Published 1/1/2013

Online Extra: The AAOS/ADA CPG on Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

An interview with David S. Jevsevar, MD, MBA

During the review process for the new clinical practice guideline (CPG), David S. Jevsevar, MD, MBA, chair of the AAOS Evidence-Based Practice Committee, took some time to talk with AAOS Now about the history of the guideline, the involvement of the American Dental Association (ADA), the improvements in wording, and the new supplemental tools.

AAOS Now: Can you provide some background information on the development of this joint CPG?

Dr. Jevsevar: Initially, the AAOS had its own statement on whether patients with orthopaedic implants who were undergoing dental procedures needed antibiotic prophylaxis and the ADA had a separate statement. In 2002, the two organizations made a joint statement, but in 2009, the AAOS changed its position and made a different statement. The idea of this CPG was to develop an all-inclusive guideline for the AAOS, the ADA, and the Infectious Disease Society of America that could represent what the literature says today.

AAOS Now: What position have orthopaedic surgeons generally taken on antibiotic prophylaxis prior to dental procedures in patients with orthopaedic implants?

Dr. Jevsevar: In the past, most orthopaedic surgeons have advocated for the use of antibiotic prophylaxis prior to dental procedures. When patients have an orthopaedic implant infection, it’s a terrible, horrendous situation for the patient, and the surgeon has a very emotional response because he or she understands what the patient’s going to go through for the next number of months or years. It’s a tough process to get through; it’s hardest on the patient, but it is also hard on the surgeon.

AAOS Now: Do you anticipate that this guideline will change that position significantly?

Dr. Jevsevar: The guideline says that you don’t have to do it, and I think a number of orthopaedic surgeons will look at this and say that’s good. I hope that orthopaedic surgeons have a discussion with the patient, looking at the patient’s specific risks for having an infection, and make a decision based on what that patient’s unique risks are.

We developed a shared decision-making template that goes along with the guideline. It doesn’t necessarily have to be used as it’s written, but the idea is that with patients, you discuss the risks, their potential needs—maybe they’re immunosuppressed, maybe they have other issues that put them at a higher risk—and to go through that discussion with them and to make a decision with them. That will include the physician, dental provider, and the patient.

AAOS Now: This guideline uses substantially different wording in indicating the strength of a recommendation and it has some new features, such as the “implications” for practitioners. Why were these changes made?

Dr. Jevsevar: One of the aspects of the CPG process that we have found to be wanting is how to apply them in practice. We added implications within the body of the CPG so that people could understand it.

AAOS Now: What impact did the ADA participants have on the development of this guideline?

Dr. Jevsevar: The workgroup was cochaired by an AAOS member, William C. Watters III, MD, and an ADA member, Michael P. Rethman, DDS, MS. The ADA workgroup members were well versed in evidence-based medicine, so they had a strong impact. Dr. Rethman wrote the executive summary, which everyone approved. I wrote the shared decision-making tool with significant involvement from the ADA and all the societies that reviewed it. Overall, the process was about as collaborative as it could be.

AAOS Now: In all cases, the workgroup says “patient preference should have a substantial influencing role.” Can you expand on that a bit?

Dr. Jevsevar: In recent years, the emphasis has been on patient-centered care. Patients need to be involved in the decision-making process. The problem in giving antibiotics is multifold. We increase bacterial resistance to antibiotics by giving them all the time. A certain number of patients have a potentially life-threatening reaction to the use of antibiotics, even if they’ve taken them in the past. Certain medical conditions are associated with the use of prophylactic antibiotics, such as toxic megacolon or C difficile diarrhea.

The point of patient-centered care is that the physician discusses both the risks and the benefits of giving antibiotics, saying that the current literature doesn’t necessarily support the use of prophylactic antibiotics. Then, the dental and orthopaedic providers and the patient can make a decision that works for that particular patient.

AAOS Now: Was the workgroup comfortable issuing a guideline based on a single study?

Dr. Jevsevar: We reviewed a lot of literature; unfortunately, most of it didn’t meet the bar for inclusion in the study criteria. By including only the best studies, in some cases, one really good study is enough. We like to see multiple good studies, but that rarely occurs.

What the limited recommendation means is that it could change, with time and new literature. When we have a really strong recommendation, what we’re saying is that it’s unlikely that any new literature will come along to change this recommendation.

AAOS Now: Realizing that most fellows won’t read all 322 pages of the guideline, which sections do you think are most important for AAOS members to read and understand?

Dr. Jevsevar: I think this is where the Journal of the AAOS will do us a really good service. If you just read the editorial and the executive summary, you get most of what you need to understand how the recommendations were developed. Some of the graphics associated with the recommendations are very telling as to how this information was evaluated and why it’s so difficult at times to look at the information that’s out there.

AAOS Now: Where is the research lacking, and where should future research be directed?

Dr. Jevsevar: We need a long duration, longitudinal outcome study that follows total joint replacement patients over time and looks at the infection rate in patients who have antibiotic prophylaxis and those who do not, or even just a longitudinal study to look at patients without antibiotic prophylaxis to see if it made a difference. We know that certain kinds of dental work put bacteria into the bloodstream, but we can’t find direct evidence that it then leads to orthopaedic implant infection.

We really need to work to develop and improve our clinical research database. We understand that not everything we do can be a level 1 or level 2 study, but any type of prospective research is beneficial and can be used in the guideline process. It doesn’t have to be a randomized controlled trial, but any type of prospective research is beneficial and helpful in the process.