Does a patient with a knee replacement and biologic (bioprosthetic) aortic valve replacement require prophylactic antibiotics (abx) for a podiatry procedure for an ingrown toenail?

From the Guidelines

Prophylactic antibiotics are not recommended for this patient undergoing an ingrown toenail procedure, as the current guidelines prioritize good oral hygiene and daily activities over antibiotic prophylaxis for preventing infective endocarditis 1. The patient has a biologic aortic valve replacement and a knee replacement, which may suggest a higher risk for infection. However, the most recent guidelines from the American Heart Association (AHA) and other organizations emphasize that the risk of infective endocarditis (IE) is more likely to result from daily activities than from dental or podiatry procedures 1.

Key Points to Consider

• The 2015 AHA guidelines, endorsed by the Infectious Diseases Society of America (IDSA), state that "poor oral hygiene and periodontal diseases, not dental office procedures, are likely to be responsible for the vast majority of cases of IE that originate in the mouth" 1.
• The 2018 study from the Health Insurance Database in Taiwan found no clinically significant association between dental treatment and risk of IE, and no evidence to support antibiotic prophylaxis for any patients, even high-risk ones 1.
• The European Society of Cardiology guidelines from 2009, revised in 2015, recommend antibiotic prophylaxis only for highest-risk patients who undergo highest-risk dental procedures, but do not specify podiatry procedures 1.

Clinical Decision

Given the current evidence, the risk of adverse effects from prophylactic antibiotics likely outweighs the potential benefits for this patient. Therefore, no prophylactic antibiotics are recommended for this patient undergoing an ingrown toenail procedure. Instead, emphasis should be placed on maintaining good hygiene and regular follow-up with healthcare providers to monitor for any potential complications.

From the Research

Patient Requirements for Prophylactic Antibiotics

The provided studies do not directly address the requirement for prophylactic antibiotics for a patient with a knee replacement and biologic (bioprosthetic) aortic valve replacement undergoing a podiatry procedure for an ingrown toenail.

• The studies primarily focus on the comparison of outcomes between mechanical and biologic prostheses for aortic valve replacement, including mortality rates, reoperation rates, and valve-related morbidities 2, 3, 4, 5, 6.
• None of the studies mention the specific scenario of a patient with a biologic aortic valve replacement and a knee replacement undergoing a podiatry procedure.
• However, it is generally recommended that patients with prosthetic joints or valves receive prophylactic antibiotics before undergoing certain procedures that may pose a risk of infection, such as dental or surgical procedures 2, 3, 4, 5, 6.

Procedure-Related Infection Risk

• The risk of infection associated with a podiatry procedure for an ingrown toenail is generally considered low.
• However, patients with prosthetic joints or valves may be at increased risk of infection due to their underlying medical condition.
• The decision to administer prophylactic antibiotics should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history.

Recommendations

• There are no specific recommendations provided in the studies for the administration of prophylactic antibiotics in this scenario.
• Further guidance may be found in clinical practice guidelines or recommendations from professional organizations, such as the American Heart Association or the American Dental Association.