Do patients with Rheumatoid Arthritis (RA) require antibiotic prophylaxis prior to dental or other surgery?

Antibiotic Prophylaxis for Patients with Rheumatoid Arthritis Undergoing Dental or Surgical Procedures

Patients with rheumatoid arthritis require antibiotic prophylaxis before dental procedures only if they have specific high-risk features: prosthetic joints combined with active immunosuppression (particularly biologic DMARDs), or cardiac conditions requiring endocarditis prophylaxis. For most RA patients without these features, prophylaxis is not indicated for routine dental care.

Risk Stratification Algorithm

For Dental Procedures

Step 1: Assess for cardiac indications (highest priority)

• Patients with prosthetic cardiac valves, previous infective endocarditis, or specific congenital heart disease require prophylaxis regardless of RA status 1, 2
• If present: Give amoxicillin 2g orally 1 hour before procedure 1, 2

Step 2: Assess for prosthetic joint + immunosuppression combination

• RA patients on biologic DMARDs (TNF inhibitors, rituximab, etc.) who also have prosthetic joints are at elevated infection risk 3, 4
• The American Academy of Orthopedic Surgeons specifically identifies RA as a high-risk condition warranting prophylaxis in the prosthetic joint context 3
• Historical data shows RA patients with joint replacements have 2-fold increased risk of postoperative infection and 7.5% risk of hematogenous infection with chronic bacteremia 4

Step 3: For RA patients meeting high-risk criteria

• Prescribe amoxicillin 2g orally as single dose, 1 hour before procedure 3
• For penicillin allergy: azithromycin 3
• Prophylaxis applies only to invasive procedures (extractions, periodontal surgery, implants) 1, 2

Step 4: For RA patients NOT meeting high-risk criteria

• No antibiotic prophylaxis is indicated for routine dental cleanings, fillings, or other non-invasive procedures 5
• RA alone without prosthetic joints or cardiac risk factors does not warrant prophylaxis 3
• The majority (61%) of scenarios do not warrant prophylaxis even in joint replacement patients 3

Management of RA Medications Around Dental Procedures

Continue conventional DMARDs without interruption:

• Methotrexate, leflunomide, hydroxychloroquine, and sulfasalazine should be continued through dental procedures 1, 5
• Evidence shows continuing these medications actually decreases infection risk (RR 0.39) compared to stopping them 1

Biologic DMARDs for routine dental procedures:

• Continue biologics for routine cleanings, fillings, and simple procedures 5
• For major oral surgery requiring general anesthesia, consider timing at end of dosing cycle when drug levels are lowest 5

Corticosteroids:

• Continue current daily dose without stress-dose supplementation 5

Surgical Procedures (Non-Dental)

For elective orthopedic surgery (total hip/knee arthroplasty):

• Withhold all biologic agents prior to surgery and plan surgery at end of dosing cycle 1
• Continue conventional DMARDs (methotrexate, leflunomide, hydroxychloroquine, sulfasalazine) 1
• Resume biologics once wound shows healing (typically 14 days), sutures removed, and no infection present 5

For other surgical procedures:

• Antibiotic prophylaxis for non-dental procedures is not recommended unless there is established active infection at the surgical site 1

Critical Pitfalls to Avoid

Do not prescribe prolonged antibiotic courses:

• Only a single pre-procedure dose is indicated when prophylaxis is needed 3, 2
• Post-procedure antibiotics are not recommended for prophylaxis 2

Do not give prophylaxis to all RA patients reflexively:

• Risk stratification is essential—most RA patients do not require prophylaxis 3
• The combination of prosthetic joint + immunosuppression is what creates high risk, not RA diagnosis alone 3, 4

Do not stop conventional DMARDs perioperatively:

• Stopping methotrexate and similar agents increases flare risk without reducing infection risk 1, 5

Emphasize oral hygiene over prophylaxis:

• Good oral hygiene and regular dental care are more important for preventing infections than antibiotic prophylaxis 3
• RA patients have higher rates of oral carriage of pathogens, making preventive dental care crucial 6

Special Considerations

Patients with chronic skin ulceration:

• RA patients with recurrent skin ulceration and infection have 7.5% risk of hematogenous joint infection and warrant heightened vigilance 4

Coordination with rheumatologist:

• For complex cases or patients on multiple immunosuppressants, communicate with the prescribing rheumatologist regarding planned procedures 5