Perspectives on Antibiotic Prophylaxis in Dentistry

Report
Perspectives on the 2007 AHA
guidelines for the prevention of infective
endocarditis
Nelson L. Rhodus, DMD, MPH, FACD
Professor
Academy of Distinguished Professors
Director, Division of Oral Medicine, Dental School
Adjunct Professor, Otolaryngology, Medical School
Diplomate, American Board of Oral Medicine
University of Minnesota
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Basis for Past AHA Guidelines
1. True or false
 Dental procedures were the source of the
bacteremias leading to IE
Basis for Past AHA Guidelines

Dental procedures were the source of the
bacteremias leading to IE

(False, Daily activities much more likely the
source)
Basis for Past AHA Guidelines


2. True or false
Magnitude of dental procedure bacteremias
were far greater than daily activities
Basis for Past AHA Guidelines

Magnitude of dental procedure bacteremias
were far greater than daily activities

(False, they are about the same, both relatively
low magnitude)
Basis for Past AHA Guidelines

3. True or false

Bleeding is the indication for bacteremia
occurring
Basis for Past AHA Guidelines

Bleeding is the indication for bacteremia
occurring

(False, it is not a reliable predictor for
bacteremia)
Basis for Past AHA Guidelines

4. True or false Prophylaxis reduces the risk of
IE from occurring
Basis for Past AHA Guidelines

Prophylaxis reduces the risk of IE from occurring


(False, antibiotics may reduce the magnitude of the
bacteremia, no evidence they will reduce the
incidence of IE)
Basis for Past AHA Guidelines

5. True or false The new 2007 guidelines are
significantly different than any previous guidelines
Basis for Past AHA Guidelines

The new 2007 guidelines are significantly
different than any previous guidelines

TRUE !
Basis for Past AHA Guidelines





Based on unproven assumptions
Dental procedures were the source of the bacteremias
leading to IE (False, Daily activities much more likely the
source)
Magnitude of dental procedure bacteremias were far greater
than daily activities (False, they are about the same, both
relatively low magnitude)
Bleeding is the indication for bacteremia occurring (False,
it is not a reliable predictor for bacteremia)
Prophylaxis reduces the risk of IE from occurring
(antibiotics may reduce the magnitude of the bacteremia,
no evidence they will reduce the incidence of IE)
Rational for 2007 Guidelines
Previous 9 AHA Guidelines – Based on the
lifetime risk for IE
 New Guidelines – Based on the risk for an
adverse outcome

2007 AHA Guidelines

First made public at the annual American Academy of Oral Medicine
meeting on May 19, 2007 in San Diego, CA.
www.aaom.com

Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et
al. Prevention of Infective Endocarditis: Guidelines From The American Heart
Association. Circulation 2007; 115:1-17. Available at
http://www.circulationaha.org, DOI:10.1116/circulationAHA.106.18309.

Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et
al. Prevention of Infective Endocarditis: Guidelines From The American Heart
Association. J Am Dent Assoc 2007:138 (6): 739-760.
Conditions Recommended for
Prophylaxis in 1997 vs 2007

High-risk lesions

Intermediate-risk

Prosthetic heart valves
Previous endocarditis
Cyanotic CHD
Aortic valve disease
Mitral regurgitation
Patent ductus arteriosus
Ventricular septal defect
Coarctation of aorta

MVP with regurgitation
Mitral stenosis
Tricuspid valve disease
Pulmonary stenosis
Septal hypertrophy
Degenerative valvular
disease in older patients
Nonvalvular intracardiac
prosthetic implants













The AHA cites the following reasons for
revision of the 1997 guidelines:


IE is much more likely to result from frequent exposure to
random bacteremias associated with daily activities than
from bacteremia caused by a dental procedure
Prophylaxis may prevent an exceedingly small number,
if any, cases of IE in individuals who undergo a dental


procedure
The risk of antibiotic associated adverse events exceeds
the benefit, if any, from prophylactic antibiotic therapy
Maintenance of optimal oral health and hygiene may
reduce the incidence of bacteremia from daily activities and
is more important than prophylactic antibiotics for a dental
procedure to reduce the risk of IE
Infective Endocarditis:
hypothetical association with
dental treatment ?
Invasive dental procedures>>>>transient
systemic bacteremia (6 min.)
 transient systemic bacteremia (6 min.)
>>>>> colonization of susceptible
endocardial surfaces ??????
 colonization of susceptible endocardial
surfaces ??????>>>>>>>>IE ??????

Infective Endocarditis:
hypothetical association with
dental treatment ?
J. Antimicrobial Chemotherapy, 4-19-2006
 A study of 273 patients = no link between
dental treatment and IE (Strom BL.,
Ann Int Med 1998 129:761-9)
 Cochrane review: no evidence to support
antimicrobial prophylaxis to prevent IE in
invasive dental procedures( Oliver R. 2006)
 Evidence-based…doesn’t exist

Rheumatic Heart
Disease
immune reaction to Streptococci or products
 fibrosis, calcification, scarring on valve
( usually mitral or aortic)
 damaged & dysfunctional valve leaflets
 murmur
 ventricular dilatation and hypertrophy
 CHF

Rheumatic Heart Disease:
concerns







angina
Arrhythmia
dyspnea
epistaxis
CHF
PV
IE
Prosthetic heart valve
usually mitral dysfunction
RF...RHD……... CHF
synthetic replacement = PV
Tissue Prosthetic Heart Valve
Little JW, Dental Management of the Medically Compromised Patient, Mosby, 2007, p 21
Infective endocarditis

fever, murmur, weakness, fatigue, malaisse,
anemia,visual problems, GI, weight loss,
fever, chills, night sweats, arthralgia,
ngina, hematuria, paresthesias or
paralysis, petechiae, Osler nodes,
Janeway lesions, retinal hemorrhages
Infective endocarditis
Has the risk changed ?
 Dx (Duke) criteria
 The use of antibiotic prophylaxis has not
changed the incidence of IE in > 50 years!

Infective endocarditis





Risk of a brain abcess resulting from extracting a tooth is
1: 10 million !
Risk of a LPJRI resulting from extracting a tooth is
1: 2.5 million !
Risk of IE resulting with a MVP-r from extracting a tooth
is 1: 1 million !
Risk of IE resulting with RHD from extracting a tooth is
1: 150,000 !
Risk of IE resulting with PVR from extracting a tooth is
1: 95,000 !
Infective endocarditis



Risk of IE resulting with PVR from extracting a tooth is
1: 95,000 !
Risk of IE resulting with any heart condition from any
dental procedure is 1:14 million !
If 10 million patients at risk undergo dental treatment
without prophylaxis 20 will get IE and 2 will die, but more
than 10 will die from acute anaphylaxis from the PCN !
Agha Z, et.al. Med. Dec. Mak. 2005 25:308-320.
Rheumatic Fever and Rheumatic
Heart Disease

mitral valve damaged 60% of those defects
 as
many as 30-40 % of cases are
un-diagnosed



Signs-symptoms
pharyngitis, athralgia,carditis, chorea, fever,
erythema marginatum, sub-q nodules, dyspnea
lab values: ESR, EKG( PR interval), strep Ab
Reported Frequency of Bacteremias Associated With
Various Dental Procedures and Daily Activities

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Procedure
Tooth extraction
Periodontal surgery
Scaling and root planing
Teeth cleaning
Rubber dam matrix/wedge
placement
Endodontic procedures
Daily Activities
Tooth brushing and flossing
Use of wooden toothpicks
Use of water irrigation devices
Chewing food

Frequency of bacteremia
10-100%
36-88%
8-80%
≤ 40%
9-32%

≤ 20%

20-68%
20-40%
7-50%
7-51%





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Initiating Bacteremia
Dental Procedures
 Most (if not all) are not associated with the
onset of IE.
 If a dental procedure is possibly associated
with the cause of IE, the symptoms of IE
should appear within less than 2 weeks.
(2:300 law suits…Pallasch)

Endocarditis prophylaxis
recommended

The new guidelines recommend that only
individuals who are at the highest risk of
an adverse outcome receive antibiotic
prophylaxis, and they include:
Endocarditis prophylaxis
recommended
*
*
*
Prosthetic cardiac valve
Previous infective endocarditis (IE)
Congenital heart disease (CHD)
with :
Endocarditis prophylaxis
recommended



- Unrepaired cyanotic CHD, including
palliative shunts and conduits
- Completely repaired CHD defect with
prosthetic material or device for first 6 months
after procedure
- Repaired CHD with residual defects at the
site or adjacent to site of prosthetic patch/
device which inhibit endothelializtion
- Cardiac transplantation recipients who
develop cardiac valvulopathy
Endocarditis prophylaxis

Compared with previous AHA guidelines,
far fewer patients will receive IE
prophylaxis. Consequently, many patients
who previously were premedicated for
dental procedures are no longer
recommended for prophylactic antibiotic
coverage.
Endocarditis prophylaxis
The AHA committee feels that IE is
much more likely to result form frequent
exposure to transient bacteremia associated
with daily activities (brushing, chewing food)
than from bacteremia caused by a dental
procedures..
*
*
Prophylaxis may prevent an exceedingly
small number of cases of IE (if any) in
individuals who undergo a dental procedure.
Endocarditis prophylaxis
*
The risk of antibiotic-associated adverse
events exceeds the benefit (if any) from
prophylactic antibiotic therapy.
*
Maintenance of optimal oral health and
hygiene may reduce the incidence of
bacteremia from daily activities and is more
important than prophylactic antibiotics for a
dental procedure in reducing the risk of IE.
Conditions Recommended for
Coverage in 2007





Based on greatest risk for adverse outcome
Prosthetic Cardiac Valve
Previous Infective Endocarditis
Congenital Heart Disease (CHD)
 Unrepaired cyanotic CHD including those with
palliative shunts and conduits
 Completely repaired CHD with prosthetic material or
device for first 6 months
 Repaired CHD with residual defects at the site
Cardiac Transplantation Recipients who Develop Cardiac
Valvulopathy
Endocarditis prophylaxis NOT
recommended (1997 vs 2007)
functional heart murmurs
 post-coronary surgeries > 6 mos.
 RF, RHD, most congential defects
 MVP with or without regurgitation
 pacemakers

Conditions Recommended for
Prophylaxis in 1997 vs 2007

High-risk lesions

Intermediate-risk

Prosthetic heart valves
Previous endocarditis
Cyanotic CHD
Aortic valve disease
Mitral regurgitation
Patent ductus arteriosus
Ventricular septal defect
Coarctation of aorta

MVP with regurgitation
Mitral stenosis
Tricuspid valve disease
Pulmonary stenosis
Septal hypertrophy
Degenerative valvular
disease in older patients
Nonvalvular intracardiac
prosthetic implants








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
1997 : Endocarditis prophylaxis
NOT recommended
routine restorative procedures
 placement of rubber dams
 routine local anesthetic injections
 intracanal endo; suture removal
 impressions, fluoride, radiographs
 insertion or adjustment of removable
prosthetic or ortho appliances

1997 : Endocarditis prophylaxis
recommended
extractions
 perio surgery-scaling-probing-prophy
 implants( or re-implantation)
 endo(only beyond apex)
 subgingival manipulation( antibiotic fibers)
 initial placement of ortho bands
 intraligamentary injections

2007 : Endocarditis prophylaxis
recommended
Any procedure which abrogates the mucosal
barrier and causes ANY bleeding !
 The amount of bleeding has no impact upon
the risk for IE !

2007 AHA Guidelines – Dental Procedures
recommended for Prophylaxis

All Dental Procedures that involve
manipulation of gingival tissue or the
periapical region of teeth or perforation of
the oral mucosa. (Includes many procedures
that in the 1997 guidelines were not
recommended for coverage)
Prevention of Infective
Endocarditis : NOTE
The MOST important factor is to maximize
oral health and reduce oral microflora
 minimize oral tissue trauma
 periodontal and plaque control
 antimicrobial mouthrinses
 proper AHA prophylactic regimen ONLY
when indicated

Prevention of Infective
Endocarditis :



standard : Amoxicillin- 2 g; 30-60 min. pre-op
IM or IV: Ampicillin-2g; 30 min. pre-op
allergic : Clindamycin- 600mg; 30-60 min.
pre-op
Cephalexin- 2 g one-hour pre-op
 Cefadroxil
 Azithromycin

or Clarithromycin- 500mg-1 hr.
aller-npo: Clindamycin- 600mg -IV;
-
or Cefazolin- 1 g; 30 min. pre-op
Antibiotic prophylaxis
Does
it really do any
good ?
Amoxicillin
Bioavailability > 95 %
 Rapid GI absorption from po
 Works fast
 Resistance ( >95 % K. pneumoniae in Japan)

Antibiotic Prophylaxis

Antibiotic Resistance
About 17% to 50% of the viridans group of
streptococci are resistant to penicillin and 13% to
27% are resistant to clindamycin.
Impact on IE prevention is unknown.
Infective endocarditis



2007…..there is no evidence that dental treatment
causes infective endocarditis or that antibiotic
prophylaxis is preventive
>95% of IE = no relation at all to dental Tx
physiologic bacteremias
regular toothbrushing
= 0-40%
chewing
= 17-51 %
cleaning-irrigating devices
= 7-50%
random periodontal disese
= 11-20%
Infective endocarditis
Toothbrushing 2 x daily = 150,000 times
risk if IE than extracting a tooth !
 All daily activities= 5 million times risk if
IE than extracting a tooth !

Endocarditis prophylaxis issues







already on previous regimen
already on an antibiotic ( lower dose)
how much dental treatment (appt. length)
interval between appointments
Patient forgot to take the antibiotic
IBD( colitis) and clindamycin
not the same as prevention of late prosthetic joint
infections
Antibiotic prophylaxis





If prophylaxis is not possible, administering the
antibiotic within 2 hours may help prevent IE
time between prophylaxis coverage periods
= 10 days ! Do as much treatment as
possible during coverage period
Rx’d antibiotics (not sufficient type or dose)
Pre-op antimicrobial mouthrinses have not shown
any benefit
monitor for signs-symptoms of IE
2007 AHA Guidelines
Patients who undergo cardiac
surgery
 A careful dental evaluation is recommended
so that required dental treatment may be
completed whenever possible before
cardiac valve surgery or replacement or
repair of CHD.

Endocarditis Prevention

Current practice

Identify the susceptible patient and use antibiotic
prophylaxis for indicated dental procedures
Medical referral to establish current status may be needed
to for patients with CHD corrected with prosthetic
material or devices.
Within 6 months of corrective surgery
Residual defect (leakage)



Nonvalvular Cardiovascular Devices
AHA does not recommend prophylaxis







Pacemakers
Defibrillators
Left ventricular assist
devices
Total artificial hearts
Arteriovenous fistulae
Closure devices for ASD,
PDA, AVF
Hemodialysis grafts







Vascular grafts
Intra-aortic balloon pumps
Dacron grafts and patches
Vena caval filters
Vascular closure devices
Ventriculoatrial shunts
Coronary artery stents
AHA, Scientific statement on Nonvalvular Cardiovascular Devices. Circulation, 108: 2015, 2003.
Nonvalvular Cardiovascular Devices

AHA does recommend Prophylaxis

Incision and Drainage of infection at other sites (I & D of dental
abscess)
Extraction of teeth or surgical procedures performed in areas of
acute infection
Residual leak following closure of PDA, ASD, VSD (follow AHA
guidelines)


AHA, Scientific statement on Nonvalvular Cardiovascular Devices. Circulation, 108: 2015, 2003.
Impact of 2007 Guidelines



Patients who have taken antibiotics for years to prevent IE
and now no longer are recommended to do such.
Patients who are still recommended to be covered but now
for just about all dental procedures.
Explain rational for new guidelines, answer questions,
consult with patient’s physician – informed consent
(record in progress notes).
Impact of 2007 Guidelines
Pallasch TJ. CDAJ 2007:35(7): 507-11

MD or patient non-acceptance: they can provide
the Rx “upon their own authority “
“
Based upon the best current scientific
evidence as published by the AHA, and
my best clinical judgement. “
Congenital heart diseasedental concerns
 Endocarditis
 Congestive
heart failure
 Endarteritis
 Excessive
 Cyanosis
 Infection
bleeding
What is Next

2007 Guidelines – Foundation set

Dental procedures not cause
No evidence that prophylaxis is effective
Adverse reactions to antibiotics
Increasing rate of resistance to antibiotics
The next set of AHA guidelines will not
recommend prophylaxis for any dental procedure
even in patients with cardiac lesions with the
greatest risk for adverse outcomes




QuickTime™ and a
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QuickTime™ and a
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QuickTime™ and a
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QuickTime™ and a
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are needed to see this picture.
QuickTime™ and a
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Prevention of Endocarditis

General concepts

Goal of “infection free” oral cavity
Follow the current (2007) AHA guidelines for selection of cardiac
conditions and dental procedures needing prophylaxis
Reduce gingival inflammation before performing restorative
procedures
Establish effective home care practices
Chlorhexidine mouth rinse can be used prior to periodontal or
surgical procedures, however several studies suggest no real benefit




Prevention of Endocarditis

General principles Cont.

Coverage is effective for 4-6 hours
Do as much dental treatment as possible during each
coverage period
Allow at least 9 days to elapse between coverage periods.
If this is not possible select an alternant antibiotic
Be alert for signs and symptoms of IE in patients
receiving antibiotic prophylaxis and those with cardiac
lesions at risk for IE



plasma levels of prophylactic antibiotics
µg/ml
3g Amox
7
5
3
2 g Amox
1.5 g Amox
1 g PenVK
------------------------------------------------
hours
1
4
6
10
Late Prosthetic Joint Infections

Wahl’s myths:
#1: There are similarities between IE
(PVE) and LPJI.
NO.
#2: Dental treatment is a probable cause
of LPJI.
NO.
#3: Animal experiments document
dental bacteremias as cause of LPJI. NO.
#4: To protect patients DDS should
always cover patients with PJ.
NO.
Prevention of late Prosthetic joint
infections: 1997 changes
ADA/AAOS advisory statement
 medical consultation with Orthopod
 No prophylaxis for pins, rods, screws,
plates, wires, implants, etc.
 healthy patient: < 2 yrs. after TJR
 chronic RA or other infection of TJR
 immunocompromised patients

Prevention of late Prosthetic joint
infections: 1997 changes
Cephalexin ( Keflex) 2g ; po ; 1 hr. pre-op
 Cephazolin; 1 g; IM/IV; 1 hr. pre-op
 Clindamycin; 600mg.; po; 1 hr. pre-op

ANTIBIOTICS









Other indications for antibiotic prophylaxis:
HIV
ESRD : hemodialysis
IDDM
Autoimmune diseases; SLE
Splenectomy
CHF, CVA; thromboemboli
Liver disease
Organ transplants
Congenital heart diseasedental concerns
 Endocarditis
 Congestive
heart failure
 Endarteritis
 Excessive
 Cyanosis
 Infection
bleeding
Rheumatic Heart Disease

DETECTION
history
echocardiography
chest radiographs
EKG
auscultation
Basis for 2007 Guidelines
 Adverse
Outcomes
Valvular dysfunction
 Congestive heart failure
 Need for valvular replacement
 Multiple embolic events
 Death


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