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Should patients who have prosthetic joints be prescribed antibiotic prophylaxis prior to undergoing dental procedures?
There is no strong clinical data to support the utility of routine antibiotic prophylaxis during dental procedures in low-risk patients with prosthetic joints. As such, the American Academy of Orthopedic Surgeons (AAOS), in conjunction with the American Dental Association (ADA) and with input from the Infectious Disease Society of America, suggests that clinicians consider discontinuing the practice of routine antibiotic prophylaxis in low-risk populations. However, this recommendation is based on low-level evidence and may not be applicable to high-risk groups. The AAOS-ADA clinical practice guideline recognizes certain clinical scenarios that may confer an increased risk of infection and justify consideration of prophylactic antibiotics. The AAOS has an online risk assessment tool that clinicians can use to enter these risk factors for specific patients and aid in decision-making (website address at the end of this chapter). Importantly, final decisions on the use of antibiotic prophylaxis should be made in consultation with the dental and orthopedic services.
Perioperative Management of Conventional Synthetic and Targeted Synthetic Disease Modifying Antirheumatic Drugs
| DMARD | Perioperative Recommendation a |
|---|---|
| Patients with RA, SpA (including PsA), JIA | |
| Methotrexate, hydroxychloroquine, sulfasalazine, leflunomide, doxycycline | Continue through the perioperative period |
| Prednisone | Continue daily dosing through the perioperative period; for most patients, stress-dosing is not necessary for knee and hip replacements |
| Tofacitinib, baricitinib, upadicitinib | Withhold for 7 days prior to surgery and resume 3–5 days post-surgery if no complications |
| Patients with SLE Severe organ manifestations (e.g., nephritis, CNS lupus, severe hemolytic anemia, cardiopulmonary disease) Induction or maintenance treatment | |
| Mycophenolate, azathioprine, cyclosporine, tacrolimus b | Continue through the perioperative period |
| Patients with SLE Non-severe manifestations | |
| Mycophenolate, azathioprine, cyclosporine, tacrolimus | Withhold 1 week prior to surgery and resume 3–5 days post-surgery if no complications |
| Corticosteroids | Continue the daily dosing throughout the perioperative period; for most patients, stress-dosing is not indicated for knee and hip replacements |
DMARD, Disease-modifying antirheumatic drug; RA, rheumatoid arthritis; SpA , spondyloarthritis; PsA, psoriatic arthritis; JIA, juvenile idiopathic arthritis; SLE, systemic lupus erythematosus.
a Medications should be resumed postoperatively once the patient is doing well (wound without infection and healing well, patient taking oral medications, no new renal/hepatic insufficiency).
b Cyclophosphamide is not included in these recommendations but patients on this agent should be considered to wait until the course of therapy is completed prior to elective surgery.
Antibiotics prescribed for these selected patients may provide benefit without excess risk. In the absence of good data, the following agents may be rational choices: amoxicillin (2 g), cephalexin (2 g), or azithromycin (500 mg) for the penicillin-allergic patient, all dosed once orally 1 hour before the procedure. Antibiotic prophylaxis is not necessary for patients with small joint (e.g., metacarpophalangeal joint) replacements, pins, plates, or screws.
