Testing Your Knowledge On Antibiotic Prophylaxis: What Would You Do In These Cases?

Warren S. Joseph DPM FIDSA

With this blog entry, I am going to try something a bit different. I know that there is a good readership of my posts but, to date, I have been somewhat disappointed in the number of comments and interactions I have received from you, the readers.

The whole idea of this blog is to be interactive. I want to hear others’ thoughts and ideas.

To this end, I would like to start a “What Would You Do?” entry. I will ask a clinical question or two, maybe present a case and ask you for feedback on what you would do in this situation. Give me your thought processes that lead you to your position. Then in a subsequent post, I will review the responses and give you my approach along with any pertinent clinical evidence I have to back it up.

Let’s start with a recent, very well done study on dental procedures and prosthetic joint infections. (I will not give you the reference until the answers come in.) This study may alter the way we look at antibiotic prophylaxis in these situations. Here are the questions/clinical scenarios I have for you.

1. You placed a prosthetic joint into a patient’s foot. Let’s even expand it out since there aren’t as many joints being placed anymore. You placed some hardware into a patient’s foot while doing surgery on that foot. Let’s say the surgery was 18 months ago. The patient calls you because she is going to the dentist for some dental hygiene and to have a crown placed on a tooth. Do you or don’t you recommend antibiotic prophylaxis for this patient before the dental work?

2. A patient comes to see you for the chief complaint of a bunion. You discuss surgical correction. After the patient agrees to have the surgery scheduled, she informs you that she had a prosthetic knee implanted 18 months ago. Do you place the patient on prophylactic antibiotics to prevent a prosthetic joint infection following your foot surgery?

Let me know how you would approach these situations. There are really no right or wrong answers (or maybe there are … it depends on the answers I get). Once I receive some input, I will give you my thoughts on the subject as well as summary of the recent aforementioned study.

Editor’s note: This blog was originally published at http://www.leinfections.com/category/antibiotics/ and has been adapted with permission from Warren Joseph, DPM, FIDSA, and Data Trace Publishing Company. For more information about the Handbook of Lower Extremity Infections, visit www.leinfections.com/ .

Comments

I would not recommend antibiotics in either of those scenarios.
Even though in scenario one, dental surgery is considered "dirty", the patient has no other medical issues identified in the example that would cause alarm other than the implant in the foot.

In scenario two, just performing surgery on the foot, with a somewhat recent history of a total knee implant, would not be a justifiable reason to recommend antibiotics in my mind. Foot surgery is not considered "dirty" so why need antibiotics?
Now if I had put a Total Ankle Implant in a somewhat immuno-compromised patient who was having dental or abdominal work done, THEN I would consider it, but not order it until discussing the case with my ID colleagues locally.

Sir,

The first case you mentioned would not require prophylaxis unless the patient has rheumatoid/vascular issues. Also if the patient has an active infection where the dental procedure is being performed, then one may consider antibiotics such as first generation cephalosporins/clyndamycin that cover Staph or Strep if there is a PCN allergy. MRSA/MRSE is not a factor with antibiotic selection in this case.

In my opinion, the second case also does not require prophylactic antibiotic since a bunionectomy is a "clean" case. However, if the patient has issues of previous infection of the prosthetic knee implant, vegitative heart valves, history of being immunocompromised (HIV,STDs,septic arthritis, autoimmune disease,chemo/radiation therapy, etc), then Ancef or Vanco if PCN allergy should be considered.

I would not recommend prophylaxis for either patient in the above scenarios. If, however, the patient had a history of endocarditis or if either implant was infected, or if there was a history of infection complicating the surgical outcome, then I would place the patient on prophylactic antibiotics.

If the patient is immunocompromised or is taking systemic steroids, then I would again consider antibiotic prophylaxis.

I get calls from dentists in my area all the time concerning this issue. They ask for my recommendation. I tell them to follow the ADA's protocol.

First Case: This patient does not need prophylaxis. ADA and AAOS guidelines do not recommend routine prophylaxis, especially considering that dental hygiene and a crown placed on a tooth are non invasive procedures!!

Second Case: I would recommend prophylaxis in this case since the prosthetic knee was implanted 18 months ago (i.e less than 2 years.

Case 1:
I would not think it is required but it is up to the dentist to make the decision.

Case 2:
I will probably be in the minority but I still routinely use antibiotic aprophylaxis in these cases. It is "clean surgery" but how do you know for sure that your instruments are "sterile"? Additionally, little breaks in protocol can compromise the patient. I still say a little prevention goes a long way.

I would give antibiotic prophylaxis in both cases because this is MY patient. Even if the literature is unclear, I know what I would do and why.

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