Factors associated with use of antibiotic prophylaxis following dental procedures in total joint replacement recipients.

Background

Total joint replacement recipients (TJR) are at risk for prosthetic joint infection (PJI), particularly those with comorbidities such as diabetes mellitus (DM) and rheumatoid arthritis (RA).

Methods

We mailed surveys to 1078 subjects undergoing primary TJR between 2011 and 2016 ​at an academic center. The survey asked about medical, dental, and orthopedic history and use of antibiotics prior to dental appointments. We generated adjusted relative risks (aRR) for using antibiotic prophylaxis less than always using Poisson regression, adjusting for demographic, clinical, and behavioral factors.

Results

We received surveys from 639 subjects; 597 were eligible and formed the analytical sample. 66 ​% reported always using antibiotic prophylaxis. DM and RA were not associated with prophylaxis use. Factors associated with less frequent use included: BMI ≥30 (aRR ​= ​1.27, 95 ​% CI [1.01, 1.60]), dental cleanings <2 times/year (aRR ​= ​1.95, 95 ​% CI [1.56, 2.43]), and expressing little concern (compared to neutral) about getting PJI (aRR ​= ​1.23, 95 ​% CI [0.97, 1.55]), though this association was not statistically significant. Greater antibiotic use was reported in subjects who had ≥3 TJRs, (aRR ​= ​0.48, 95 ​% CI [0.29, 0.80]), underwent more invasive dental procedures (aRR ​= ​0.74, 95 ​% CI [0.59, 0.93]), and were concerned (vs. neutral) about PJI (aRR ​= ​0.53, 95 ​%CI [0.33, 0.84]).

Conclusions

Two-thirds of TJR recipients in an academic center reported always using antibiotic prophylaxis prior to dental visits. Usage rates varied by demographics, BMI, number of TJRs, type of dental procedure, and behavioral factors -- but not by comorbidities associated with higher PJI risk.

Informations de copyright

© 2021 The Author(s).

Déclaration de conflit d'intérêts

Dr. Lange reports receiving consulting fees from Conformis (Billerica, MA USA).Appendix Table 1Patient Characteristics by Dental Antibiotic Prophylaxis Use (Ever/ Never)Appendix Table 1All (N ​= ​597)Ever Used Antibiotics N ​= ​527Never used antibiotics (N ​= ​70)NN( ​%)N( ​%)Age at Survey8069(86.25)11(13.75) ≤ 60 60–656759(88.06)8(11.94) 65–70122110(90.16)12(9.84) 70–75146134(91.78)12(8.22)> 75181154(85.08)27(14.92) Unknown11(100.00)0(0)Sex Female360310(86.11)50(13.89) Male228210(92.11)18(7.89) Unknown97(77.78)2(22.22)Education High School or less9470(74.47)24(25.53) Some College/Associates degree179157(87.71)22(12.29) Collegiate Degrees317295(93.06)22(6.94) Unknown75(71.43)2(28.57)Non-Hispanic White No5340(75.47)13(24.53) Yes528473(89.58)55(10.42) Unknown1614(87.50)2(12.50)Year Category 2011–2013304273(89.80)31(10.20) 2014–2016293254(86.69)39(13.31)Number of TKR/THR Procedures 1–2 TKR/THR522454(86.97)68(13.03) ≥3 TKR/THR7573(97.33)2(2.67)TKR/THR Revision No Knee/Hip Revision531471(88.70)60(11.30) Had Knee/Hip Revision6656(84.85)10(15.15)BMI (kg/m2)< 25110102(92.73)8(7.27) 25–30194171(88.14)23(11.86) 30–35150137(91.33)13(8.67) 35–407263(87.50)9(12.50) ≥406751(76.12)16(23.88) Unknown43(75.00)1(25.00)Comorbidities Neither RA nor DM396357(90.15)39(9.85) RA (w/or w/o DM)9783(85.57)14(14.43) DM only10487(83.65)17(16.35)TJR Surgery Type THR283251(88.69)32(11.31) TKR314276(87.90)38(12.10)Infection in the last 6 years that required hospitalization? No518458(88.42)60(11.58) Yes7969(87.34)10(12.66)Bleeding level of Dental Procedure Low192147(76.56)45(23.44) Intermediate151142(94.04)9(5.96) High243229(94.24)14(5.76) Unknown119(81.82)2(18.18)Routine teeth cleaning Frequency Never or < 2 times/year152108(71.05)44(28.95)= 2 times/year331311(93.96)20(6.04)> 2 times/year107103(96.26)4(3.74) Unknown75(71.43)2(28.57)Do you think taking antibiotics before dental procedures does more harm than good, or more good than harm? More harm than good2825(89.29)3(10.71) More good than harm288281(97.57)7(2.43) I don't know263210(79.85)53(20.15) Unknown1811(61.11)7(38.89)Worry about getting infection in prosthetic knee or hip Strongly/Agree10097(97.00)3(3.00) Neutral165149(90.30)16(9.70) Disagree148128(86.49)20(13.51) Strongly disagree167143(85.63)24(14.37) Unknown1710(58.82)7(41.18)∗: Bleeding level of dental procedure is Intermediate if patients have had one or more of the less bloody procedures (Cavity filling, Bridge placement, Dental crown, Orthodontics) but none of the more bloody procedures (Root canal, Dental implant placement, Tooth extraction); High if patients have had one or more of the bloody procedures (Root canal, Dental implant placement, Tooth extraction); Low if they have had none of these procedures.Appendix Table 2Adjusted Relative Risk (aRR) of Never vs. Ever used Dental Antibiotic Prophylaxis (DAP)Appendix Table 2Adjusted Relative Risk (aRR)[95 ​% CI]Never Use DAP vs.Used DAPP-valueAdjusted Relative Risk (aRR) [95 ​%CI]Never Use DAP vs.Used DAPP-valueAdjusted Relative Risk (aRR) [95 ​%CI]Never Use DAP vs.Used DAPP-valueDemographic ModelGlobal ModelMost Parsimonious modelYear2011–20132014–20160.78 [0.47, 1.31]Ref0.3507Race & EthnicityOtherNon- Hispanic White0.91 [0.39, 2.10]Ref0.8214Age≤ 70> 70Ref0.85 [0.50, 1.41]0.5250SexFemaleMaleRef0.62 [0.35,1.10]0.0809Ref0.69 [0.41, 1.17]0.1473EducationHigh School or lessSome college/AssociateCollegiate DegreeRef0.53 [0.29,0.99]0.34 [0.18, 0.64]0.0187Ref0.59 [0.34, 1.03]0.53 [0.30, 0.96]0.1349Ref0.57 [0.34, 0.96]0.48 [0.27,0.85]0.0706Clinical ModelComorbidityNeither RA nor DMRA/DM or BothRef1.46 [0.90, 2.38]0.1526Ref1.49 [0.93, 2.37]0.1176Number of TJR≤2≥3Ref0.14 [0.02, 0.97]0.0002Ref0.12 [0.02, 0.87]0.0004Ref0.12 [0.02, 0.90]0.0006BMI (kg/m2)< 40≥40Ref2.84 [1.68, 4.78]0.0088Ref1.93 [1.15, 3.23]0.0383Ref1.95 [1.17, 3.24]0.0331History of Hospitalized InfectionNoYesRef0.92 [0.46, 1.82]0.8044Bleeding level of Dental Procedure∗LowIntermediate or highRef0.25 [0.15, 0.43]<.0001Ref0.42 [0.24, 0.70]0.0013Ref0.41 [0.24, 0.70]0.0011Surgery typeTKRTHR0.92 [0.57, 1.48]Ref0.7301Revision of ProcedureYesNo1.44 [0.74, 2.81]Ref0.3547Behavioral modelRoutine Teeth Cleaning FrequencyNever or < 2 times/yr≥2 times/yr5.70 [3.35, 9.68]Ref<.00014.21 [2.46, 7.22]Ref<.00014.11 [2.40, 7.04]Ref<.0001Worry about getting infection in prosthetic knee or hipNeutralStrongly/AgreeStrongly/DisagreeRef0.25 [0.06, 1.03]1.37 [0.79, 2.38]0.0004Ref0.37 [0.09, 1.50]1.56 [0.93, 2.62]0.0038Ref0.33 [0.08, 1.36]1.49 [0.89, 2.50]0.0042Note.∗DAP: Dental Antibiotic Prophylaxis.∗∗For interpreting purpose, we didn't include behavior/attitude variables in the Global Model.Appendix Table 3Factors associated with report of whether antibiotics did more good than harmAppendix Table 3All N ​= ​597More harm than good N ​= ​28More good than harm N ​= ​295I don't know N ​= ​278NN( ​%)N( ​%)N( ​%)Age at Survey ≤ 60803(3.75)35(43.75)40(50.00) 60–65672(2.99)31(46.27)33(49.25) 65–701226(4.92)60(49.18)53(43.44) 70–751468(5.48)82(56.16)50(34.25)> 751819(4.97)80(44.20)86(47.51) Unknown10(0)0(0)1(100.00)Sex Female36012(3.33)182(50.56)154(42.78) Male22815(6.58)105(46.05)105(46.05) Unknown91(11.11)1(11.11)4(44.44)Education High School or less941(1.06)39(41.49)50(53.19) Some College/Associates degree1798(4.47)83(46.37)84(46.93) Collegiate Degree31719(5.99)165(52.05)125(39.43) Unknown7001(14.29)4(57.14)Non-Hispanic White No533(5.66)18(33.96)30(56.60) Yes52824(4.55)264(50.00)227(42.99) Unknown161(6.25)6(37.50)6(37.50)Year Category: 2011–201330417(5.59)136(44.74)139(45.72) 2014–201629311(3.75)152(51.88)124(42.32)Number of TKR/THR Procedures 1–2 TKR/THR52228(5.36)242(46.36)237(45.40)≥ 3 TKR/THR750046(61.33)26(34.67)TKR/THR Revision No Knee/Hip Revision53126(4.90)251(47.27)240(45.20) Had Knee/Hip Revision662(3.03)37(56.06)23(34.85)BMI (kg/m2)< 251109(8.18)45(40.91)51(46.36) 25–301946(3.09)98(50.52)87(44.85) 30–351508(5.33)74(49.33)64(42.67) 35–40721(1.39)40(55.56)30(41.67)≥ 40674(5.97)29(43.28)30(44.78) Unknown4002(50.00)1(25.00)Comorbidities39622(5.56)191(48.23)175(44.19) Neither RA nor DM RA (w/or w/o DM)974(4.12)53(54.64)36(37.11) DM only1042(1.92)44(42.31)52(50.00)Surgery Type: THR28311(3.89)130(45.94)134(47.35) TKR31417(5.41)158(50.32)129(41.08)Infection in the last 6 years that required hospitalization? No51823(4.44)256(49.42)224(43.24) Yes795(6.33)32(40.51)39(49.37)Bleeding level of Dental Procedure Low1929(4.69)82(42.71)95(49.48) Intermediate1516(3.97)81(53.64)61(40.40) High24313(5.35)120(49.38)102(41.98) Unknown11005(45.45)5(45.45)Routine teeth cleaning Frequency Never or < 2 times/year1529(5.92)56(36.84)83(54.61)= 2 times/year33113(3.93)175(52.87)135(40.79)> 2 times/year1076(5.61)55(51.40)43(40.19) Unknown7002(28.57)2(28.57)Worry about getting infection in prosthetic knee or hip Strongly/Agree1003(3.00)62(62.00)34(34.00) Neutral1655(3.03)76(46.06)83(50.30) Disagree1488(5.41)62(41.89)71(47.97) Strongly disagree16711(6.59)86(51.50)66(39.52) Unknown171(5.88)2(11.76)9(52.94)RA ​= ​rheumatoid arthritis; DM ​= ​diabetes mellitus; TKR ​= ​total knee replacement; THR ​= ​total hip replacement.∗: Bleeding level of dental procedure is Intermediate if patients have had one or more of the less bloody procedures (Cavity filling, Bridge placement, Dental crown, Orthodontics) but none of the more bloody procedures (Root canal, Dental implant placement, Tooth extraction); High if patients have had one or more of the bloody procedures (Root canal, Dental implant placement, Tooth extraction); None if they have had none of these procedures.