Aim. A previous Dutch guideline for prophylaxis of hematogenous PJI (HPJI) caused defensive medicine and incorrect own guidelines. There was a need for a better national guideline, developed cooperatively by orthopedic surgeons and dentist. Method. A committee of Dutch Orthopedic and Dental Society, performed a systematic literature review to answer the question: “Is there a difference in the risk for hematogenous infection between always or never giving antibiotic prophylaxis to patients with a joint prosthesis undergoing a dental procedure”. We included 9 papers as follows:. 1. RCT's and systematic reviews: 539 abstracts > 33 full papers > 1 paper included. 2. observational studies: 289 abstracts > 12 full papers > 5 papers. 3. reference-to-reference: 3 papers. The nine papers’ quality was scored according the GRADE method. In addition we studied in non-included literature on further information about additional questions of pathophysiology, risk factors and risk procedures. Results. No evidence was found that prophylactic antibiotics have an effect on the incidence of HPJI (Grade score: very low). We concluded from the non-included literature that:. 1. Bacteremia in dental procedures is frequent, but even more frequent in daily life. The influence of antibiotics on bacteremia is uncertain. 2. There is no evidence that in the first 2 years after implantation the risk for HPJI is increased. 3. There is no evidence that “bleeding” during dental procedures is associated with more bacteremia. 4. The relation between decreased immune status and the risk for HPJI is unclear. Also in these patients the cumulative dose of bacteremia is much higher in daily life as compared with dental procedures. 5. A risk/benefit analysis could not be made, since the data are too uncertain of effectivety of antibiotics, incidence of HPJI and of side effects of antibiotics. 6. For the same reason a cost/effectivety analysis was not possible. Even reliable data are missing about the prevalence of joint prosthesis patients. 7. There are increasing data about the relation between the oral and general health. Therefore good oral hygiene and regular dental controls is advised. 8. We could not conclude if the prophylactic use of oral Chlorhexidine prior to a dental procedure has any positive influence on HPJI incidence. Conclusions. the guideline states:. 1. there is no indication for antibiotic prophylaxis in dental procedures. 2. also not in case of decreased immunity. 3. patients should be advised to maintain good oral hygiene and have regular dental control

Background:. Antibiotic prophylaxis prior to dental and other procedures when patients have joint replacements in situ remains controversial. Recommendations seem to generally be intuitive and not based on any sound scientific evidence. Recently, the American Academy of Orthopaedic Surgeons altered their previous standpoint and suggested that orthopaedic surgeons review their current practice of routine prescription of antibiotic prophylaxis. Method:. We conducted an electronic survey of members of the South African Orthopaedic Association to determine the opinion of the average orthopaedic surgeon in South Africa in respect of this prophylaxis. 111 surgeons responded. Results:. 73% of respondents were of the opinion that patients with joint replacements in situ should take antibiotic prophylaxis prior to undergoing any dental procedure. 65% of surgeons were of the opinion that this prophylaxis should be life-long. 59% of surgeons recommended that prophylaxis start before the procedure, 24% at the same time as the procedure. 35% of surgeons recommended prophylaxis with every dental procedure, and 61% only with more invasive procedures. We also show that working in private practice and greater surgical experience increases the likelihood that surgeons will prescribe prophylactic antibiotics prior to dental procedures. Scientific evidence linking bacteraemia from dental procedures with infected prosthetic implants is limited, however 19% of surgeons reported managing an infected implant as a result of dental surgery. Conclusion:. We could find no evidence to substantiate the practice of using antibiotic prophylaxis prior to dental or any other procedures in those patients with joint replacements in situ. Practice in South Africa is at odds with world-wide trends and we would recommend that these patients do not use antibiotic prophylaxis prior to dental and other procedures, except possibly those that may be immune-compromised

Aim. As the populations of patients who have multiple prosthetic joints increase these years, the fate of a single joint periprosthetic joint infection in these patients is still unknown. Risk factors leading to a subsequent infection in another prosthetic joint are unclear. Our goal is to identify the risk factors of developing a subsequent infection in another prosthetic joint and describe the organism profile to the second prosthetic infection. Method. We performed a retrospective cohort study of all PJI cases underwent surgical intervention at our institute, a tertiary care referral center over 11 years, during January 2006 to December 2016. We identified 96 patients with periprosthetic joint infection who had another prosthetic joint in place at the time of presentation. The comorbidity, number of prosthetic joints, date and type of each arthroplasty, times of recurrent infection at each prosthetic joint with subsequent debridement or 2-stage resection arthroplasty, organisms from every infection episode, the outcome of each periprosthetic joint infection in these patients were analyzed. Results. During January 2006 to May 2017, we retrospective collected 294 PJI cases (159 hips, 135 knees) in our institute. Patients with single prosthetic joint were excluded and finally 96 patients were included. Of the 96 patients, 19 (19.79%) developed a periprosthetic joint infection in a second joint. The type of organism was the same as the first infection in 12 (63.16%) of 19 patients. The time to developing a second infection averaged 2.16 years (range, 0–9.3 years). The risk factors leading to a subsequent infection in another prosthetic joint are albumin level (< 3.5 mg/dl), long-term steroid usage (> 5mg/day, > 3 months), history of necrotizing fasciitis, history of invasive dental procedure (> Grade IV procedure), 3-stage resection arthroplasty or more, and PJI caused by vacomycin-resistent enterococcus (VRE). Conclusions. A PJI might predispose patients to subsequent PJI in another prosthesis. Patients and surgeons must be aware of the risk factors contribute to this devastating complication. Most organisms in the second PJI are identical to the first one, and we believe the bacteremia may be the pathogenesis, but need further proved. The preventive policy may be needed in the future for this population who has multiple prosthetic joints

Aim. The risk of haematogenic periprosthetic joint infection (PJI) after dental procedures is discussed controversially. To our knowledge, no study has evaluated infections according to the origin of infection based on the natural habitat of the bacteria. We investigated the frequency of positive monomicrobial cultures involving bacteria from oral cavity in patients with suspected PJI compared to bone and joint infections without joint prosthesis. Method. In this retrospective study we included all patients with suspected PJI or bone and joint infection without endoprosthesis, hospitalized at our orthopaedic clinic from January 2009 through March 2014. Excluded were patients with superficial surgical site infections or missing data. Demographic, clinical and microbiological data were collected using a standardized case report form. Groups were compared regarding infections caused by oral bacteria. χ2 test or Fisher's exact test was employed for categorical variables and t-test for continuous variables. Results. A total of 1673 patients were included, of whom 996 (60%) had a suspected PJI and 677 (40%) an osteoarticular infection without joint endoprosthesis (control group). In patients with suspected PJI the median age (standard deviation) was 67 (14) years; 407 (41%) were males. The anatomic location of the prosthesis was hip in 522 (52%) patients, knee in 437 (44%), megaprostheses in 14 (1%), shoulder in 8 (1%) and other endoprosthesis in 15 (2%) patients. In 437 (44%) of PJI cases pathogen(s) were detected, 271 (62%) were monomicrobial and 166 (38%) polymicrobial. Of 996 patients with suspected PJI, 2.4% (n = 24) had monomicrobial infections caused by bacteria belonging to the normal oral flora, predominantly oral streptococci (n = 21). In contrast, only 0.4% (n =3) of the control group without joint prosthesis had monomicrobial infections caused by oral bacteria. This difference was statistically significant (p = 0.002), whereas the patient age (p = 0.058) and the anatomic location of the joint prosthesis (p = 0.622) did not have any effect on the infections due to oral bacteria. Conclusions. The incidence of infections caused by oral bacteria was significantly higher in patients with endoprosthesis than in other osteoarticular infections (2.4% versus 0.4%). This finding indicates that joint prostheses are at risk of haematogenous PJI originating from oral cavity. Future prospective studies need to determine the exact risk of haematogenic PJI caused by oral bacteria, as well as the potential of preventing these infections by antibiotic prophylaxis

Introduction:. Infection as an indication for revision has increased to 12% of the total revisions (UK NJR 9. th. report). However, it is next to impossible to find out the cause for a delayed prosthetic infection. With increasing number of arthroplasty procedures, is there a need for prophylactic antibiotics in patients with prostheses?. Methods:. At London Knee Meeting 2012, a total of 163 surgeons were asked to take part in a survey. This was to find out if they knew of any existing guidelines for prophylaxis for dental procedures, if there was a need to practice more uniformly, and if they recommend such prophylaxis to their patients routinely. The grade of the surgeon and their experience in years was also noted. Results:. Among the 163 surgeons who participated, 102 (62.6%) were arthroplasty surgeons. Of these, 73 (71.5%) were consultants with 3 or more years of experience. For this study, responses from these 102 surgeons were taken into consideration. Out of the 102 surgeons, only 39 (38%) were aware of AAOS recommendations. However, only 26 (25.5%) felt the need for such prophylaxis, other 37 (36%) were not sure if such prophylaxis was necessary. The remaining 39 (38.5%) did not think the prophylaxis was necessary. There was no difference found in the responses between the consultant and non-consultant surgeons. Conclusions:. From this survey, it is clear that there is no uniformity of the knowledge of existing recommendations for prophylaxis of such patients with prostheses. There is probably a need to develop robust guidelines for prophylaxis, given the devastating nature of an infected prosthesis

Periprosthetic joint infection (PJI) complicates between 0.5% and 1.2% primary total hip arthroplasties (THAs) and may have devastating consequences. The traditional assessment of patients suffering from PJI has involved the serological study of inflammatory markers and microbiological analysis of samples obtained from the joint space. Treatment has involved debridement and revision arthroplasty performed in either one or two stages.

We present an update on the burden of PJI, strategies for its diagnosis and treatment, the challenge of resistant organisms and the need for definitive evidence to guide the treatment of PJI after THA.

Cite this article: Bone Joint J 2016;98-B(1 Suppl A):27–30.