Original Contributions
Antibiotic Prophylaxis
Cost-effectiveness of antibiotic prophylaxis for dental patients with prosthetic joints: Comparisons of antibiotic regimens for patients with total hip arthroplasty

https://doi.org/10.1016/j.adaj.2015.05.014Get rights and content

Abstract

Background

Clinician uncertainty concerning the need for antibiotic prophylaxis to prevent prosthetic joint infection (PJI) after undergoing dental procedures persists. Improved understanding of the potential clinical and economic risks and benefits of antibiotic prophylaxis will help inform the debate and facilitate the continuing evolution of clinical management guidelines for dental patients with prosthetic joints.

Methods

The authors developed a Markov decision model to compare the lifetime cost-effectiveness of alternative antibiotic prophylaxis strategies for dental patients aged 65 years who had undergone total hip arthroplasty (THA). On the basis of the authors’ interpretation of previous recommendations from the American Dental Association and American Academy of Orthopaedic Surgeons, they compared the following strategies: no prophylaxis, prophylaxis for the first 2 years after arthroplasty, and lifetime prophylaxis.

Results

A strategy of foregoing antibiotic prophylaxis before dental visits was cost-effective and resulted in lower lifetime accumulated costs ($11,909) and higher accumulated quality-adjusted life years (QALYs) (12.375) when compared with alternative prophylaxis strategies.

Conclusions

The results of Markov decision modeling indicated that a no-antibiotic prophylaxis strategy was cost-effective for dental patients who had undergone THA. These results support the findings of case-control studies and the conclusions of an American Dental Association Council on Scientific Affairs report that questioned general recommendations for antibiotic prophylaxis before dental procedures.

Practical Implications

The results of cost-effectiveness decision modeling support the contention that routine antibiotic prophylaxis for dental patients with total joint arthroplasty should be reconsidered.

Section snippets

Model design

We used cost-effectiveness decision modeling to evaluate antibiotic prophylaxis strategies for preventing PJI after dental visits.13 We compared expenditures and costs and related health outcomes (associated with PJIs) for alternative antibiotic prophylaxis strategies. We developed a Markov decision model to project lifetime harms, benefits, and economic outcomes for a hypothetical cohort of 65-year-old patients who had undergone THA. We studied alternative routine antibiotic prophylaxis

Results

The analysis showed that the no-antibiotic prophylaxis strategy was the least costly and most effective for dental patients aged 65 years with a prosthetic hip replacement. Foregoing antibiotic prophylaxis before dental visits, consistent with the first recommendation of the 2012 AAOS/ADA guideline11 and the 2015 ADA guideline,12 was the most cost-effective strategy, as it resulted in lower accumulated costs ($11,909) and higher accumulated QALYs (12.3745) than the alternative prophylaxis

Discussion

Antibiotic prophylaxis before dental procedures for patients with total joint prostheses remains controversial.5, 37 Compelling evidence that prophylaxis reduces dental patients’ risk of experiencing PJI is lacking. Routine prophylaxis may confer adverse clinical risks and associated costs. In our study, which compared dental prophylaxis strategies using lifetime cost-effectiveness modeling, we attempted to inform this discussion by including these issues. The results of our cost-effectiveness

Conclusions

It is indisputable that PJI is a serious, potentially debilitating, and costly complication that can occur after total joint arthroplasty, and that it is of great concern to clinicians. The tendency of orthopedists and dentists to prescribe prophylactic antibiotics to patients before they undergo invasive dental procedures is understandable. The incidence of bacteremia after dental procedures is well documented; however, the incidence of bacteremia developing as a result of common activities of

Dr. Skaar is an associate professor, Division of Periodontology, Department of Developmental and Surgical Sciences, School of Dentistry, University of Minnesota, 7-368 Moos Tower, Minneapolis, MN 55455.

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    Dr. Skaar is an associate professor, Division of Periodontology, Department of Developmental and Surgical Sciences, School of Dentistry, University of Minnesota, 7-368 Moos Tower, Minneapolis, MN 55455.

    Dr. Park is an assistant professor, Department of Pharmaceutical and Administrative Sciences, St. Louis College of Pharmacy, St. Louis, MO.

    Dr. Swiontkowski is a professor, Department of Orthopaedic Surgery, Medical School, and an adjunct professor, School of Public Health, University of Minnesota, Minneapolis, MN.

    Dr. Kuntz is a professor, Division of Health Policy & Management, School of Public Health, University of Minnesota, Minneapolis, MN.

    Disclosure. None of the authors reported any disclosures.

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