophylactic antibiotics are not recommended prior to dental procedures to prevent prosthetic joint infection. However, if prophylaxis is indicated, the appropriate antibiotic regimen should match the AHA cardiac recommendations previously described in Table 6. As always, if any doubt exists, it is always best to consult with the patient’s physician.
Table 7: Patients at Potential Increased Risk of Experiencing Hematogenous Total Joint Infection Patient Type Condition Placing Patient at Risk
All patients during the first two years following joint replacement Immunocompromised or immunosuppressed patients
• Not applicable.
• Inflammatory arthropathies such as rheumatoid arthritis, systemic lupus erythematosus. • Drug- or radiation-induced immunosuppression.
Patients with comorbidities*
• Previous prosthetic joint injections. • Malnourishment.
• Hemophilia. • HIV infection. • Insulin-dependent (type 1) diabetes. • Malignancy. * Conditions shown for patients in this category are examples only; there may be additional conditions that place such patients at risk of experiencing hematogenous total joint infections. Note . Adapted from “Antibiotic Prophylaxis for Dental Patients With Total Joint Replacements,” by the American Dental Association and American Academy of Orthopedic Surgeons, 2003, Journal of the American Dental Association, 134 (7), 895-899.
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