Which Is Single High Dose Gentamicin For Orthopedic Surgery
Single high dose gentamicin for perioperative prophylaxis in orthopedic surgery: Evaluation of nephrotoxicity Yanina Dubrovskaya,1Rainer Tejada,2Joseph Bosco, III,3Anna Stachel,2Donald Chen,2Melinda Feng,2Andrew Rosenberg,4and Michael Phillips2,5 Yanina Dubrovskaya 1Department of Pharmacy, NYU Langone Medical Center, New York, NY, USA
Antibiotic Prophylaxis Protocol After Total Joint Replacement
The following precautions should be taken for AT LEAST TWO YEARS after total joint replacement to reduce the risk of infection around the implant. Patients at increased risk of infection should use antibiotic prophylaxis for the rest of their lifetime. These conditions include, and are not limited to:
Antibiotic prophylaxis is needed for the following procedures:
- If you are not allergic to penicillin, take 2grams of Amoxicillin by mouth one hour prior to your procedure
- You are allergic to penicillin, take 600mg of Clindamycin by mouth one hour prior to your procedure
Please try to avoid scheduling any elective dental procedure for at 3 months following your joint replacement
Extending The Life Of Your Knee Implant
Currently, more than 90% of modern total knee replacements are still functioning well 15 years after the surgery. Following your orthopaedic surgeon’s instructions after surgery and taking care to protect your knee replacement and your general health are important ways you can contribute to the final success of your surgery.
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Stop Premedicating Ada Review Examines Treatment Of Patients With Prosthetic Joints
We have faced this issue in practice too many times to count. Your patient has a hip or knee replacement, and the orthopedic surgeon recommends antibiotic premedication for life. Previous recommendations from the American Heart Association had been to premedicate for a short period of time. Those guidelines were later updated. The dentist you work for follows a practice of premedicating the patient for two years. Another dentist premedicates patients with prosthetic joints for six months only. Patients forget to take their antibiotics prior to their dental hygiene appointment and then you are left with the conundrum of having the patient take a dose five minutes prior to the appointment, not taking the medicine at all, or taking the antibiotic after the appointment.
All of these situations were made worse when, in 2012, a panel of experts representing the American Academy of Orthopaedic Surgeons and the American Dental Association published a systematic review and clinical practice guidelines that offered no clear recommendations at all. In fact, their report generated more questions than ever even though the report clearly showed no evidence supporting the need for prophylactic antibiotics following joint replacement.
How Your New Knee Is Different
Improvement of knee motion is a goal of total knee replacement, but restoration of full motion is uncommon. The motion of your knee replacement after surgery can be predicted by the range of motion you have in your knee before surgery. Most patients can expect to be able to almost fully straighten the replaced knee and to bend the knee sufficiently to climb stairs and get in and out of a car. Kneeling is sometimes uncomfortable, but it is not harmful.
Most people feel some numbness in the skin around your incision. You also may feel some stiffness, particularly with excessive bending activities.
Most people also feel or hear some clicking of the metal and plastic with knee bending or walking. This is a normal. These differences often diminish with time and most patients find them to be tolerable when compared with the pain and limited function they experienced prior to surgery.
Your new knee may activate metal detectors required for security in airports and some buildings. Tell the security agent about your knee replacement if the alarm is activated.
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Ada And Orthopedic Society Antibiotic Recommendations
The American Dental Association is the professional society for dentists. The ADAs official recommendations are as follows: For patients with prosthetic joint implants, prophylactic antibiotics are not recommended prior to dental procedures to prevent prosthetic joint infection. They recommend abstaining from prophylactic antibiotics because they assert that there is no evidence that dental procedures are associated with PJIs. They also argue that there is no evidence to suggest that giving patients prophylactic antibiotics before dental procedures prevents PJIs. The ADA asserts that antibiotic resistance is a major concern, and the theoretical benefits are not enough to make up for this concern. However, they state that each patient should be considered individually, taking into account their personal risk factors.
American Academy of Orthopedic Surgeons
Just as the ADA is the professional society for American dentists, the AAOS is the professional society for orthopedic surgeons. They have released their own guidelines for surgeons when considering prophylactic antibiotics for dental procedures.
Signs And Symptoms Of Infection After Knee Surgery
For 3 to 6 months after knee replacement surgery, its normal to have mild swelling in your knee or ankle and some redness and warmth around the incision.
Its also normal for the incision to itch. If you cant walk without pain in the time frame you and your doctor talked about, make sure to follow up and tell them.
Tell your doctor if you have signs of an infection.
The signs and symptoms of a superficial infection include:
- increased redness, warmth, tenderness, swelling, or pain around the knee
- a fever higher than 100°F
- drainage from the incision after the first few days, which may be grayish and have a bad smell
Deep infections may not have the same symptoms as superficial ones. You should also watch out for:
- a recurrence of pain after your pain had stopped
- pain that gets worse over a month
Its normal to have some pain after knee surgery, but if it gets worse over time, this may be a sign of infection. Always talk to your doctor about knee pain.
Your doctor may be able to tell you have an infection if they see redness and drainage around the surgical incision. They may give you some tests to locate the infection or to learn the type of bacteria causing it.
These tests may include:
The best treatment for an infection after total knee replacement depends on the type of infection and its severity. Treatment is more complicated if the infection has been present for a long time.
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Dental Work And Joint Replacements
When orthopedic surgeons discuss joint replacements with their patients, they often discuss the patients dental history. While dentistry and joint replacements may seem like very different fields, an infection in one can cause an infection in the other. For that reason, orthopedic surgeons will often prescribe antibiotics for their patients with joint replacements who are undergoing dental procedures. There are multiple professional societies that help clinicians decide when to use antibiotics before dental procedures in patients who have joint replacements.
When Should I Premedicate For Dental Treatment
It now recommends premedication for patients with:
- artificial heart valves.
- a history of infective endocarditis, which is an infection of the lining inside the heart or heart valves.
- a heart transplant that developed a heart valve problem.
- certain types of congenital heart conditions.
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Antibiotic Prophylaxis In Dental Treatments After Joint Replacement Surgery New Updates
Orthopedic Surgeons and Dental surgeons mention that after having a knee replacement surgery it is important to not have any invasive dental treatments involving surgical procedures performed on the patient for a time period of 8-12 weeks. This is to make sure that no bacteria from the site of surgical procedure travels to the prosthetic knee and leads to infection of the knee. Even after the said time frame it is important for patients who have prosthetic knee implants to mention to their dentists about it, as it is recommended to get Antibiotic Prophylaxis before any dental procedures in patients with knee implants. Dental procedures like Dental Extraction, Dental Implant placement, Flap Surgery, Root canal treatment, etc.
Complications seen in Joint replacement patients is the hematogenous spread of bacteria to the replacement location leading to bacteremia due to tooth extraction. According to latest research, there is no direct spread of bacteria to the joint replacement but it appears to be Transient in nature. The prosthetic joint infection is caused due to chronic infections elsewhere in the body such as UTI, skin infections, pulmonary infections etc. Severe chronic Odontogenic infections are seen to cause prosthetic joint infections in certain patients.
Possible Complications Of Surgery
The complication rate following total knee replacement is low. Serious complications, such as a knee joint infection, occur in fewer than 2% of patients. Major medical complications such as heart attack or stroke occur even less frequently. Chronic illnesses may increase the potential for complications. Although uncommon, when these complications occur, they can prolong or limit full recovery.
Discuss your concerns thoroughly with your orthopaedic surgeon prior to surgery.
Infection. Infection may occur in the wound or deep around the prosthesis. It may happen within days or weeks of your surgery. It may even occur years later. Minor infections in the wound area are generally treated with antibiotics. Major or deep infections may require more surgery and removal of the prosthesis. Any infection in your body can spread to your joint replacement.
Blood clots. Blood clots in the leg veins are one of the most common complications of knee replacement surgery. These clots can be life-threatening if they break free and travel to your lungs. Your orthopaedic surgeon will outline a prevention program, which may include periodic elevation of your legs, lower leg exercises to increase circulation, support stockings, and medication to thin your blood.
Blood clots may form in one of the deep veins of the body. While blood clots can occur in any deep vein, they most commonly form in the veins of the pelvis, calf, or thigh.
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Exact Answer: Six To Eight Weeks
Deep Infection after Total Joint Replacement can be a significant, severe, and expensive consequence, needing a longer hospital stay, several surgical procedures, and long-term antibiotic usage in certain circumstances.
Bacteria that typically reside in the mouth or oral cavity are considered to be responsible for a tiny percentage of such infections. It is widely understood that oral germs enter the circulation during dental treatment or even aggressive tooth cleaning/flossing. These newly circulating bacteria can lodge themselves on the edge of a joint replacement implant, where they cling tightly to the metal and proliferate, potentially leading to an infection that is difficult for the body to remove.
Evaluation Of Appropriate Prophylaxis
In 2002, the Centers for Medicare and Medicaid Services and the CDCimplemented the National Surgical Infection Prevention Project .The goal of this project was to reduce postoperative morbidity andmortality through appropriate selection of antimicrobials, appropriatetiming of prophylactic doses, and proper discontinuation ofantimicrobials.25 In accordance with national guidelines, thethree performance measures included use of cefazolin or cefuroximeunless the patient had a documented severe allergy or the risk of MRSAwas high a preoperative antimicrobial dose given within 1 hour prior toincision and discontinuation of antimicrobial prophylaxis within 24hours.25 A baseline sample of Medicare patients assessed in2003 showed that the majority of antimicrobials used were consistentwith the guidelines , but only 59.7%% of orthopedic patientsreceived their antibiotic within 60 minutes of surgery and only 36.7% ofantibiotics were discontinued within 24 hours.25
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Recognizing The Signs Of A Blood Clot
Follow your orthopaedic surgeon’s instructions carefully to reduce the risk of blood clots developing during the first several weeks of your recovery. He or she may recommend that you continue taking the blood thinning medication you started in the hospital. Notify your doctor immediately if you develop any of the following warning signs.
Warning signs of blood clots. The warning signs of possible blood clots in your leg include:
- Increasing pain in your calf
- Tenderness or redness above or below your knee
- New or increasing swelling in your calf, ankle, and foot
Warning signs of pulmonary embolism. The warning signs that a blood clot has traveled to your lung include:
- Sudden shortness of breath
- Sudden onset of chest pain
- Localized chest pain with coughing
Antibiotics For Dental Work
Certain types of dental work can cause infections elsewhere in the body. There are many different types of bacteria in the mouth. Depending on the patient, the bacteria can cause an infection in different organ systems. For example, some patients can become bacteremic, meaning they develop a bacterial infection in their blood. Others may develop pneumonia, cardiovascular infections, or inflammatory conditions. Different patients have different risk factors.
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Can A Tooth Infection Affect A Knee Replacement
If the infection eroded the bone around the implant, the patient may need another joint replacement operation. The risk, however, is considered hypothetical, says Dr. Susan Sutherland, chief of dentistry at Sunnybrook Health Sciences Centre. There is no evidence directly linking dental procedures to implant infections.
Duration Of Antibiotic Therapy
Antimicrobial prophylaxis should be discontinued within 24 hours after the operation.10,11 In a trial comparing 1 day versus 3 days of cefazolin, the infection rate was identical .20 In another trial, a single preoperative dose of cefazolin prevented infection just as well as 1 day of cefuroxime.21Since judicious use of antibiotics is imperative to reduce the risk ofantimicrobial resistance, antimicrobials should be used for the shortestduration possible without increasing the risk of infection. Inorthopedic procedures requiring drain placement, there is no evidencesuggesting that antimicrobials should be continued until all drains areremoved thus, antibiotics should be discontinued within 24 hours.11
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If You’ve Had Joint Replacement You May Need Antibiotics Before Dental Work
If youve had a total joint replacement or similar procedure, you will want your surgeon to decide if you need to take an antibiotic before you undergo dental work. This is a precaution to prevent a serious infection known as bacteremia.
Bacteremia occurs when bacteria become too prevalent in the bloodstream and cause infection in other parts of the body, especially in joints and bone with prosthetic substances. Its believed that during invasive dental procedures bacteria in the mouth can enter the bloodstream through incisions and other soft tissue disruptions.
Joint infections are a serious matter and can require extensive therapy to bring it under control. Out of this concern, the use of antibiotics as a prophylactic against bacteremia once included a wide range of patients for a variety of conditions and procedures. But after an in-depth study in 2007, the American Dental Association concluded that the risks for many of these patient groups for infection triggered by a dental procedure was extremely low and didnt warrant the use of antibiotic premedication therapy.
The guidelines for antibiotic premedication can be complex. Its best, then, to speak with both your orthopedic surgeon and us about whether you should undergo antibiotic therapy before you undergo a dental procedure. The ultimate goal is to reduce the risks of any disease and to keep both your mouth and your body safe from infection.
Dental Treatment In The First Three Months After Hip Or Knee Replacement:
- Non-infected dental problem not causing pain: Delay non-urgent and non-infected dental procedures until 3-6 months after joint replacement
- Dental abscess : Proceed with urgent and aggressive dental treatment to clear the abscess. Treat the cause of the abscess. Treatment should occur under antibiotic coverage
- Treatment of dental pain: Provide emergency dental treatment for pain. Antibiotics are recommended if a medium or high risk dental procedure is to be performed.
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Why Patients With Joint Implants No Longer Need Antibiotics Before A Dental Visit
QUESTION: When my knee was replaced with an artificial joint, the surgeon said I should always take antibiotics before any dental procedure. He said the bacteria in my mouth could get into my bloodstream and cause an infection around the implant. But my dentist said not to worry and that I actually dont need antibiotics. Who is correct?
ANSWER: For several years, orthopaedic surgeons and dentists have given conflicting advice about whether a patient with a prosthetic joint implant needs antibiotics to prevent potential infections a practice known as antibiotic prophylaxis.
The surgeons believed that antibiotics were necessary because a joint infection could jeopardize the implant. Dentists, on the other hand, felt that mouth bacteria didnt pose a risk to the implants and patients shouldnt be taking the drugs needlessly.
The mixed messages have certainly caused confusion for a lot of patients. But, thankfully, the dentists and surgeons have finally settled their differences and come to a common position. After reviewing the available scientific evidence, they recently concluded that antibiotics arent needed before dental procedures after all.
The national bodies that represent the two professions , plus infectious disease specialists have issued a joint statement calling for an end to the practice.
To understand how we got to this point, its worthwhile reviewing the long history of this controversy.
S To Take Before Surgery
In the weeks before surgery, see your dentist to check for cavities or other problems that need attention. This is because an infection from your mouth, or anywhere else in your body, can go to your knee.
Before your knee surgery, the following steps can help prevent infections:
- Antibiotics. Your healthcare team will usually give you antibiotics in the hour before surgery, and then at 24 hour intervals afterwards.
- Testing for and reducing nasal bacteria. There is some evidence that testing for Staphylococcus bacteria in the nasal passages, and using intranasal antibacterial ointment before surgery, could reduce infections.
- Washing with chlorohexidine. Some evidence says that washing with cloths soaked in chlorhexidine in the days leading up to surgery could help prevent infection. Brands include Betasept and Hibiclens.
- Avoid shaving. Opt not to shave your legs before surgery as this can increase the bacterial load.
The surgeon may recommend rescheduling your surgery if there are any changes in your medical condition, cuts or scratches on the skin, signs of a urinary tract infection, or symptoms of a cold.
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