Reply to Comment in Hong Kong Med J. 2010 Aug;16(4):320published_or_final_versio

Chiu, PKY

Kuong, EE

Hong Kong Medical Journal

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Title Antibiotic prophylaxis after total joint replacements (Authors'reply to Letters to the Editor)Author(s) Kuong, EE; Chiu, PKYCitation Hong Kong Medical Journal, 2010, v. 16 n. 4, p. 321Issued Date 2010URL http://hdl.handle.net/10722/139568Rights Creative Commons: Attribution 3.0 Hong Kong License320	 Hong	Kong	Med	J		Vol	16	No	4	#	August	2010	#		www.hkmj.orgTo the Editor—In a recent edition of this journal, Kuong et al1 advocated adherence to the new American Association of Orthopaedic Surgeons recommendations that all patients irrespective of underlying medical conditions, or length of time a prosthetic joint has been in place, require prophylactic antibiotic coverage when having invasive dental treatment. The authors in their review of the literature noted that 6 to 11% of all cases of infected prosthetic joints are attributable to dental procedures and then noted that the offending microorganisms were mainly viridians streptococci, Gemella spp, Peptostreptococcus spp, Neisseria spp, Actinomyces spp, Prevotella ssp, and other anaerobes. This construct unfortunately does not take into account that staphylococci from the oral cavity also contribute to late joint infections. Staphylococci may initially arise from the skin, nasal tract, or gastro-intestinal tract, but they then often migrate and transiently reside in the oral cavity with adherence mechanisms permitting a portion of them to be retained in the periodontal pocket. Furthermore, because of micro-ulceration of the gingival sulcular and pocket lining epithelium and proximity to the bloodstream, staphylococcal bacteraemias are quite possible as is the resultant staphylococcal infection of a prosthetic joint. Specifically, older (≥70 years), healthy, non–denture-wearing individuals have been shown to have a higher isolation frequency (P<0.05) and a higher proportion (P=0.056) with staphylococci in their unstimulated whole saliva than younger persons.2 The wearing of partial dentures increases the proportion of staphylococci in the saliva of older individuals.3 Among individuals (mean age, 59 years) with rheumatoid arthritis (RA) and concomitant xerostomia who require long-term immunosuppressive steroid therapy, there is also a high prevalence with Staphylococcus aureus on the tongue and in the oropharynx.4 Thus, the elderly and those with RA—the two groups of individuals who very frequently require joint replacement—often harbour staphylococci in their oral cavity. Furthermore, in individuals with signs of chronic or acute dental infections, the presence of staphylococcal species is even more significant. Specifically, young (age range, 32-59; mean, 45 years) healthy individuals with periodontitis evidence, harbour both S aureus and Staphylococcus epidermidis in their subgingival sulci.5 Studies using molecular technology indicate that the virulence factors (FgBP genes) associated with S aureus and S epidermidis are present in some aseptically opened pulp chambers of non-vital teeth having neither coronal leakage around restoration margins nor sinus tracts.6 The above noted citations lead me to conclude that the research results cited by Kuong et al1 to define oral/dental flora possibly involving prosthetic joint infections were too restrictive. The information that I have cited from the literature further supports Kuong et al’s contention that patients with prosthetic joints having invasive dental treatment require prophylactic antibiotic coverage.AH Friedlander, DMDEmail: arthur.friedlander@med.va.govOral and Maxillofacial Surgery, UCLA Dental SchoolQuality Assurance, Hospital Dental Service, UCLA Medical CenterVA Greater Los Angeles Healthcare System11301 Wilshire Blvd.Los Angeles, CA 90073United StatesAntibiotic prophylaxis after total joint replacementL E T T E R S  T OT H E  E D I T O RReferences1. Kuong EE, Ng FY, Yan CH, Fang CX, Chiu PK. Antibiotic prophylaxis after total joint replacements. Hong Kong Med J 2009;15:458-62.2. Percival RS, Challacombe SJ, Marsh PD. Age-related microbiological changes in the salivary and plaque miroflora of healthy adults. J Med Microbiol 1991;35:5-11.3. Marsh PD, Percival RS, Challacombe SJ. The influence of denture-wearing and age on the oral microflora. J Dent Res 1992;71:1374-81.4. Jacobson JJ, Patel B, Asher G, Woolliscroft JO, Schaberg D. Oral staphylococcus in older subjects with rheumatoid arthritis. J Am Geriatr Soc 1997;45:590-3.5. Murdoch FE, Sammons RL, Chapple IL. Isolation and characterization of subgingival staphylococci from periodontitis patients and controls. Oral Dis 2004;10:155-62.6. Bate AL, Ma JK, Pitt Ford TR. Detection of bacterial virulence genes associated with infective endocarditis in infected root canals. Int Endod J 2000;33:194-203.	 Hong	Kong	Med	J		Vol	16	No	4	#	August	2010	#		www.hkmj.org	 321Authors’ replyTo the Editor—We thank Professor Friedlander for his further insight into the bacteriology of patients with dental conditions and the recognition that after joint replacement surgery, antibiotic cover is imperative for all patients. Indeed, over half of infected joint replacements are due to staphylococci, while streptococci fall a distant second causing only 6% of the infected cases.1 The data quoted from our literature search suggesting that infected prostheses after invasive dental procedures are mainly due to viridans streptococci and other oral flora, come from blood cultures following dental work in general.2 Elderly patients wearing dentures, rheumatoid arthritic patients on long-term immunosuppressive therapy, and patients with known periodontitis fall into the ‘high-risk’ category as advocated by the American Dental Association.3 As suggested in our paper, extra caution should be exercised in prescribing prophylactic antibiotics for this subset of patients. On the other hand, surgeons should not be lulled into a false sense of security in patients who are seemingly dentally ‘fit’ as it is also recognised that routine daily activities such as toothbrushing and even chewing may produce greater degrees of bacteraemia than dental procedures.2 To reiterate our conclusion, clinical judgement tailor-made to each individual is paramount in safeguarding prosthetic joints in our patients. Evelyn E Kuong, MB, BS, MRCSEmail: eekuong@gmail.comPeter KY Chiu, FRCS, FHKCOSDepartment of Orthopaedics and TraumatologyQueen Mary HospitalPokfulam Hong KongReferences1. Steckelberg JM, Osmon DR. Prosthetic joint infections. In: Bisno AL, Waldvogel FA, editors. Infections associated with indwelling medical devices. 3rd ed. Washington DC: American Society of Microbiology Press; 2000: 173-209.2. Uçkay I, Pittet D, Bernard L, Lew D, Perrier A, Peter R. Antibiotic prophylaxis before invasive dental procedures in patients with arthroplasties of the hip and knee. J Bone Joint Surg Br 2008;90:833-8.3. Advisory statement. Antibiotic prophylaxis for dental patients with total joint replacements. American Dental Association; American Academy of Orthopaedic Surgeons. J Am Dent Assoc 1997;128:1004-8.

Antibiotic prophylaxis after total joint replacements (Authors' reply to Letters to the Editor)

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Antibiotic prophylaxis after total joint replacements (Authors' reply to Letters to the Editor)

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