Endocarditis antibiotic prophylaxis: Difference between revisions
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==Antibiotic Prophylaxis with Dental Procedures Background== | ==Antibiotic Prophylaxis with Dental Procedures Background== | ||
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. | |||
Major changes include: | |||
*Consideration that frequent exposures to [[bacteremias]] associated with daily activities are considered more likely to induce endocarditis than are endodontic-procedural induced [[bacteremias]]. | |||
In 1955, the American Heart Association (AHA) published the first of ten subsequent | #Optimal oral hygiene is emphasized as an important practice for endocarditis prevention. | ||
#A patient’s lifetime acquisition risk of endocarditis is no longer a consideration for initiating prophylactic antibiotic therapy. | |||
#Optimal oral hygiene is emphasized as an important practice for | |||
#A patient’s lifetime acquisition risk of | |||
#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. | #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. | ||
<blockquote>'''2007 AHA Guideline Recommendation for Which patients require Antiobiotic Prophylaxis Prior to Dental Procedure are those with documented'''</blockquote> | <blockquote>'''2007 AHA Guideline Recommendation for Which patients require Antiobiotic Prophylaxis Prior to Dental Procedure are those with documented'''</blockquote> | ||
Revision as of 22:56, 20 March 2011
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Associate Editors-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Template:MWT
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Antibiotic Prophylaxis with Dental Procedures Background
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.[1] 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. Major changes include:
- Consideration that frequent exposures to bacteremias associated with daily activities are considered more likely to induce endocarditis than are endodontic-procedural induced bacteremias.
- Optimal oral hygiene is emphasized as an important practice for endocarditis prevention.
- A patient’s lifetime acquisition 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.
2007 AHA Guideline Recommendation for Which patients require Antiobiotic Prophylaxis Prior to Dental Procedure are those with documented
- Prosthetic cardiac valve.
- Previous IE
- Cardiac transplantation recipients who develop cardiac valvulopathy.
- Congential heart disease:
- Unrepaired cyanotic CHD: shunts and conduits
- Completely repaired congential heart defect during 1st 6months following procedure.
- Repaired CHD with residual defects at site of prostetic patch or device.
Endodontic Procedures and Endocarditis risk
- Following dental intervention, the absolute risk for developing IE is estimated at 1 case per 14 million dental procedures.[2]
- IE acquisition risk estimates following an endodontic induced bacteremia in patients with congenital heart disease are 1 per 475,000; rheumatic heart disease, 1 per 142,000; prosthetic heart valve, 1 per 114,000; and previous IE, 1 per 95,000 dental procedures.[3]
- 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.[4]
- The most recent case-control study of 104 patients with known, high-risk structural heart disease discovered that patients who developed IE 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]).[5]
- 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.[6]
- 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.
These findings have led the AHA to conclude 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.
Prophylactic Antibiotic Efficacy
- 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.[7]
- 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,[8]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[9]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[10]
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%.[11]
- Fatal anaphylaxis among patients receiving single-dose penicillin, ampillicin or amoxicillin therapy is approximately 20 cases per 1 million patients treated.[12]
- Single-dose, cephalosporin-associated fatal anaphylaxis risk is estimated at 0.5-5.7 cases per 10 million patients treated.[13]
- Macrolide and clindamycin single-dose fatal anaphylaxis risk is estimated at 0-5 cases per 1 million patients treated.[14]
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.[15]
- 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.
SUMMARY for antibiotic prophlaxis prior to endodontic procedure
- The presumed correlation of endodontic induced bacteremia, and new onset IE 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 IE 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.
- Case-control studies have reported conflicting results on the protective efficacy conferred from providing pre-procedural antibiotic prophylaxis to at-risk patients.
The AHA acknowledges that even if chemoprophylaxis conferred 100% efficacy, few cases of IE would be prevented as the incidence of endodontic induced IE is so low.
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 IE.
- 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 from a single-dose of pre-dental IE prophylaxis oral amoxicillin.
- The 2007, AHA guidelines appropriately advocate against providing chemoprophylaxis to moderate-risk patients and appropriately advocate for chemoprophylaxis to high-risk patients prior to endodontic procedure as this is a cost-effective practice for IE prevention.
Finally, there are other events 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.
In this limited patient population, prophylactic antimicrobial therapy should be directed against Streptococcus viridans.
As a summary; individuals at the highest risk group who need procedures listed below require proper antibiotic prophylaxis;[16]
- Any type of dental extractions
- Any type of periodontal procedures and gingival surgery
- 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
Antibiotic prophylaxis with Procedures on Infected Skin, Skin Structure, or Musculoskeletal Tissue
These infections are often polymicrobial, but only staphylococci and beta hemolytic beta-hemolytic streptococci are likely to cause Infective Endocarditis.
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 beta-hemolytic streptococci, such as an antistaphylococcal penicillin or a cephalosporin.
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.[16]
References
- ↑ 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.
- ↑ Pallasch TJ. Antibiotic prophylaxis: problems in paradise. Dent Clin North Am. 2003;47:665-679.
- ↑ Pallasch TJ, Wahl MJ. Focal infection: new age or ancient history? Endodontic Topics. 2003;4:32-45.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Oliver R, Roberts GJ, Hooper L. Penicillins for the prophylaxis of bacterial endocarditis in dentistry. Cochrane Database of Systematic Reviews 2004, Issue 2.
- ↑ 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.
- ↑ 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.
- ↑ Imperiale TF, Horwitz RI. Does prophylaxis prevent post-dental infective endocarditis? A controlled evaluation of protective efficacy. Am J Med. 1990;88:131-136.
- ↑ 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.
- ↑ 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.
- ↑ Kelkar P,James T. Current concepts: cephalosporin allergy. N Engl J Med. 2001;345:804-9.
- ↑ Mazur N, Greenberger P, Regalado J. Clindamycin hypersensitivity appears to be rare. Ann Allergy Asthma Immunol. 1999;82:443–5.
- ↑ Agha Z, Lofgren RP, VanRuiswyk JV. Is antibiotic prophylaxis for bacterial endocarditis cost-effective? Med Decis Making. 2005;25:308-320.
- ↑ 16.0 16.1 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 (2007). "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". Circulation. 116 (15): 1736–54. PMID 17446442.