Analysis of prosthetic joint infections following invasive dental procedures in England

Importance

Dentists in the United States are under pressure from orthopaedic surgeons and their patients with prosthetic joints to provide antibiotic prophylaxis (AP) before invasive dental procedures (IDP) to reduce the risk of late prosthetic joint infection (LPJI). This has been a common practice for decades despite a lack of evidence for an association between IDP and LPJI, a lack of evidence of AP efficacy, cost of providing AP, and risk of both adverse drug reactions and the potential for promoting antibiotic resistance.

Objective

Our objective was to quantify if there is any temporal association between IDP and subsequent LPJI.

Design

A case-crossover and time trend study of any potential association between IDP and LPJI.

Setting

The population of England (55 million) was chosen because AP has never been recommended to prevent LPJI in England and any association between IDP and LPJI would therefore be fully exposed.

Participants

All patients admitted to hospital in England for LPJI from December 25th, 2011, through March 31st, 2017, for whom dental records were available. Analyses were performed between May 2018 and June 2021.

Exposures

Exposure to IDP

Main Outcomes and Measures

A case-crossover analysis comparing the incidence IDP in the 3-months before LPJI hospital admission (case-period) with the incidence in the 12-months before that (control-period).

Results

We identified 9,427 LPJI hospital admissions with dental records (mean age 67), including 4,897 (52%) men. Of these, 2,385 (25.3%) had hip, 3,168 (33.6%) knee, 259 (2.8%) other and 3,615 (38.4%) unknown prosthetic joint types. Despite having sufficient statistical power to detect a clinically significant association, our analysis identified no significant temporal association between IDP and subsequent LPJI. Indeed, there was a lower incidence of IDP in the three months prior to LPJI (incidence rate ratio = 0.89, 95% confidence interval 0.82 to 0.96, p=0.002).

Conclusions and Relevance

In the absence of a significant positive association between IDP and LPJI, there is no rationale to administer AP before IDP in patients with prosthetic joints. Maintenance of good oral hygiene, however, may be important in preventing the small number of LPJI cases where oral bacterial species are implicated.