Jared R. Anderson, DDS
Surgical antibiotic prophylaxis is described as the use of antibiotics to prevent infections at the surgical place. Prophylaxis has become the standard of care for contaminated and clean-contaminated surgery and for surgery involving insertion of artificial devices. The antibiotic selected should only cover the likely pathogens. It should be given at the correct time. For most parenteral antibiotics this is usually on induction of anesthesia. A single dose of antibiotic is usually sufficient if the duration of surgery is four hours or less. Inappropriate use of antibiotics for surgical prophylaxis increases both cost and the selective pressure favoring the emergence of resistant bacteria.
Duration of antibiotic administration
Persistence of tissue concentrations past the period of surgery and recovery of normal physiology following anesthesia does not improve efficacy and increases toxicity and cost. If the operation lasts four hours or less, one antibiotic dose is usually sufficient. If surgery is greater than four hours, further antibiotic doses may be required to maintain the concentration, particularly if the antibiotic has a short half-life. Continuing antibiotic prophylaxis until surgical drains have been removed is illogical and also of unproven benefit.
- Compared with previous suggestions, there are currently relatively few patient subpopulations for which antibiotic prophylaxis may be indicated prior to certain dental procedures.
- In patients with prosthetic joint implants, a January 2015 ADA clinical practice guideline, based on a 2014 systematic review states, “In general, for patients with prosthetic joint implants, prophylactic antibiotics are not recommended prior to dental procedures to prevent prosthetic joint infection."
- According to the ADA (Chairside Guide), for patients with a history of complications associated with their joint replacement surgery who are undergoing dental procedures that include gingival guidance or mucosal incision, prophylactic antibiotics should only be considered after consultation with the patient and orthopedic surgeon; in cases where antibiotics are deemed necessary, it is most appropriate that the orthopedic surgeon recommend the appropriate antibiotic regimen and, when reasonable, write the prescription.
- For infective endocarditis prophylaxis, 2007 guidelines by the (American Heart Association), written with input from the ADA and approved by the CSA as they relate to dentistry in 2008, support premedication for a smaller group of patients than previous versions. This change was based on a review of scientific evidence, which showed that the risk of adverse reactions to antibiotics generally outweighs the benefits of prophylaxis for many patients who would have been considered eligible for prophylaxis in previous versions of the guidelines. Concerns about the development of drug-resistant bacteria were a factor also.
- Infective endocarditis prophylaxis for dental procedures should be recommended only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis. For patients with these underlying cardiac conditions, prophylaxis is recommended for all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa.
Prevention of Prosthetic Joint Infection
In 2014, the ADA Council on Scientific Affairs assembled an expert panel to update and clarify the clinical recommendations found in the 2012 evidence report and 2013 guideline, Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures.
As was found in 2012, the updated systematic review undertaken in 2014 and published in 2015 found no association between dental procedures and prosthetic joint infections. Based on this evidence review, the 2015 ADA clinical practice guideline states, "In general, for patients with prosthetic joint implants, prophylactic antibiotics are not recommended prior to dental procedures to prevent prosthetic joint infection.”
A co-published editorial by Meyer also states:
"The new CSA guideline clearly states that for most patients, prophylactic antibiotics are not indicated before dental procedures to prevent [prosthetic joint infections]. The new guideline also takes into consideration that patients who have previous medical conditions or complications associated with their joint replacement surgery may have specific needs calling for premedication. In medically compromised patients who are undergoing dental procedures that include gingival manipulation or mucosal inclusion, prophylactic antibiotics should be considered only after consultation with the patient and orthopedic surgeon. For patients with serious health conditions, such as immunocompromising diseases, it may be appropriate for the orthopedic surgeon to recommend an antibiotic regimen when medically indicated, as footnoted in the new chair-side guide."
Surgical antibiotic prophylaxis is an effective management strategy for reducing postoperative infections, provided that appropriate antibiotics are given at the correct time for appropriate durations and for appropriate surgical procedures. In most cases, surgical antibiotic prophylaxis is given as a single intravenous dose as soon as the patient is stabilized under anesthetic, prior to skin incision. It is important to use a narrow color antibiotic appropriate to the site of surgery. Hospital surgical antibiotic prophylaxis protocols should be regularly reviewed, as both the cost of individual antibiotics and the endemicity of multi-resistant bacteria in certain units or hospitals are subject to frequent change.
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