Are prophylactic antibiotics required for dental procedures in patients with a spinal cord stimulator (SCS)?

From the Guidelines

Patients with spinal cord stimulators do not require prophylactic antibiotics before dental procedures, as the risk of infection is extremely low and the benefits of prophylaxis do not outweigh the potential risks, including the development of antibiotic-resistant bacterial pathogens and fatal allergic reactions 1.

Key Points to Consider

• The American Heart Association guidelines do not recommend antimicrobial prophylaxis for dental or other invasive procedures not directly related to device manipulation to prevent cardiovascular implantable electronic device (CIED) infection, and this principle can be applied to spinal cord stimulators as well 1.
• The bloodstream is typically only transiently contaminated during dental work, and the spinal cord stimulator is not considered a high-risk site for hematogenous seeding like prosthetic heart valves.
• If the patient has other conditions that independently warrant antibiotic prophylaxis, such as prosthetic heart valves or a history of infective endocarditis, they should receive appropriate antibiotics according to those guidelines.
• Patients should always inform their dentist about their spinal cord stimulator and any other medical devices or conditions.
• Consultation between the dentist and the physician who manages the spinal cord stimulator may be warranted to make an individualized decision if there are specific concerns about infection risk due to immunocompromise or other factors.

Important Considerations for Clinical Practice

• The decision to use prophylactic antibiotics should be based on the individual patient's risk factors and medical history, rather than a blanket recommendation for all patients with spinal cord stimulators.
• The potential risks and benefits of prophylactic antibiotics should be carefully weighed, taking into account the low risk of infection and the potential for adverse effects from antibiotic use.

From the Research

Spinal Cord Stimulator and Prophylactic Antibiotics for Dental Procedures

• The use of prophylactic antibiotics for dental procedures in patients with spinal cord stimulators (SCS) is not directly addressed in the provided studies 2, 3, 4, 5, 6.
• However, the studies provide information on the use of antibiotics in SCS implantation and the potential risks of infection.
• A study on antibiotic use during SCS trials and implants found that 82% and 69% of physicians do not utilize nasal swabs for methicillin-sensitive Staphylococcus aureus (MSSA) or methicillin-resistant Staphylococcus aureus (MRSA), respectively, prior to SCS trial and implantation 2.
• Another study investigated the impact of dental devices on neurostimulators and found that the probability of damage to the SCS by dental devices such as apex locators, electric pulp testers, and electrocautery units was negligible 3.
• A review of the literature on anesthetic considerations and perioperative management of SCS found that monopolar electrocautery is contraindicated but often used, and that bipolar cautery is favored 5.
• A study on postoperative oral antibiotic use and infection-related complications after SCS surgery found that the rates of infection following SCS surgery reported in the literature range from 2.8% to 10%, and that several studies indicated no potential benefit of postoperative antibiotics (beyond 24 hours) on subsequent device infection 6.

Antibiotic Use in SCS Implantation

• The study by 2 found that during SCS trials, 47% of providers administer a single dose of antibiotics, 35% administer antibiotics for the duration of the trial, and 17% do not administer antibiotics.
• During implantation, 44% of physicians administer a single dose during the procedure, 11% administer antibiotics up to 24 hours, 24% administer antibiotics between 3-5 days, 14% administer antibiotics for more than 5 days, and 4% do not administer antibiotics 2.
• The study by 6 found that postprocedural oral antibiotics were prescribed for 35.3% of SCS surgery patients, and that the most commonly used postprocedural antibiotics were cephalexin and sulfamethoxazole-trimethoprim.

Risks of Infection

• The study by 6 found that superficial surgical site infection, deep SSI, device infection, or any infection within 90 days occurred in 2.9%, 1.0%, 1.8%, and 4%, respectively, of the patients undergoing SCS surgery.
• The review by 5 found that the anesthesia care team needs working knowledge of where the device resides in the neuraxial space and what risks different medical technologies pose to the patient and device.