Natasha Press (biography and disclosures)
What I have noticed in the management of this condition
For more than 50 years, the American Heart Association (AHA) has been recommending antibiotic prophylaxis before invasive procedures to prevent infectious endocarditis. The rationale for antibiotic prophylaxis is to eliminate bacteremia that could cause endocarditis. Although antibiotic prophylaxis remains standard of care, there is limited data to support its use. In fact, we know that transient bacteremia occurs due to daily activities, such as chewing or brushing teeth, and not just from invasive procedures. Therefore, the most recent AHA guidelines (2007) have limited antibiotic prophylaxis to those patients at highest-risk for developing endocarditis and who are undergoing high-risk invasive procedures.1
There has also been a paucity of data regarding whether patients with prosthetic joints should receive antibiotic prophylaxis to prevent prosthetic joint infections.2
Some authorities question the routine use of antibiotics, arguing that its use is unproven, expensive, and potentially harmful in terms of emergence of resistant organisms, and adverse effects.3 Since 2008, the United Kingdom has stopped all antibiotic prophylaxis, and they have not noticed a large increase in the incidence of infective endocarditis since then (although their data is limited).4
Data that answers these questions or gaps
The Cochrane Oral Health Group carried out a review to determine if antibiotic prophylaxis was necessary in patients at high-risk for infective endocarditis. They concluded that there is a lack of evidence to support previously published guidelines, and that it is unclear whether taking antibiotics is effective or not.3
The United Kingdom did a before-and-after study to determine if their policy of no antibiotic prophylaxis impacted the rate of endocarditis. They concluded that there was not a significant increase in cases of endocarditis since stopping antibiotic prophylaxis. However, they felt that further data was needed to determine if antibiotic prophylaxis still has a role in high-risk patients.4
What I recommend
I follow the AHA 2007 guidelines and recommend antibiotic prophylaxis to high-risk patients undergoing high-risk procedures.
High-risk patients include:
- Patients with prosthetic heart valves (mechanical or tissue), or prosthetic material used for cardiac valve repair
- Patients with a prior history of infective endocarditis
- Cardiac transplant patients with leaflet pathology/regurgitation
- Some patients with congenital heart disease, including unrepaired cyanotic, repaired with prosthetic material within 6 months, and repaired with residual defects at the site of the prosthetic device
High-risk procedures include:
- Dental: manipulation of gingival tissue or oral mucosa (NOT routine cleaning, anaesthetic injection through tissue, or placement of orthodontic appliances)
- Respiratory: incision/biopsy of respiratory tract mucosa (e.g. tonsillectomy, bronchoscopy with biopsy)
- Genitourinary: no prophylaxis
- Gastrointestinal: no prophylaxis
- Skin and musculoskeletal: no prophylaxis
The only time to recommend antibiotic prophylaxis in genitourinary, gastrointestinal, skin, and musculoskeletal invasive procedures is when the procedure involves an area of active infection.
When antibiotic prophylaxis is necessary, I recommend single-dose amoxicillin 2 g (other options for patients with amoxicillin allergy include a single-dose of: cephalexin 2 g, or azithromycin 500 mg, or clindamycin 600 mg).
For patients with prosthetic joints, I follow the Canadian Dental Association Position Statement (2013). It recommends no antibiotic prophylaxis for patients with prosthetic joint undergoing dental procedures, or gastrointestinal or genitourinary procedures. So, I don’t recommend antibiotic prophylaxis to prevent prosthetic joint infections.
Although controversy still exists regarding the value of antibiotic prophylaxis to prevent infective endocarditis, there is consensus that excellent dental hygiene is important to prevent transient bacteremia leading to endocarditis. I try to get my patients, especially those with poor dental care, to see a dentist, and to practice dental hygiene.
- Wilson W. et al. Prevention of infective endocarditis: 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. 2007; 116:1736-54. (View with CPSBC or UBC)
- 2013 CDA Position on Dental Patients with Prosthetic Joint Replacement. J Can Dent Assoc. 2013; 79:d126. (http://www.jcda.ca/article/d126, Free full text)
- Glenny A.M., Oliver R., Roberts G.J., Hooper L., Worthington H.V. Antibiotics for the prophylaxis of bacterial endocarditis in dentistry. Cochrane Database of Systematic Reviews. 2013; Issue 10. Art. No.: CD003813. (View with CPSBC or UBC)
- Thornhill M., Dayer, M.J., Forde, J.M., Corey, G.R., Chu, V.H., Couper, D.J., and Lockhart, P.B. Impact of the NICE guideline recommending cessation of antibiotic prophylaxis for prevention of infective endocarditis: before and after study. BMJ. 2011; 342:d2392. (View with CPSBC or UBC)