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Da Book

Standard Operating Procedures and Notes for the Shoulder Team

 

Joint Replacement Prophylaxis Standard Operating Procedure (SOP)

 

 

 

All patients who receive and arthroplasty from the Shoulder and Elbow team are advised to take antibiotics prior to any procedure that may cause bacteremia.  These procedures include dental work, sigmoidoscopy, proctoscopy, cystoscopy, or pretty much any procedure with the respiratory, digestive or urinary tract.

 

Patients should not have any procedures that may cause bacteremia for 2 weeks prior and 3 months post any arthroplasty surgery.

 

Dental Procedures

Members of the Arthritis Team (Shoulder, Elbow, Hip and Knees) should feel free to prescribe prophylactic antibiotics for joint replacement patients prior to a dental procedure.  For dental procedures we follow the ADA and AAOS recommendations for antibiotics but extend use of them for life (as opposed to two years following arthroplasty and for high risk patients).

 

Respiratory, Digestive and Urinary Tract procedures

Since some of the choices for antibiotic include vancomycin and/or gentamicin, we reserve prescribing of these antibiotics to the surgeon doing the procedure - so that they can work up and follow the patient.  If there are questions as what antibiotic course to take, we can give information about the AHA's recommendations for endocarditis prophylaxis and the AAOS' recommendations listed/linked below.  It is also important to note that we consider all of our patients at high risk and recommend treatment for life, compared to the common practice of only provide prophylactic treatment for two years following arthroplasty surgery.

 

Patient Handout

 

Dental Antibiotic Prophylaxis as per the ADA recommendations:

 

J Am Dent Assoc, Vol 134, No 7, 895-898.

Antibiotic prophylaxis for dental patients with total joint replacements

American Dental Association; American Academy of Orthopedic Surgeons.
 

 

AHA Procedures for which endocarditis prophylaxis is recommended

Respiratory tract

  • Tonsillectomy and/or adenoidectomy

  • Surgical operations that involve respiratory mucosa

  • Bronchoscopy with a rigid bronchoscope
     

Gastrointestinal tract

  • Sclerotherapy for esophageal varices

  • Esophageal stricture dilation
    Endoscopic retrograde cholangiography with biliary obstruction

  • Biliary tract surgery

  • Surgical operations that involve intestinal mucosa
     

Genitourinary tract

  • Prostatic surgery

  • Cystoscopy

  • Urethral dilation

 

 

Prophylactic Regimens for Dental, Oral, Respiratory Tract, or Esophageal Procedures. (Follow-up dose no longer recommended.) Total children’s dose should not exceed adult dose.

I. Standard general prophylaxis for patients at risk:

Amoxicillin: Adults, 2.0 g (children, 50 mg/kg) given orally one hour before procedure.

 

II. Unable to take oral medications:

Ampicillin: Adults, 2.0 g (children 50 mg/kg) given IM or IV within 30 minutes before procedure.
 

III. Amoxicillin/ampicillin/penicillin allergic patients:

Clindamycin: Adults, 600 mg (children 20 mg/kg) given orally one hour before procedure. -OR-
Cephalexin* or Cefadroxil*: Adults, 2.0 g (children 50 mg/kg) orally one hour before procedure. -OR-
Azithromycin or Clarithromycin: Adults, 500 mg (children 15 mg/kg) orally one hour before procedure.

 

IV. Amoxicillin/ampicillin/penicillin allergic patients unable to take oral medications:

Clindamycin: Adults, 600 mg (children 20 mg/kg) IV within 30 minutes before procedure. -OR-
Cefazolin*: Adults, 1.0 g (children 25 mg/kg) IM or IV within 30 minutes before procedure.
 

*Cephalosporins should not be used in patients with immediate-type hypersensitivity reaction to penicillins.

 

 

Prophylactic Regimens for Genitourinary/Gastrointestinal Procedures: (Joint Replacement Patients should be considered High Risk for our purposes)

I. High-risk patients:

Ampicillin plus gentamicin: Ampicillin (adults, 2.0 g; children 50 mg/kg) plus gentamicin 1.5 mg/kg (for both adults and children, not to exceed 120 mg) IM or IV within 30 minutes before starting procedure. 6 hours later, ampicillin (adults, 1.0 g; children, 25 mg/kg) IM or IV, or amoxicillin (adults, 1.0 g; children, 25 mg/kg) orally.

 

II. High-risk patients allergic to ampicillin/amoxicillin:

Vancomycin plus gentamicin: Vancomycin (adults, 1.0 g; children, 20 mg/kg) IV over 1–2 hours plus gentamicin 1.5 mg/kg (for both adults and children, not to exceed 120 mg) IM or IV. Complete injection/infusion within 30 minutes before starting procedure.

 

III. Moderate-risk patients:

Amoxicillin: Adults, 2.0 g (children 50 mg/kg) orally one hour before procedure -OR-
Ampicillin: Adults, 2.0 g (children 50 mg/kg) IM or IV within 30 minutes before starting procedure.
 

IV. Moderate-risk patients allergic to ampicillin/amoxicillin:

Vancomycin: Adults, 1.0 g (children 20 mg/kg) IV over 1–2 hours. Complete infusion within 30 minutes of starting the procedure.

 

 

JAMA. 1997 Jun 11;277(22):1794-801

Prevention of bacterial endocarditis. Recommendations by the American Heart Association.

Dajani AS, Taubert KA, Wilson W, Bolger AF, Bayer A, Ferrieri P, Gewitz MH, Shulman ST, Nouri S, Newburger JW, Hutto C, Pallasch TJ, Gage TW, Levison ME, Peter G, Zuccaro G Jr.
 

 

 

AAOS Antibiotic Prophylaxis for Urological Patients with Total Joint Replacements 2002

Risk Stratification of Bacteremic Urologic Procedures

Higher Risk*

  • Any stone manipulation (includes shock wave lithotripsy)
  • Any procedure with transmural incision into urinary tract (does not include simple ligation with excision or percutaneous drainage procedure)
  • Any endoscopic procedures of upper tract (ureter and kidney)
  • Any procedure that includes bowel segments
  • Transrectal prostate biopsy
  • Any procedure with entry into the urinary tract (except for transurethral catheterization) in individuals with higher risk of bacterial colonization:
    • Indwelling catheter or intermittent catheterization
    • Indwelling ureteral stent
    • Urinary retention
    • History of recent / recurrent urinary tract infection or prostatitis
    • Urinary diversion

 

Lower Risk**

  • Endoscopic procedures into urethra and bladder without stone manipulation or incision (includes fulguration and mucosal biopsy, if no incision)
  • Open surgical or laparoscopic procedures without stone manipulation or incision into the urinary tract
  • Catheterization for drainage or diagnostic instrumentation, including both transurethral and percutaneous access

* Prophylaxis for higher risk patients should be considered for patients with total joint replacement that meet the criteria in Table 1. No other patients should be considered for antibiotic prophylaxis prior to urologic procedures on the basis of the orthopaedic implant alone, although antibiotics still may be indicated for prophylaxis against urinary tract or other infections.

** Prophylaxis for lower risk patients not indicated on the basis of the orthopaedic implant alone, although antibiotics still may be indicated for prophylaxis against urinary tract or other infections.

Suggested Antibiotic Prophylaxis Regimens

A prophylactic antibiotic is chosen on the basis of its activity against endogenous flora likely to be encountered, its toxicity, and its cost. In order to prevent bacteriuria, an appropriate dose of a prophylactic antibiotic should be given preoperatively so that effective tissue concentration is present at the time of instrumentation or incision.

  • Recommended agents include
  • A single systemic level dose of a quinolone (e.g., ciprofloxacin, 500 mg; levofloxacin, 500 mg; ofloxacin, 400 mg) orally one to two hours preoperatively.
  • Ampicillin 2 gm IV (or Vancomycin 1 gm IV over 1 to 2 hours, in patients allergic to ampicillin) plus Gentamicin 1.5 mg/kg IV 30 to 60 minutes preoperatively.9
  • For some procedures, additional or alternative agents may be considered for prophylaxis against specific organisms.

 

Also see AAOS Antibiotic Prophylaxis for Dental Patients with Total Joint Replacements

 

 

  1. Bartzokas CA, Johnson R, Jane M, Martin MV, Pearce PK, Saw Y: Relation between mouth and haematogenous infections in total joint replacement. BMJ 1994;309:506-508.
  2. Bender IB, Naidorf IJ, Garvey GJ: Bacterial endocarditis: A consideration for physicians and dentists. J Amer Dent Assoc 1984;109:415-420.
  3. Berbari EF, Hanssen AD, Duffy MC, Ilstrup DM, Harmsen WS, Osmon DR: Risk factors for prosthetic joint infection: case-control study. Clin Infectious Dis 1998; 27:1247-1254.
  4. Brause BD: Infections associated with prosthetic joints. Clin Rheum Dis 1986;12:523-536.
  5. Ching DW, Gould IM, Rennie JA, Gibson PH: Prevention of late haematogenous infection in major prosthetic joints. J Antimicrob Chemother 1989;23:676-680.
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  7. Christiano AP, Hollowell CMP, Kim H, Kim J, Patel R, Bales GT, Gerber GS: Double-blind randomized comparison of single-dose ciprofloxacin versus intravenous cefazolin in patients undergoing outpatient endourologic surgery. Urology 2000; 55: 182-185.
  8. Cundiff GW, McLennan, MT, Bent, AE: Randomized trial of antibiotic prophylaxis for combined urodynamics and cystourethroscopy. Obstetrics & Gynecology 1999; 93: 749-752.
  9. Dajani AS. Taubert KA. Wilson W. Bolger AF. Bayer A. Ferrieri P. Gewitz MH. Shulman ST. Nouri S. Newburger JW. Hutto C. Pallasch TJ. Gage TW. Levison ME. Peter G. Zuccaro G Jr. Prevention of bacterial endocarditis. Recommendations by the American Heart Association. JAMA. 1997; 277:1794-1801.
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  13. Hanssen AD, Osmon DR, Nelson CL: Prevention of deep prosthetic joint infection. J Bone Joint Surg 1996;78-A(3):458-471.
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  15. Jacobson JJ, Patel B, Asher G, Wooliscroft JO, Schaberg D: Oral Staphyloccus in elderly subjects with rheumatiod arthritis. J Amer Geriatr Soc 1997;45:1-5.
  16. Johnson DP, Bannister GG: The outcome of infected arthroplasty of the knee. J Bone Joint Surg 1986;688:289-291.
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  20. Murray RP, Bourne WH, Fitzgerald RH: Metachronus infection in patients who have had more than one total joint arthroplasty. J Bone Joint Surg 1991;73-A:1469-1474.
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  22. Olson E, Cookson B: Do antimicrobials have a role in preventing septicaemia following instrumentation of the urinary tract? Journal of Hospital Infection 2000: 85-97.
  23. Pallasch TJ, Slots J: Antibiotic prophylaxis and the medically compromised patient. Periodontology 2000 1996;10:107-138
  24. Pearle MS and Roehrborn CG: Antimicrobial prophylaxis prior to shock wave lithotripsy in patients with sterile urine before treatment: a meta-analysis and cost-effectiveness analysis. Urology 1997; 49: 679-686.
  25. Poss R, Thornhill TS, Ewald FC, Thomas WH, Batte NJ, Sledge CB: Factors influencing the incidence and outcome of infection following total joint arthroplasty. Clin Orthop 1984;182:117-126.
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  27. Scholz M, Luftenegger W, Harmuth H, Wolf D and Holtl W: Single-dose antibiotic prophylaxis in transurethral resection of the prostate: a prospective randomized trial. Br. J. Urology 1998; 81: 827-829.
  28. Terris MK: Recommendations for prophylactic antibiotic use in genitourinary surgery. Contemporary Urology Sept 2001; 12-27.
  29. Pallasch TJ, Slots J: Antibiotic prophylaxis and the medically compromised patient. Periodontology 2000 1996;10:107-138
  30. Rubin R, Salvati EA, Lewis R: Infected total hip replacement after dental procedures. Oral Surg. 1976;41:13-23.
  31. Hanssen AD, Osmon DR, Nelson CL: Prevention of deep prosthetic joint infection. J Bone Joint Surg 1996;78-A(3):458-471.
  32. Bender IB, Naidorf IJ, Garvey GJ: Bacterial endocarditis: A consideration for physicians and dentists. J Amer Dent Assoc 1984;109:415-420.
  33. Everett ED, Hirschmann JV: Transient bacteremia and endocarditis prophylaxis: A review. Medicine 1977; 56:61-77.
  34. Guntheroth WG: How important are dental procedures as a cause of infective endocarditis? Amer J Cardiol 1984;54:797-801.
  35. Jacobson JJ, Schweitzer SO, DePorter DJ, Lee JJ: Antibiotic prophylaxis for dental patients with joint prostheses? A decision analysis. Int J Technol Assess Health Care 1990;6:569-587.
  36. Tsevat J, Durand-Zaleski I, Pauker SG: Cost-effectiveness of antibiotic prophylaxis for dental procedures in patients with artificial joints. Amer J Pub Health 1989;79:739-743.
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  39. Bartzokas CA, Johnson R, Jane M, Martin MV, Pearce PK, Saw Y: Relation between mouth and haematogenous infections in total joint replacement. BMJ 1994;309:506-508.
  40. Ching DW, Gould IM, Rennie JA, Gibson PH: Prevention of late haematogenous infection in major prosthetic joints. J Antimicrob Chemother 1989;23:676-680.
  41. Council on Dental Therapeutics. Management of dental patients with prosthetic joints. J Amer Dent Assoc 1990;121:537-538.
  42. Eskinazi D, Rathburn W: Is systematic antimicrobial prophylaxis justified in dental patients with prosthetic joints? Oral Surg Oral Med Oral Pathol 1988;66:430-431.
  43. Cawson RA: Antibiotic prophylaxis for dental treatment: For hearts but not for prosthetic joints. Br Dent J 1992;304:933-934.
  44. Brause BD: Infections associated with prosthetic joints. Clin Rheum Dis 1986;12:523-536.
  45. Murray RP, Bourne WH, Fitzgerald RH: Metachronus infection in patients who have had more than one total joint arthroplasty. J Bone Joint Surg 1991;73-A:1469-1474.
  46. Poss R, Thornhill TS, Ewald FC, Thomas WH, Batte NJ, Sledge CB: Factors influencing the incidence and outcome of infection following total joint arthroplasty. Clin Orthop 1984;182:117-126.
  47. Jacobson JJ, Millard HD, Plezia R, Blankenship JR: Dental treatment and late prosthetic joint infections. Oral Surg Oral Med Oral Pathol 1986; 61:413-417.
  48. Johnson DP, Bannister GG: The outcome of infected arthroplasty of the knee. J Bone Joint Surg 1986;688:289-291.
  49. Jacobson JJ, Patel B, Asher G, Wooliscroft JO, Schaberg D: Oral Staphyloccus in elderly subjects with rheumatiod arthritis. J Amer Geriatr Soc 1997;45:1-5.
  50. Berbari EF, Hanssen AD, Duffy MC, Ilstrup DM, Harmsen WS, Osmon DR: Risk factors for prosthetic joint infection: case-control study. Clin Infectious Dis 1998; 27:1247-1254.
  51. Dajani AS, Taubert KA, Wilson W, Bolger AF, Bayer A, Ferrieri P, Gewitz MH, Shulman ST, Nouri S, Newburger JW, Hutto C, Pallasch TJ, Gage TW, Levison ME, Peter G, Zuccaro G: Prevention of bacterial endocarditis: Recommendations by the American Heart Association. From the Committee on Rheumatic Fever, Endocarditis and Kawasaki Disease, Council on Cardiovascular Disease in the Young. JAMA 1997;277:1974-1801.