New App: Using Appropriate Use Criteria to Determine Dental Procedure Antibiotics

Monday, March 6, 2017

R.L. Wynn

The American Academy of Orthopedic Surgeons (AAOS) has provided guidance on when it may be appropriate to consider antibiotic administration prior to dental procedures in patients with joint replacements.

The AAOS began developing Appropriate Use Criteria (AUC) in 2011 as a tool to implement evidence-based clinical practice guidelines. It enabled the clinician to decide on the appropriateness of various treatments in a set of hypothetical, clinically realistic patient scenarios. To date, a list of 13 orthopedic conditions has been generated for which Appropriate Use Criteria have been established.

Authored by Terry Stanton and Sheryl Cash, the latest report added “Management of patients with orthopedic implants undergoing dental procedures" to the list of conditions for which it has established AUC.

The AUC guidelines relative to the dental antibiotic prophylaxis issue were developed through a collaboration of orthopedic surgeons, dentists, oral surgeons, and epidemiologists. The authors note that, according to the guidelines, most patients are not at risk for infection following dental procedures and do not require antibiotic administration. However, antibiotic therapy should be considered for certain subsets of patients, primarily those with the following conditions:

  • Severely compromised immune systems related to AIDS/HIV
  • Uncontrolled diabetes
  • Chemotherapy
  • Recent history of joint infection
  • Taking certain drugs for rheumatoid arthritis or to prevent organ transplant complications

AAOS Access Page Statements

The access Web page elaborating on the “Management of patients with orthopedic implants in patients undergoing dental procedures” guidelines offers some general statements and several associated assumptions.

It states: “This AUC was developed as a decision support tool to facilitate the treatment of defined ‘high-risk’ and ‘immunocompromised’ patients who are on the more severe end of the clinical spectrum of disease. In the absence of readily available laboratory data of suggestive clinical suspicion, it would be reasonable to assume that most patients will fall outside of this criteria and therefore lie outside the confines of our strict definitions. As always, sound judgment should guide clinical decisions about when it may be necessary or prudent to delay a dental procedure until more information is available.”

Several assumptions follow:

  1. Virtually all dental procedures have the potential to cause bacteremia.
  2. Oral bacteremia frequently occurs secondary to activities of daily living, such as tooth brushing and eating.
  3. The chance of oral bacteremia being related to joint infections is extremely low, with no evidence for an association.

AAOS Introduces an AUC APP

The AAOS has released an AUC app, available through the AAOS OrthoGuidelines website. Scroll to bottom to click “I have read and understand the assumptions and disclaimer,” and this will then open the AUC app.

The app uses input from the dental professional to gauge risk related to the overall health of the patient, the timing since joint replacement, and the type of dental procedure to be performed. The app has 64 scenarios, each having an antibiotic “appropriateness rating” from 1 to 9, as determined by the 14-member voting panel of orthopedic surgeons, oral surgeons, dentists and epidemiologists. A rating of 1 to 3 indicates that antibiotic use is “rarely appropriate,” whereas 4 to 6 means antibiotics “may be appropriate,” and a rating between 7 and 9 means that antibiotic use is “appropriate for the indication provided and is likely to improve health outcomes or survival.”

The app provides the following fields and criteria:

  • Planned dental procedure
    • Dental procedures that do not result in the manipulation of periapical tissues or perforation of the oral mucosa
    • Dental procedures that involve manipulation of periapical tissues or perforation of the oral mucosa
  • Immunocompromised status
    • Not severely immunocompromised
    • Severely immunocompromised
  • Diabetic glycemic control
    • No current or active diabetes diagnosis
    • Active known diabetic with hemoglobin A1C < 8 or blood glucose < 200
    • Active known diabetic with hemoglobin A1C > 8 or blood glucose > 200
    • Active known diabetic with hemoglobin A1C unknown, blood glucose unknown
  • History of periprosthetic or deep prosthetic joint infection that required an operation
    • No history of periprosthetic or deep prosthetic infection that required an operation
    • History of periprosthetic or deep prosthetic infection that required an operation that required operation
  • Timing since joint replacement procedure
    • Less than 1 year
    • 1 year or longer

Example patient scenario

The following is a scenario using the AUC app:

  • Planned dental procedure: Select “Dental procedures that involve manipulation of periapical tissues or perforation of the oral mucosa”
  • Immunocompromised status: Select: “Severely immunocompromised”
  • Diabetic glycemic control: Select: “Active known diabetic, hemoglobin A1C < 8 or blood glucose < 200
  • History of periprosthetic or deep prosthetic joint infection that required an operation: Select: “No history of periprosthetic or deep prosthetic infection that required an operation”
  • Timing since joint replacement procedure: Select “1 year or longer”

After clicking “Submit,” the app generates the following procedure recommendations: “May be appropriate to prescribe prophylactic antibiotics — Level 6.”

From the result, you can link to a statement describing information on the antibiotic dosage recommendations.

With another click on the disclaimer bar at the bottom, the user is led to the “indication profile,” which generates procedure recommendations based on additional responses to the following fields:

  • Is the patient is allergic to penicillin or ampicillin or not?
  • Is the patient able or unable to take oral medication?
  • Is the patient an adult or child?

For example, with an adult patient able to take oral medication and not allergic to penicillin, the procedure recommendations are to take 2g amoxicillin. If he is allergic to penicillin and ampicillin, then the procedure recommendations list 2g cephalexin or 500 mg of azithromycin or clarithromycin, in that order.

The specific antibiotic and antibiotic dosage recommendations are provided as an additional resource and based on the antibiotic regimens from the American Heart Association in 2007 (Circulation 2007; 116:1736-1754). One adjustment from the American Heart Association original 2007 statement is the removal of clindamycin as an antibiotic option. According to the orthopedic document, the change was based on recently published evidence. Thus, optional antibiotics in penicillin-allergic patients lists cephalexin, in lieu of clindamycin, then azithromycin followed by clarithromycin.

According to the AAOS, cross-reactivity of the cephalosporin antibiotics in patients with penicillin allergy is 5% for first generation drugs and 1% for third generation drugs. These drugs should be used, unless there is a history of anaphylaxis with penicillin administration. If there is concern, the patient should be referred for allergy testing prior to administering antibiotic.

Richard L. Wynn, BS Pharm, PhD, is professor of pharmacology at the Baltimore College of Dental Surgery, Dental School, University of Maryland Baltimore.

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