What is the recommended lifelong prophylactic antibiotic regimen for a patient with a history of prosthetic joint replacement?

From the Guidelines

There is no recommended lifelong prophylactic antibiotic regimen for patients with prosthetic joint replacements. Current guidelines, as outlined in the 2015 ADA statement [@6@] and the 2017 AAOS/ADA recommendations [@8@], do not support routine antibiotic prophylaxis for dental procedures or other invasive procedures in patients with prosthetic joints. The previous practice of prescribing antibiotics before dental work for these patients has been abandoned due to lack of evidence showing benefit and concerns about antibiotic resistance, adverse drug reactions, and cost.

Instead, maintaining good oral hygiene and regular dental care is recommended for preventing infections. Prophylactic antibiotics are only considered in specific high-risk situations, such as in immunocompromised patients or those with previous prosthetic joint infections, as noted in the 2017 AAOS/ADA guidelines [@8@]. When antibiotics are deemed necessary for specific procedures, they are prescribed for short durations surrounding the procedure, not as lifelong regimens. The risk of hematogenous seeding of prosthetic joints from transient bacteremia is extremely low, and the potential harms of long-term antibiotic use (including resistance development, adverse effects, and microbiome disruption) outweigh any theoretical benefits, as highlighted in studies such as those by Berbari et al [@28@] and Skaar et al [@31@].

Key points to consider include:

• The lack of association between dental procedures and prosthetic joint infections, as demonstrated in studies by Berbari et al [@28@], Skaar et al [@31@], and Swan et al [@32@].
• The potential risks of antibiotic use, including antibiotic resistance, adverse drug reactions, and disruption of the gut microbiome, as discussed in the context of studies on antibiotic stewardship and the risks associated with clindamycin use [1, @35@, @36@, @37@, @38@, @39@].
• The importance of maintaining good oral hygiene and regular dental care for preventing infections, as emphasized by the ADA and AAOS guidelines.

From the Research

Lifelong Prophylactic Antibiotic Regimen for Patients with Prosthetic Joints

• The American Academy of Orthopedic Surgeons recommends amoxicillin prophylaxis for high-risk patients with prosthetic joints 2.
• However, studies suggest that the use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints is not recommended in general, due to the lack of evidence demonstrating an association between dental procedures and prosthetic joint infection (PJI) 3.
• The American Dental Association Council on Scientific Affairs developed an evidence-based clinical practice guideline that states prophylactic antibiotics are not recommended prior to dental procedures to prevent PJI in patients with prosthetic joint implants 3.
• Other studies suggest that antibiotics are not necessary in most patients with prosthetic joints who are undergoing dental procedures, and that the use of antibiotics should be based on individual patient risk factors and medical history 4, 5.
• In terms of specific antibiotic regimens, cefazolin is considered the drug of choice for prophylaxis during surgery, while cefoxitin or cefotetan may be used when both aerobic and anaerobic infections are a concern 4.
• For patients with prosthetic joints, the choice of antibiotic prophylaxis should be based on the individual patient's risk factors, medical history, and the type of dental procedure being performed, rather than a lifelong prophylactic regimen 3, 5.

Considerations for Antibiotic Prophylaxis

• The risk of antibiotic resistance and adverse reactions should be considered when prescribing antibiotic prophylaxis for patients with prosthetic joints 3, 5.
• The patient's medical history, including the presence of comorbidities and the type of prosthetic joint, should be taken into account when determining the need for antibiotic prophylaxis 2, 5.
• The type of dental procedure being performed should also be considered, with invasive procedures potentially requiring antibiotic prophylaxis in high-risk patients 2.