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Capturing Orthopaedic Surgical Site Infection Data and Assessing Dental Recommendations With Respect to Total Joint Arthroplasty

Florschutz, Anthony V. MD, PhD; Parsley, Brian S. MD; Shapiro, Irving M. BDS, PhD

JAAOS - Journal of the American Academy of Orthopaedic Surgeons: April 2015 - Volume 23 - Issue suppl - p S55–S59
doi: 10.5435/JAAOS-D-14-00419
Supplement Article

Greater documentation of patient history and clinical course is crucial for identifying factors that can influence surgical outcomes. The Centers for Medicare and Medicaid Services have already begun public reporting of hospital data on readmission, complication, and infection rates and will soon launch a website to make physician-specific outcomes data public. The orthopaedic community has the opportunity to lead the way in ensuring that adequate and accurate data is collected to facilitate appropriate comparisons that are based on patients’ true risk of complications and the complexity of treatment. Several studies have reported a link between oral pathogens and periprosthetic infection, although it remains unclear whether organisms unique to dental tissues are also present in osteoarthritic joints and tissues affected by periprosthetic joint infection. The American Academy of Orthopaedic Surgeons and the American Dental Association are aware of these concerns and have created guidelines for antibiotic prophylaxis in patients who have undergone total hip or knee arthroplasty and require high-risk dental procedures. Because these guidelines have received considerable criticism, recommendations that are based on scientific and case-controlled clinical studies and provide effective guidance on this important subject are needed.

From the Department of Orthopaedics, Orlando Regional Medical Center, Orlando, FL (Dr. Florschutz), the Department of Orthopaedic Surgery, Baylor College of Medicine, Bellaire, TX (Dr. Parsley), and the Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA (Dr. Shapiro).

Dr. Parsley or an immediate family member has received royalties and research of institutional support from ConforMIS; is a member of a speakers’ bureau or has made paid presentations on behalf of ConforMIS and Nimbic Systems; serves as a paid consultant to and has stock or stock options held in Nimbic Systems; and serves as a board member, owner, officer, or committee member of the American Association of Hip and Knee Surgeons. Dr. Shapiro or an immediate family member has stock or stock options held in Smith & Nephew. Neither Dr. Florschutz nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article.

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Capturing Patient-specific Data

In this world of evolving electronic health records and the need for greater documentation of the patient's history and clinical course, capturing risk stratification data is critical for documentation of all patient factors that can influence the surgical outcome. Public reporting of surgical outcomes has already begun. The Centers for Medicare and Medicaid Services (CMS) has implemented public reporting of comparative data on hospital 30-day readmission rates and complication and infection rates.1 In 2015, CMS will launch a similar website to allow public comparison of physician-specific outcomes data.2 The CMS risk adjustment model that uses 30-day readmission and complication rates is based solely on administrative billing data and International Classification of Diseases-9 comorbidity codes, which makes the model highly inaccurate, with insufficient clinically refined measures and a lack of granularity in the reporting process.3,4 In addition, risk stratification is severely limited because of the lack of adequate data; this prevents a true comparison of patient outcomes based on risk stratification.5 In the near future, hospital and physician payments will be adjusted by 3% to 5% based on these publicly reported outcomes, which lack the appropriate risk adjustment based on complexity, comorbidities, or socioeconomic factors.4 It is important that the orthopaedic community lead the way to ensure that the data collected are adequate and accurate to allow for appropriate comparisons to made based on patients' risk of complications and the complexity of each case such that hospitals and physicians who treat high-risk patients are not at a disadvantage. Inappropriate risk adjustment may lead to a reluctance to treat these patients as well as limited patient access to appropriate medical care.

An important way that orthopaedic surgeons can engage and facilitate the process of data collection is to collect comprehensive patient-specific data at the initial clinical evaluation and update this information before any surgical procedure. This valuable information should be included in the hospital administrative database as part of the patient record and should reflect significant aspects of the patient’s medical history (Table 1). The patient record should also include orthopaedic-specific risk factors that can also influence surgical outcomes. These risk factors include severe angular deformity, congenital abnormalities, history of local or systemic infection, retained hardware, prior surgery/revision on the affected joint, congenital hip dysplasia, previous radiation treatment to the affected joint, and narcotic use for >1 year.

Table 1

Table 1

The use of electronic health records in physician offices can facilitate the capture of these valuable data through online information sheets that are filled out by the patient or family before the office visit or at the initial office check-in. The data should be double-checked by the admission staff to ensure accuracy and completeness and can easily be reviewed at the visit so that potential risk factors can be discussed to provide patients with an estimated risk of complications following the surgical procedure. Implementation of these steps now would be beneficial to begin capturing these data and would allow time to refine the process before it becomes mandatory.

There is also a growing interest in the further development and support of a national joint registry (the American Joint Replacement Registry) to collect data and follow outcomes on a larger population-based scale.6 In addition to the American Joint Replacement Registry, the number of institutional, regional, and state registries has grown.7 This increase in registry development and implementation reflects the need for greater accountability of outcomes and the capture of meaningful data that have the potential to have a positive outcome on patient care. Ongoing efforts will continue to refine the information collected to prompt further improvement in patient care.

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Dental Disease and Orthopaedic Surgical Site Infection

Orthopaedic surgeons have mixed feelings about the impact of dental disease, particularly periodontal disease, on periprosthetic joint infection (PJI). Members of the dental profession share this ambivalence. Because oral surgery, periodontal curettage, endodontia, and exodontia often precipitate bacteremia, there is a need to know if PJI is initiated or exacerbated by oral organisms and whether these pathogens are involved in the pathogenesis of osteoarthritis. The American Academy of Orthopaedic Surgeons (AAOS) and the American Dental Association (ADA) have responded to these concerns by convening an expert panel of dentists, orthopaedic surgeons, and infectious disease specialists to review the available research findings and generate guidelines for both professions. ADA and AAOS practice guidelines published in 2003 advised that antibiotics should not be given to arthroplasty patients who undergo dental procedures.8 The only deviation from this recommendation was for patients who were immunocompromised or had comorbidities. Antibiotic prophylaxis was advised in these patients when they undergo high-risk dental procedures regardless of the timing after arthroplasty.

In 2009, the AAOS and the ADA went even further and advised that, if there was a risk of dentally induced bacteremia, antibiotic prophylaxis should be extended for the life of an arthroplasty patient.9 This recommendation was further modified in 2012 by yet another AAOS and ADA joint committee to include high-risk dental procedures such as dental abscess therapy, extractions, filings, hygiene, periodontal treatment, and mouth surgery.10 The procedures chosen were based on somewhat conflicting findings on bacteremia associated with each of the treatment protocols.

Although the goal of the AAOS and the ADA 2012 recommendations was to prevent orthopaedic implant infection in patients undergoing dental procedures, the recommendations provided minimum guidance to the professions. For example, the first recommendation was that the practitioner might consider discontinuing the practice of routinely prescribing prophylactic antibiotics for patients with hip and knee prosthetic joint implants who are undergoing dental procedures. The AAOS-ADA panel was unable to recommend for or against the use of topical or oral antimicrobials in patients who are undergoing dental procedures and have prosthetic joint implants or other orthopaedic implants. Finally, in an even more vague comment, the panel concluded that, in the absence of reliable evidence linking poor oral health to PJI, patients with prosthetic joint implants or other orthopaedic implants should maintain appropriate oral hygiene.

The concept of recommending antibiotic prophylaxis to arthroplasty patients met with careful critique11 as well as stinging rebuttals. Morris and Howie12 noted that “bacteremia-induced PJIs are extremely rare events (if they occur at all), and it is, therefore, implausible that any intervention to reduce bacteremia will be shown to be effective.” They posed the question, “is it appropriate to recommend up to 2 tonnes of antibiotics every 6–12 months for an unproved benefit? As ‘stewards’ of antibiotics—whose job it is to ensure that patients get the right antibiotics when they need them—we would answer ‘no’ unequivocally.” Similar views were enunciated by Assael,13 van der Bruggen and Mudrikova14 and Sandhu et al.15 All of these authors recommended that rigorous analyses be conducted to provide epidemiological evidence that PJI is indeed a result of a dental bacteremia. As Berbari et al16 and others pointed out, the only way to really determine whether there is a significant relationship between PJI and dental procedures is by performing a case-controlled, retrospective or prospective study. This has not been done. In addition to this concern, there was the growing worry, which was first enunciated by Morris and Howie,12 that overuse or improper use of antibiotics could lead to development of drug-resistant bacteria. There was also the concern that even if antibiotics were used prophylactically, there was no evidence that they would be effective.17

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The Role of Dental and Oral Pathogens in Osteoarthritis and PJI

Numerous reports exist on the microbial species present in PJI, but a detailed discussion of this topic is beyond the scope of this article. Zimmerli et al18 found that infected tissues contain coagulase-negative Staphylococcus (in 30% to 43% of cases), S aureus (12% to 23%), mixed bacteria (10% to 11%), Streptococcus species (9% to 10%), and gram-negative rods (3% to 6%). In >300 cases of periprosthetic hip or knee infection, β-hemolytic streptococci, Peptostreptococcus, Actinomyces, and Streptococcus viridans were reported to be present in significant numbers; together, the oral biotia accounted for >10% of implant infections.11 LaPorte et al19 inferred that infection after dental procedures is more common than previously considered. The authors recommended that if the patient was being treated for extensive dental disease or had an underlying systemic condition, then antibiotic treatment is appropriate. Likewise, Maderazo et al20 noted that the most frequently found oral organisms in patients with PJI were S aureus and S epidermidis. Smith et al21 confirmed that staphylococci were present in the oral cavity and may cause systemic infection. Indeed, numerous studies have shown that staphylococci are present in saliva, plaque, and periodontal tissues.

Although these studies provide some support for the notion that oral pathogens are involved in PJI, the more critical question is whether there is evidence of unique dental organisms in tissues affected by PJI and in osteoarthritic joints. Detecting dental organisms can be difficult because many of the pathogens are fastidious. Hence, conventional microbiologic methods for isolating and identifying organisms via culture are inadequate and often provide skewed views of the actual infective state of the tissue. Nevertheless, Grif et al22 showed that there was substantial underrepresentation of infective organisms in cultures of joint tissue tested using 16S and 18S ribosomal RNA polymerase chain reaction analysis. Ehrlich et al23 performed a more detailed DNA analysis of the organisms present in cartilage before primary knee arthroplasty; samples collected for DNA analysis were culture negative. Polymerase chain reaction–based electron spray ionization time-of-flight mass spectrometry indicated that >75% of the samples analyzed contained at least one bacterial species, and most of the detected species were gram-positive facultative anaerobes or anaerobes, with S aureus and S epidermidis being the most prevalent species.23,24 The oral pathogens Treponema denticola and Porphyromonas gingivalis were also evident. The presence of periodontal pathogens was confirmed using fluorescent in situ hybridization, which clearly demonstrated that these organisms were deeply invested within the host tissue and not simply casual contaminants.23 A similar approach was used by Walter et al25 who analyzed bone and joint infections caused by anaerobic bacteria and showed that polymicrobial contaminants were present in joint cartilage. This observation supported the notion that microorganisms were present in nominally sterile degenerative osteoarthritic cartilage and indicated that some pathogens had been mobilized from the oral cavity. The presence of the oral microorganisms together with the more common facultative anaerobes or anaerobes, such as S aureus and S epidermidis, raises the question of whether these organisms would be susceptible to antibiotic therapy.

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Lowering the Incidence of PJI With Antibiotic Therapy

Studies of back pain associated with degenerative intervertebral disk disease may provide support for the argument that bacterial organisms in joints respond to antibiotic therapy.26,27 In a study of >200 patients treated for disk herniation, Stirling et al26 reported that, of 36 patients with severe sciatica 19 (53%) had positive microbiologic cultures, and Propionibacterium acnes was isolated from 16 of 19 (84%) positive samples. In a double-blind randomized controlled trial, patients with chronic low back pain and vertebral bone edema who were treated with amoxicillin-clavulanate for 100 days exhibited marked improvements in global pain scores, leg pain, and global perceived health.27 Improvement was most substantial in patients considered to be treatment-resistant; for this and other reasons, the authors concluded that the antibiotic provided a useful clinical approach for management of recalcitrant chronic low back pain.

Sensitivity to antibiotics is based on several factors, especially the physical environment. Free-floating (planktonic) organisms are most sensitive to antibiotics, whereas those encased in a biofilm are often resistant to antibiotic treatment. Dastgheyb et al28 recently observed that when exposed to synovial fluid, pathogens clump and form floating biofilms (ie, biofloats). Because clump formation would probably modulate bacterial metabolism, it is likely that, similar to biofilm, the presence of pathogen clumps influences not just antibiotic sensitivity but also immune cell surveillance. This raises the question of whether dissolution of a condensed mat of bacteria would release organisms that were previously inaccessible to antibiotics (and hence promote disease progression) or make the planktonic organisms more susceptible to antibiotics.

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Summary and Future Directions

Currently, there are no answers to many of the questions that we have posed here. Thus, it is critical that case-controlled clinical investigations be undertaken and, based on these findings, more direct guidelines generated. In terms of understanding the relationship between PJI and oral infection, analysis of accumulating evidence suggests that, as a result of oral bacteremia, organisms migrate to the joints where they act in a dysbiotic manner to promote local inflammation. The role of oral bacteremia with regard to initiation and propagation of the inflammatory response is unknown. The influence of the host response to these organisms and local events like tissue trauma could impact the bioburden and enhance microbial accumulation and speciation in affected tissues. Finally, because oral pathogens can cause an asymptomatic bacteremia and possibly play a role in initiating and propagating disease, more attention to lifelong dental hygiene would decrease the bioburden, impact the prevalence of both osteoarthritis and PJI, and lower the rate of infection following arthroplasty.

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