Endocarditis antibiotic prophylaxis: Difference between revisions

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{{Endocarditis}}


{{CMG}}
{{CMG}}; '''Associate Editors-in-Chief:''' {{CZ}}; [[Michael W. Tempelhof]], M.D.; {{AKK}}


'''Associate Editors-in-Chief:''' {{CZ}}; {{MWT}}
==Overview==
Administration of antibiotic prophylaxis is only recommended to high-risk patients undergoing specific procedures. Generally, [[amoxicillin]] 30-60 minutes prior to the procedure is preferred for prophylaxis against endocarditis.


{{EJ}}
==Antibiotic Prophylaxis==
===Antimicrobial Regimen===
* 1. '''Prophylactic Regimens for Dental Procedures'''<ref name="pmid24589852">{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= 129 | issue= 23 | pages= 2440-92 | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852  }} </ref><ref name="pmid23474606">{{cite journal| author=Vahanian A, Alfieri O, Andreotti F, Antunes MJ, Baron-Esquivias G, Baumgartner H et al.| title=[Guidelines on the management of valvular heart disease (version 2012). The Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)]. | journal=G Ital Cardiol (Rome) | year= 2013 | volume= 14 | issue= 3 | pages= 167-214 | pmid=23474606 | doi=10.1714/1234.13659 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23474606  }} </ref><ref name=AHA guideline 2014>{{cite web | title = AHA guideline 2014 | url = http://www.heart.org/idc/groups/heart-public/@wcm/@hcm/documents/downloadable/ucm_307644.pdf }}</ref><ref name="pmid17446442">{{cite journal| author=Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M et al.| title=Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. | journal=Circulation | year= 2007 | volume= 116 | issue= 15 | pages= 1736-54 | pmid=17446442 | doi=10.1161/CIRCULATIONAHA.106.183095 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17446442  }} </ref>


==Summary: Patients Requiring Antibiotic Prophylaxis Prior to Dental Procedures (2007 AHA Guideline Recommendations)==
:* 1.1 '''Oral regimen'''
The presumed correlation of endodontic induced bacteremia, and new onset endocarditis made pre-procedural antibiotic prophylaxis a reasonable practice for the preceding 60 years. However, there is a paucity of evidence in support of providing chemoprophylaxis for effective endocarditis prevention. Chewing, dental hygiene practices, kidney disease, diabetes, and skin colonization present a greater risk of significant bacteremia and greater cumulative IE acquisition risk than any single invasive dental procedure. The AHA recommends reducing the incidence of bacteremia with the optimization of oral hygiene in at-risk patients and does not recommend indiscriminant pre-procedural chemoprophylaxis as a safe, IE prevention practice. The AHA acknowledges that even if chemoprophylaxis conferred 100% efficacy, few cases of IE would be prevented as the incidence of endodontic induced endocarditis is so low.
::* Preferred regimen: [[Amoxicillin]] 2 g PO single dose (30-60 minutes before procedure)
<blockquote>The AHA now recommends the administration of pre-endodontic procedural prophylactic antibiotics to patients with the highest risk of adverse outcomes subsequent to the development of endocarditis<ref name=Wilson>{{cite journal | author = Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, Bolger A, Cabell CH, Takahashi M, Baltimore RS, Newburger JW, Strom BL, Tani LY, Gerber M, Bonow RO, Pallasch T, Shulman ST, Rowley AH, Burns JC, Ferrieri P, Gardner T, Goff D, Durack DT| title = American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee; American Heart Association Council on Cardiovascular Disease in the Young; American Heart Association Council on Clinical Cardiology; American Heart Association Council on Cardiovascular Surgery and Anesthesia; Quality of Care and Outcomes Research Interdisciplinary Working Group. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group| journal = Circulation | volume = 116 | issue = 15 | pages = 1736-54 | year = 2007 | id = PMID 17446442}}</ref>:</blockquote>
::* Pediatric dose: [[Amoxicillin]] 50 mg/kg PO single dose (30-60 minutes before procedure)


:* Patients with a prosthetic cardiac valve
:* 1.2 '''Unable to take oral medication'''
:* Patients with a prior history of [[infective endocarditis]]
::* Preferred regimen: [[Ampicillin]] 2 g IM/IV single dose (30-60 minutes before procedure) {{or}} [[Cefazolin]] 1 g IM/IV single dose (30-60 minutes before procedure) {{or}} [[Ceftriaxone]] 1 g IM/IV single dose (30-60 minutes before procedure)
:* [[Cardiac transplantation]] recipients who develop cardiac valvulopathy
::* Pediatric dose: [[Ampicillin]] 50 mg/kg; [[Cefazolin]] 50 mg/kg; [[Ceftriaxone]] 50 mg/kg
:* Patients with [[congenital heart disease]]:
::*Patients with unrepaired cyanotic CHD in which shunts and conduits are present
::*Patients who have undergone completely repair of a congential heart defect within the past 6 months
::*Patient with repaired congenital heart disease with residual defects at the site of a prosthetic patch or device


The following endodontal procedures require coverage in this high risk population:
:* 1.3 '''Allergic to penicillins or ampicillin - Oral regimen'''
:*Any type of dental extractions
::* Preferred regimen: [[Cephalexin]] 2 g single dose (30-60 minutes before procedure) {{or}} [[Clindamycin]] 600 mg single dose (30-60 minutes before procedure) {{or}} [[Azithromycin]] 500 mg single dose ()30-60 minutes before procedure) {{or}} [[Clarithromycin]] 500 mg  single dose (30-60 minutes before procedure).
:*Any type of periodontal procedures and gingival surgery
::* Pediatric doses:  [[Cephalexin]] 50 mg/kg single; [[Clindamycin]] 20 mg/kg; [[Azithromycin]] 15 mg/kg; [[Clarithromycin]] 15 mg/kg
:**Placement of dental implants and avulsed teeth replantation
:**Dental canal or root surgery
:**Antibiotic fibres or strips placement at subgingival area
:**Initial placement of orthodontic brackets
:**Intraligamentous injection of local anesthetic drugs  
:**Bleeding during prophylactic cleaning of teeth or implants


Other scenarios that are not dental procedures and for which prophylaxis is not recommended, such as shedding of deciduous teeth and trauma to the lips and oral mucosa.
:* 1.4 '''Allergic to penicillins or ampicillin and unable to take oral medication'''
::*  Preferred regimen: [[Cefazolin]] 1 g IM/IV single dose (30-60 minutes before procedure) {{or}} [[Ceftriaxone]] 1 g IM/IV single dose (30-60 minutes before procedure) {{or}} [[Clindamycin]] 600 mg IM/IV single dose (30-60 minutes before procedure)
::* Pediatric doses: [[Cefazolin]] 50 mg/kg; [[Ceftriaxone]] 20 mg/kg


In this limited patient population, prophylactic antimicrobial therapy should be directed against [[Streptococcus viridans]]. Acknowledging an estimated 10-20 fold greater risk of single-dose fatal anaphylaxis with [[amoxicillin]] compared to single dose cephalosporin, macrolide and clindamycin regimens, the AHA believes prophylaxis with [[amoxicillin]] is a safe practice as there have been no reports of fatal [[anaphylaxis]] arising from a single-dose of pre-dental endocarditis prophylaxis using oral amoxicillin.
* 2. '''Gastrointestinal/Genitourinary Procedures'''
:* Preferred regimen: Antibiotic prophylaxis to prevent [[IE]] is no longer recommended for patients who undergo a GI or GU tract procedure.
:* Note: High risk patients who already have an established [[GI]] or GU tract infection, it is reasonable to administer [[Ampicillin]] 2 g IM/IV single dose


==Summary of Recommendations Regarding Antibiotic Prophylaxis Prior to Procedures on Infected Skin or Musculoskeletal Tissue==
* 3. '''Regimens for Respiratory Tract Procedures'''
:* 3.1 '''Oral regimen'''
::* Preferred regimen: [[Amoxicillin]] 2 g single dose (30-60 minutes before procedure)
::* Pediatric dose: [[Amoxicillin]] 50 mg/kg single dose (30-60 minutes before procedure)


These infections are often polymicrobial, but only staphylococci and beta hemolytic [[streptococci|beta-hemolytic streptococci]] are likely to cause Infective Endocarditis.
:* 3.2 '''Unable to take oral medication'''
::* Preferred regimen: [[Ampicillin]] 2 g IM/IV single dose (30-60 minutes before procedure) {{or}} [[Cefazolin]] 1 g IM/IV single dose (30-60 minutes before procedure) {{or}} [[Ceftriaxone]] 1 g IM/IV single dose (30-60 minutes before procedure)


For patients with high risk conditions who undergo a surgical procedure that involves infected skin, skin structure, or musculoskeletal tissue, it may be reasonable that the therapeutic regimen administered for treatment of the infection contain an agent active against [[staphylococci]] and [[streptococci|beta-hemolytic streptococci]], such as an antistaphylococcal [[penicillin]] or a [[cephalosporin]].
::* Pediatric doses: [[Ampicillin]] 50 mg/kg; [[Cefazolin]] 50 mg/kg; [[Ceftriaxone]] 50 mg/kg


[[Vancomycin]] or [[clindamycin]] may be administered to patients unable to tolerate a [[beta-lactam]] or who are known or suspected to have an infection caused by a [[methicillin-resistant staphylococcus aureus]].<ref name=Wilson>{{cite journal | author = Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, Bolger A, Cabell CH, Takahashi M, Baltimore RS, Newburger JW, Strom BL, Tani LY, Gerber M, Bonow RO, Pallasch T, Shulman ST, Rowley AH, Burns JC, Ferrieri P, Gardner T, Goff D, Durack DT| title = American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee; American Heart Association Council on Cardiovascular Disease in the Young; American Heart Association Council on Clinical Cardiology; American Heart Association Council on Cardiovascular Surgery and Anesthesia; Quality of Care and Outcomes Research Interdisciplinary Working Group. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group| journal = Circulation | volume = 116 | issue = 15 | pages = 1736-54 | year = 2007 | id = PMID 17446442}}</ref>
:* 3.3 '''Allergic to penicillins or ampicillin — Oral regimen'''
::* Preferred regimen: [[Cephalexin]] 2 g single dose (30-60 minutes before procedure {{or}} [[Clindamycin]] 600 mg single dose (30-60 minutes before procedure) {{or}} [[Azithromycin]] 500 mg single dose (30-60 minutes before procedure) {{or}} [[Clarithromycin]] 500 mg  single dose (30-60 minutes before procedure)
::* Pediatric doses:  [[Cephalexin]] 50 mg/kg; [[Clindamycin]] 20 mg/kg; [[Azithromycin]] 15 mg/kg; [[Clarithromycin]] 15 mg/kg


==Basis for AHA Recommendations Regarding Antibiotic Prophylaxis for Dental Procedures==
:* '''Allergic to penicillins or ampicillin and unable to take oral medication'''
Endodontic procedures have been associated with a high incidence of [[bacteremia]] since the 1920s. Therefore, dental procedures were implicated as an independent risk factor for the development of bacterial [[endocarditis]]. However, only 4%-7.5% of all bacterial endocarditis cases are related to endodontic associated bacteremia.<ref>Gendron R, Grenier D, Maheu-Robert L. The oral cavity as a reservoir of bacterial pathogens for focal infections. Microbes Infect. 2000;2:897-906.  </ref> In 1955, the American Heart Association (AHA) published the first of ten subsequent [[endocarditis]] prevention guidelines. The most recent, 2007 guidelines underwent changes intended to clarify patient eligibility criteria for receiving [[endocarditis]] prophylaxis.
::*  Preferred regimen: [[Cefazolin]] 1 g IM/IV single dose (30-60 minutes before procedure) {{or}} [[Ceftriaxone]] 1 g IM/IV single dose (30-60 minutes before procedure) {{or}} [[Clindamycin]] 600 mg IM/IV (30-60 minutes before procedure)
Major changes include:
::* Pediatric doses: [[Cefazolin]] 50 mg/kg; [[Ceftriaxone]] 20 mg/kg
* [[Bacteremias]] associated with daily activities (which are frequent) are considered more likely to cause [[endocarditis]] than are endodontic-procedural induced [[bacteremias]].
*Optimal oral hygiene is emphasized as an important practice to prevent endocarditis.
*A patient’s lifetime risk of endocarditis is no longer a consideration for initiating prophylactic antibiotic therapy.
*The AHA now recommends the administration of single-dose prophylactic antibiotics prior to endodontic procedure only to patients with cardiac conditions associated with the highest risk of adverse outcomes following the acquisition of bacterial endocarditis (see the list above).


===The Risk of Endocarditis Following Endodontic Procedures=
* 4. '''Regimens for Procedures on Infected Skin, Skin Structure, or Musculoskeletal Tissue'''
Based in the findings below, the AHA has concluded that the cumulative background bacteremia associated with chewing, daily dental hygiene practices, kidney disease, diabetes, and skin colonization present a greater risk of significant bacteremia than any single invasive dental procedure.
:* Patients who undergo a surgical procedure that involves infected skin, skin structure, or musculoskeletal tissue, it may be reasonable that the therapeutic regimen administered for treatment of the [[infection]] contain an agent active against [[staphylococci]] and beta-hemolytic [[streptococci]], such as an antistaphylococcal [[penicillin]] or a [[cephalosporin]].


*Following dental intervention, the absolute risk for developing endocarditis is estimated at 1 case per 14 million dental procedures.<ref>Pallasch TJ. Antibiotic prophylaxis: problems in paradise. Dent Clin North Am. 2003;47:665-679.</ref>
==Impact of Restricting Prophylactic Antibiotics==
*The risk of endocarditis following an endodontic induced bacteremia in high risk patients is as follows<ref>Pallasch TJ, Wahl MJ. Focal infection: new age or ancient history?
There is data showing that the institution of these more restrictive guidelines does not increase the risk of endocarditis. The NICE guidelines recommended no antibiotic prophylaxis for any patient, and despite a 78.6% reduction in the administration of IE prophylaxis, there was no documentation of an increase in IE cases due to streptococci.<ref>Thornhill MH et al. BMJ 2011;342:d2392.</ref> In France, following restricted use of antibiotics the incidence of IE was stable.<ref>Duval X, et al. J Am Coll Card 2012;59:1968-76.</ref>
Endodontic Topics. 2003;4:32-45.
</ref>:
:*[[Congenital heart disease]]: 1 per 475,000
:*[[Rheumatic heart disease]]: 1 per 142,000;
:*Patients with a prosthetic heart valve, 1 per 114,000
:*Patients with previous endocarditis: 1 per 95,000 dental procedures.
*Inocula of 1 x 108 (100 million) colony forming units [cfu]/mL or greater are required to consistently induce experimental endocarditis.
**Recent human quantitative blood culture data support the implication that endodontic associated bacteremia inocula are of insufficient magnitude to induce endocarditis. Bacteremia intensities immediately following invasive human dental procedures are 1.5 cfu/ml-5.9 cfu/ml 10 fold less then necessary to induce IE in the animal model.<ref>Roberts GJ. Dentists are innocent! Everyday" bacteremia is the real culprit: A review and assessment of the evidence that dental surgical procedures are a principal cause of bacterial endocarditis in children. Pediatric Cardiology. 1999;20:317.</ref>


*The most recent case-control study of 104 patients with known, high-risk structural heart disease discovered that patients who developed endocarditis were actually less likely to have experienced an endodontic procedure within the 180 days prior to diagnosis than did control patients who did not develop IE (OR 0.2 [95% CI 0.04-0.7]).<ref>Strom BL, Abrutyn E, Berlin JA, Kinman JL, Feldman RS, Stolley PD, et al. Dental and cardiac risk factors for infective endocarditis: A population-based, case-control study. Ann Int Med. 1998;129:761-769.</ref>
==2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease (VHD)==
 
*Among high-risk patients with underlying structural heart disease, kidney disease (OR 16.9 [95% CI 1.5-193.0]), diabetes (OR 2.7 [95% CI 1.4-5.2]) and skin flora infection (OR 3.5 [95% CI 0.7-17.0]) were associated with a greater risk for the development of bacterial endocarditis.<ref>Strom BL, Abrutyn E, Berlin JA, Kinman JL, Feldman RS, Stolley PD, et al. Risk factors for infective endocarditis: oral hygiene and nondental exposures. Circulation. 2000;102:2842.</ref>
 
*Daily activities such as chewing and oral hygiene practices result in bacteremias more frequently, of longer duration and of greater magnitude in comparison to high-risk endodontic procedures.
 
===The Efficacy of Prophylactic Antibiotic===
*The efficacy of antibiotic regimens for IE prophylaxis has never been assessed under the scrutiny of a randomized controlled trial.
*Evidence supporting pre-endodontic chemoprophylaxis efficacy is extrapolated from data demonstrating reductions in bacteremia magnitudes immediately following the administration of antibiotics.
 
'''Antibiotic prophylaxis is reasonable for patients with the conditions who undergo any dental procedure that involves the gingival tissues or periapical region of a tooth and for those procedures that perforate the oral mucosa. Although Infective Endocarditis prophylaxis is reasonable for these patients, its effectiveness is unknown.'''
 
===Efficacy Assesment===
The '''Cochran Collaboration''' assessed whether prophylactic administration of penicillin to moderate- to high-risk patients prior to endodontic intervention conferred a mortality, serious illness or endocarditis incidence benefit.<ref>Oliver R, Roberts GJ, Hooper L. Penicillins for the prophylaxis of bacterial endocarditis in dentistry. Cochrane Database of Systematic Reviews 2004, Issue 2.</ref>
*The pooled, adjusted Odds Ratio across all studies for the development of IE among patients receiving prophylaxis was non-significant (0.56 [95% CI (0.15-2.15)]).
'''The Cochrane Collaboration concluded; it is unclear whether antibiotic prophylaxis is effective and there is a lack of evidence to support published guidelines using penicillin as chemoprophylaxis for IE.'''
 
'''' To date, only 4 case-control studies has assessed antibiotic efficacy for IE prevention.''''
#Strom et al discovered the administration pre-endodontic procedural antibiotics did not provide a protective benefit against the development of IE (OR 0.5 [CI .01-9.6]).
#Van Der Meer et al,<ref>Van der Meer JT, Thompson J, Valkenburg HA, Michel MF. Epidemiology of bacterial endocarditis in The Netherlands II. Antecedent procedures and use of prophylaxis. Arch Intern Med. 1992;152:1869-1873.</ref>8/48 case pts (16%) received antibiotics.26/200 control pts (13%) received antibiotics.Stratified Odds Ratio: 0.51 (0.11-2.29).Protective Efficacy 49%.
#Lacassin et al<ref>Lacassin F, Hoen B, Leport C, Selton-Suty C, Delahaye F, Goulet V, et al. Procedures associated with infective endocarditis in adults - A case control study. Eur Heart J. 1995;16:1968-1974.</ref>6/37 case pts (23%) received antibiotics.6/33 control pts (27%) received antibiotics.Matched and Adjusted Odds Ratio: 0.2 (0-0.8) Protective Efficacy 20%.
#Imperiale et al<ref>Imperiale TF, Horwitz RI. Does prophylaxis prevent post-dental infective endocarditis? A controlled evaluation of protective efficacy. Am J Med. 1990;88:131-136.</ref>
1/8 case pts (13%) received antibiotics.15/24 control pts (63%) received antibiotics.
Matched Odds Ratio: .09 (CI upper limit of 0.93) (p=.025)Protective Efficacy 91%.
 
==Safety Concerns with Antibiotic Prophylaxis==
''Adverse reactions associated with the administration of beta-lactam antibiotics are common.''
*Ranging in severity from purititus to fatal anaphylactic shock, the frequency of all adverse reactions from the administration of penicillin to the general population is 0.7% to 10%.<ref>Idsoe O, Guthe T, Willcox RR, De Weck A. Nature and extent of penicillin side-reactions, with particular reference to fatalities from anaphylactic shock. Bull World Health Organ. 1968;38:159-188.</ref>
*Fatal anaphylaxis among patients receiving single-dose penicillin, ampillicin or amoxicillin therapy is approximately 20 cases per 1 million patients treated.<ref>The International Collaborative Study of Severe Anaphylaxis. Risk of anaphylaxis in a hospital population in relation to the use of various drugs: an international study. Pharmacoepidemiology and drug safety. 2003;12:195-202.</ref>
*Single-dose, cephalosporin-associated fatal anaphylaxis risk is estimated at 0.5-5.7 cases per 10 million patients treated.<ref>Kelkar P,James T. Current concepts: cephalosporin allergy. N Engl J Med. 2001;345:804-9.</ref>
*Macrolide and clindamycin single-dose fatal anaphylaxis risk is estimated at 0-5 cases per 1 million patients treated.<ref>Mazur N, Greenberger P, Regalado J. Clindamycin hypersensitivity
appears to be rare. Ann Allergy Asthma Immunol. 1999;82:443–5.
</ref>
'''With the highest associated mortality rate of all the recommended antibiotic regimens, the risk of anaphylaxis with the initiation of beta-lactam IE prophylactic therapy must be considered.'''
 
#The risk of mortality associated with the single-dose administration of beta-lactam antibiotics for IE prophylaxis is estimated at 1-3 anaphylactic deaths per 1 million patients treated.
#According to the AHA, single dose administration of a beta-lactam antibiotic for IE prophylactic therapy is a safe practice as it has never resulted in a reportable case of fatal anaphylaxis.
 
==Cost Effectiveness of Oral Antibiotic Prophylaxis==
''To date, one report has addressed the cost-effectiveness of providing chemoprophylaxis to patients of moderate- and high-risk of IE acquisition prior to endodontic procedure.''<ref>Agha Z, Lofgren RP, VanRuiswyk JV. Is antibiotic prophylaxis for bacterial endocarditis cost-effective? Med Decis Making. 2005;25:308-320.</ref>
#The risk of drug-induced anaphylaxis and associated loss of QALYs with prophylactic oral amoxicillin or ampicillin to moderate-risk patients rendered this practice ineffective and therefore the authors did not complete a cost-effectiveness analysis.
#The estimated cost-effectiveness ratio for the prophylaxis of 10 million moderate-risk patients with clarithromycin, clindamycin or cephalexin, was $88,007, $101,142 and $99,373 per QALY saved, respectively.
#Cost-effectiveness ratio for the use of clarithromycin in patients with the prior diagnosis of endocarditis was $40,334, and in patients with prosthetic valves, $16,818 per QALY saved.
#Cost-effectiveness ratio of treating 10 million high-risk patients administered single dose clindamycin was $46,678 (prior endocarditis) and $19,936 (prosthetic valve) per QALY saved. #Cephalexin was associated with a cost-effectiveness of $37,916 per QALY saved in patients with a history of IE and $14,060 per QALY saved, in patients with a prosthetic valves.
'''''The cost-effective analyses suggest that the 2007 AHA IE prevention guidelines advocating chemoprophylaxis to patients with a high-risk of adverse outcomes upon acquisition of IE is a reasonable, cost-effective practice.'''''
 
The term of prophylaxis required procedure '''include''' biopsies, suture removal, and placement of orthodontic bands, but it '''does not include''' routine anesthetic injections through non-infected tissue, the taking of dental radiographs, placement of removable prosthodontic or orthodontic appliances, placement of orthodontic brackets, or adjustment of orthodontic appliances.


===Recommendation for Infective Endocarditis (IE) Prophylaxis===


{| class="wikitable" style="width: 80%; text-align: justify;"
! style="width:12%" | '''COR'''
! style="width:8%" | ''' LOE'''
! style="width:40%" | '''RECOMMENDATION'''
! style="width:40%" | '''COMMENT/RATIONALE'''
|-
| bgcolor="LemonChiffon" | IIa || bgcolor="LightBlue" | C-LD || Prophylaxis against IE is reasonable before dental procedures that involve manipulation of gingival tissue, manipulation of the periapical region of teeth, or perforation of the oral mucosa in patients with the following:
'''1.''' Prosthetic cardiac valves, including transcatheter- implanted prostheses and homografts.
'''2.''' Prosthetic material used for cardiac valve repair, such as annuloplasty rings and chords.
'''3.''' Previous IE.
'''4.''' Unrepaired cyanotic congenital heart disease or
repaired congenital heart disease, with residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch or prosthetic device.
'''5.''' Cardiac transplant with valve regurgitation due to a structurally abnormal valve.
|| '''{{Fontcolor|#FF0000|MODIFIED:}}''' LOE updated from B to C-LD. Patients with transcatheter prosthetic valves and patients with prosthetic material used for valve repair, such as annuloplasty rings and chords, were specifically identified as those to whom it is reasonable to give IE prophylaxis. This addition is based on observational studies demonstrating the increased risk of developing IE and high risk of adverse outcomes from IE in these subgroups. Categories were rearranged for clarity to the caregiver.
|}


===Recommendations for Infective Endocarditis Intervention===


{| class="wikitable" style="width: 80%; text-align: justify;"
! style="width:12%" | '''COR'''
! style="width:8%" | ''' LOE'''
! style="width:40%" | '''RECOMMENDATION'''
! style="width:40%" | '''COMMENT/RATIONALE'''
|-
| bgcolor="LightGreen" | I || bgcolor="LightBlue" | B || Decisions about timing of surgical intervention should be made by a multispecialty Heart Valve Team of cardiology, cardiothoracic surgery, and infectious disease specialists. ||2014 recommendation remains current.
|-
| bgcolor="LightGreen" | I || bgcolor="LightBlue" | B ||Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) is indicated in patients with IE who present with valve dysfunction resulting in symptoms of HF. ||2014 recommendation remains current.
|-
| bgcolor="LightGreen" | I || bgcolor="LightBlue" | B ||Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) is indicated in patients with left-sided IE caused by S. aureus, fungal, or other highly resistant organisms. ||2014 recommendation remains current.
|-
| bgcolor="LightGreen" | I || bgcolor="LightBlue" | B ||Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) is indicated in patients with IE complicated by heart block, annular or aortic abscess, or destructive penetrating lesions. ||2014 recommendation remains current.
|-
| bgcolor="LightGreen" | I || bgcolor="LightBlue" | B ||Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) for IE is indicated in patients with evidence of persistent infection as manifested by persistent bacteremia or fevers lasting longer than 5 to 7 days after onset of appropriate antimicrobial therapy. ||2014 recommendation remains current.
|-
| bgcolor="LightGreen" | I || bgcolor="LightBlue" | C ||Surgery is recommended for patients with prosthetic valve endocarditis and relapsing infection (defined as recurrence of bacteremia after a complete course of appropriate antibiotics and subsequently negative blood cultures) without other identifiable source for portal of infection. ||2014 recommendation remains current.
|-
| bgcolor="LightGreen" | I || bgcolor="LightBlue" | B ||Complete removal of pacemaker or defibrillator systems, including all leads and the generator, is indicated as
part of the early management plan in patients with IE with documented infection of the device or leads.
|2014 recommendation remains current.
|-
| bgcolor="LemonChiffon" | IIa || bgcolor="LightBlue" | B ||Complete removal of pacemaker or defibrillator systems, including all leads and the generator, is reasonable in patients with valvular IE caused by S. aureus or fungi, even without evidence of device or lead infection. ||2014 recommendation remains current.
|-
| bgcolor="LemonChiffon" | IIa || bgcolor="LightBlue" | C ||Complete removal of pacemaker or defibrillator systems, including all leads and the generator, is reasonable in patients undergoing valve surgery for valvular IE. ||2014 recommendation remains current.
|-
| bgcolor="LemonChiffon" | IIa || bgcolor="LightBlue" | B ||Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) is reasonable in patients with IE who present with recurrent emboli and persistent vegetations despite appropriate antibiotic therapy. ||2014 recommendation remains current.
|-
| bgcolor="LemonChiffon" | IIb || bgcolor="LightBlue" | B ||Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) may be considered in patients with native valve endocarditis who exhibit mobile vegetations greater than 10 mm in length (with or without clinical evidence of embolic phenomenon). ||2014 recommendation remains current.
|-
| bgcolor="LemonChiffon" | IIb || bgcolor="LightBlue" | B-NR ||Operation without delay may be considered in patients with IE and an indication for surgery who have suffered a stroke but have no evidence of intracranial hemorrhage or extensive neurological damage. ||'''{{Fontcolor|#FF0000|NEW:}}''' The risk of postoperative neurological deterioration is low after a cerebral event that has not resulted in extensive neurological damage or intracranial hemorrhage. If surgery is required after a neurological event, recent data favor early surgery for better overall outcomes.
|-
| bgcolor="LemonChiffon" | IIb || bgcolor="LightBlue" | B-NR ||Delaying valve surgery for at least 4 weeks may be considered for patients with IE and major ischemic stroke or intracranial hemorrhage if the patient is hemodynamically stable. ||'''{{Fontcolor|#FF0000|NEW:}}''' In patients with extensive neurological damage or intracranial hemorrhage, cardiac surgery carries a high risk of death if performed within 4 weeks of a hemorrhagic stroke.
|}


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}


[[Category:Emergency medicine]]
[[Category:Cardiology]]
[[Category:Cardiology]]
[[Category:Emergency medicine]]
 
[[Category:Infectious disease]]
[[Category:Intensive care medicine]]
[[Category:Intensive care medicine]]
 
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Latest revision as of 13:37, 26 October 2017
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2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease

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Endocarditis antibiotic prophylaxis On the Web

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Michael W. Tempelhof, M.D.; Arzu Kalayci, M.D. [3]

Overview

Administration of antibiotic prophylaxis is only recommended to high-risk patients undergoing specific procedures. Generally, amoxicillin 30-60 minutes prior to the procedure is preferred for prophylaxis against endocarditis.

Antibiotic Prophylaxis

Antimicrobial Regimen

  • 1. Prophylactic Regimens for Dental Procedures[1][2][3]
  • 1.1 Oral regimen
  • Preferred regimen: Amoxicillin 2 g PO single dose (30-60 minutes before procedure)
  • Pediatric dose: Amoxicillin 50 mg/kg PO single dose (30-60 minutes before procedure)
  • 1.2 Unable to take oral medication
  • Preferred regimen: Ampicillin 2 g IM/IV single dose (30-60 minutes before procedure) OR Cefazolin 1 g IM/IV single dose (30-60 minutes before procedure) OR Ceftriaxone 1 g IM/IV single dose (30-60 minutes before procedure)
  • Pediatric dose: Ampicillin 50 mg/kg; Cefazolin 50 mg/kg; Ceftriaxone 50 mg/kg
  • 1.3 Allergic to penicillins or ampicillin - Oral regimen
  • 1.4 Allergic to penicillins or ampicillin and unable to take oral medication
  • Preferred regimen: Cefazolin 1 g IM/IV single dose (30-60 minutes before procedure) OR Ceftriaxone 1 g IM/IV single dose (30-60 minutes before procedure) OR Clindamycin 600 mg IM/IV single dose (30-60 minutes before procedure)
  • Pediatric doses: Cefazolin 50 mg/kg; Ceftriaxone 20 mg/kg
  • 2. Gastrointestinal/Genitourinary Procedures
  • Preferred regimen: Antibiotic prophylaxis to prevent IE is no longer recommended for patients who undergo a GI or GU tract procedure.
  • Note: High risk patients who already have an established GI or GU tract infection, it is reasonable to administer Ampicillin 2 g IM/IV single dose
  • 3. Regimens for Respiratory Tract Procedures
  • 3.1 Oral regimen
  • Preferred regimen: Amoxicillin 2 g single dose (30-60 minutes before procedure)
  • Pediatric dose: Amoxicillin 50 mg/kg single dose (30-60 minutes before procedure)
  • 3.2 Unable to take oral medication
  • Preferred regimen: Ampicillin 2 g IM/IV single dose (30-60 minutes before procedure) OR Cefazolin 1 g IM/IV single dose (30-60 minutes before procedure) OR Ceftriaxone 1 g IM/IV single dose (30-60 minutes before procedure)
  • 3.3 Allergic to penicillins or ampicillin — Oral regimen
  • Allergic to penicillins or ampicillin and unable to take oral medication
  • Preferred regimen: Cefazolin 1 g IM/IV single dose (30-60 minutes before procedure) OR Ceftriaxone 1 g IM/IV single dose (30-60 minutes before procedure) OR Clindamycin 600 mg IM/IV (30-60 minutes before procedure)
  • Pediatric doses: Cefazolin 50 mg/kg; Ceftriaxone 20 mg/kg
  • 4. Regimens for Procedures on Infected Skin, Skin Structure, or Musculoskeletal Tissue
  • Patients who undergo a surgical procedure that involves infected skin, skin structure, or musculoskeletal tissue, it may be reasonable that the therapeutic regimen administered for treatment of the infection contain an agent active against staphylococci and beta-hemolytic streptococci, such as an antistaphylococcal penicillin or a cephalosporin.

Impact of Restricting Prophylactic Antibiotics

There is data showing that the institution of these more restrictive guidelines does not increase the risk of endocarditis. The NICE guidelines recommended no antibiotic prophylaxis for any patient, and despite a 78.6% reduction in the administration of IE prophylaxis, there was no documentation of an increase in IE cases due to streptococci.[4] In France, following restricted use of antibiotics the incidence of IE was stable.[5]

2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease (VHD)

Recommendation for Infective Endocarditis (IE) Prophylaxis

COR LOE RECOMMENDATION COMMENT/RATIONALE
IIa C-LD Prophylaxis against IE is reasonable before dental procedures that involve manipulation of gingival tissue, manipulation of the periapical region of teeth, or perforation of the oral mucosa in patients with the following:

1. Prosthetic cardiac valves, including transcatheter- implanted prostheses and homografts.

2. Prosthetic material used for cardiac valve repair, such as annuloplasty rings and chords.

3. Previous IE.

4. Unrepaired cyanotic congenital heart disease or repaired congenital heart disease, with residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch or prosthetic device.

5. Cardiac transplant with valve regurgitation due to a structurally abnormal valve.

MODIFIED: LOE updated from B to C-LD. Patients with transcatheter prosthetic valves and patients with prosthetic material used for valve repair, such as annuloplasty rings and chords, were specifically identified as those to whom it is reasonable to give IE prophylaxis. This addition is based on observational studies demonstrating the increased risk of developing IE and high risk of adverse outcomes from IE in these subgroups. Categories were rearranged for clarity to the caregiver.

Recommendations for Infective Endocarditis Intervention

COR LOE RECOMMENDATION COMMENT/RATIONALE
I B Decisions about timing of surgical intervention should be made by a multispecialty Heart Valve Team of cardiology, cardiothoracic surgery, and infectious disease specialists. 2014 recommendation remains current.
I B Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) is indicated in patients with IE who present with valve dysfunction resulting in symptoms of HF. 2014 recommendation remains current.
I B Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) is indicated in patients with left-sided IE caused by S. aureus, fungal, or other highly resistant organisms. 2014 recommendation remains current.
I B Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) is indicated in patients with IE complicated by heart block, annular or aortic abscess, or destructive penetrating lesions. 2014 recommendation remains current.
I B Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) for IE is indicated in patients with evidence of persistent infection as manifested by persistent bacteremia or fevers lasting longer than 5 to 7 days after onset of appropriate antimicrobial therapy. 2014 recommendation remains current.
I C Surgery is recommended for patients with prosthetic valve endocarditis and relapsing infection (defined as recurrence of bacteremia after a complete course of appropriate antibiotics and subsequently negative blood cultures) without other identifiable source for portal of infection. 2014 recommendation remains current.
I B Complete removal of pacemaker or defibrillator systems, including all leads and the generator, is indicated as

part of the early management plan in patients with IE with documented infection of the device or leads.

2014 recommendation remains current.
IIa B Complete removal of pacemaker or defibrillator systems, including all leads and the generator, is reasonable in patients with valvular IE caused by S. aureus or fungi, even without evidence of device or lead infection. 2014 recommendation remains current.
IIa C Complete removal of pacemaker or defibrillator systems, including all leads and the generator, is reasonable in patients undergoing valve surgery for valvular IE. 2014 recommendation remains current.
IIa B Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) is reasonable in patients with IE who present with recurrent emboli and persistent vegetations despite appropriate antibiotic therapy. 2014 recommendation remains current.
IIb B Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) may be considered in patients with native valve endocarditis who exhibit mobile vegetations greater than 10 mm in length (with or without clinical evidence of embolic phenomenon). 2014 recommendation remains current.
IIb B-NR Operation without delay may be considered in patients with IE and an indication for surgery who have suffered a stroke but have no evidence of intracranial hemorrhage or extensive neurological damage. NEW: The risk of postoperative neurological deterioration is low after a cerebral event that has not resulted in extensive neurological damage or intracranial hemorrhage. If surgery is required after a neurological event, recent data favor early surgery for better overall outcomes.
IIb B-NR Delaying valve surgery for at least 4 weeks may be considered for patients with IE and major ischemic stroke or intracranial hemorrhage if the patient is hemodynamically stable. NEW: In patients with extensive neurological damage or intracranial hemorrhage, cardiac surgery carries a high risk of death if performed within 4 weeks of a hemorrhagic stroke.

References

  1. ↑ Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA; et al. (2014). "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines". Circulation. 129 (23): 2440–92. doi:10.1161/CIR.0000000000000029. PMID 24589852.
  2. ↑ Vahanian A, Alfieri O, Andreotti F, Antunes MJ, Baron-Esquivias G, Baumgartner H; et al. (2013). "[Guidelines on the management of valvular heart disease (version 2012). The Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)]". G Ital Cardiol (Rome). 14 (3): 167–214. doi:10.1714/1234.13659. PMID 23474606.
  3. ↑ Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M; et al. (2007). "Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group". Circulation. 116 (15): 1736–54. doi:10.1161/CIRCULATIONAHA.106.183095. PMID 17446442.
  4. ↑ Thornhill MH et al. BMJ 2011;342:d2392.
  5. ↑ Duval X, et al. J Am Coll Card 2012;59:1968-76.

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