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Sperotto F, France K, Gobbo M, Bindakhil M, Pimolbutr K, Holmes H, Monteiro L, Graham L, Hong CHL, Sollecito TP, Lodi G, Lockhart PB, Thornhill M, Diz Dios P, Turati F, Edefonti V. Antibiotic Prophylaxis and Infective Endocarditis Incidence Following Invasive Dental Procedures: A Systematic Review and Meta-Analysis. JAMA Cardiol 2024; 9:599-610. [PMID: 38581643 PMCID: PMC10999003 DOI: 10.1001/jamacardio.2024.0873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 03/18/2024] [Indexed: 04/08/2024]
Abstract
Importance The association between antibiotic prophylaxis and infective endocarditis after invasive dental procedures is still unclear. Indications for antibiotic prophylaxis were restricted by guidelines beginning in 2007. Objective To systematically review and analyze existing evidence on the association between antibiotic prophylaxis and infective endocarditis following invasive dental procedures. Data Sources PubMed, Cochrane-CENTRAL, Scopus, Web of Science, Proquest, Embase, Dentistry and Oral Sciences Source, and ClinicalTrials.gov were systematically searched from inception to May 2023. Study Selection Studies on the association between antibiotic prophylaxis and infective endocarditis following invasive dental procedures or time-trend analyses of infective endocarditis incidence before and after current antibiotic prophylaxis guidelines were included. Data Extraction and Synthesis Study quality was evaluated using structured tools. Data were extracted by independent observers. A pooled relative risk (RR) of developing infective endocarditis following invasive dental procedures in individuals who were receiving antibiotic prophylaxis vs those who were not was computed by random-effects meta-analysis. Main Outcomes and Measures The outcome of interest was the incidence of infective endocarditis following invasive dental procedures in relation to antibiotic prophylaxis. Results Of 11 217 records identified, 30 were included (1 152 345 infective endocarditis cases). Of them, 8 (including 12 substudies) were either case-control/crossover or cohort studies or self-controlled case series, while 22 were time-trend studies; all were of good quality. Eight of the 12 substudies with case-control/crossover, cohort, or self-controlled case series designs performed a formal statistical analysis; 5 supported a protective role of antibiotic prophylaxis, especially among individuals at high risk, while 3 did not. By meta-analysis, antibiotic prophylaxis was associated with a significantly lower risk of infective endocarditis after invasive dental procedures in individuals at high risk (pooled RR, 0.41; 95% CI, 0.29-0.57; P for heterogeneity = .51; I2, 0%). Nineteen of the 22 time-trend studies performed a formal pre-post statistical analysis; 9 found no significant changes in infective endocarditis incidence, 7 demonstrated a significant increase for the overall population or subpopulations (individuals at high and moderate risk, streptococcus-infective endocarditis, and viridans group streptococci-infective endocarditis), whereas 3 found a significant decrease for the overall population and among oral streptococcus-infective endocarditis. Conclusions and Relevance While results from time-trend studies were inconsistent, data from case-control/crossover, cohort, and self-controlled case series studies showed that use of antibiotic prophylaxis is associated with reduced risk of infective endocarditis following invasive dental procedures in individuals at high risk, while no association was proven for those at low/unknown risk, thereby supporting current American Heart Association and European Society of Cardiology recommendations. Currently, there is insufficient data to support any benefit of antibiotic prophylaxis in individuals at moderate risk.
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Affiliation(s)
- Francesca Sperotto
- Department of Cardiology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Katherine France
- Department of Oral Medicine, University of Pennsylvania, Philadelphia
| | - Margherita Gobbo
- Unit of Oral and Maxillofacial Surgery, Ca’Foncello Hospital, Treviso, Italy
| | - Mohammed Bindakhil
- Division of Oral Medicine, Department of Oral Biology and Diagnostic Sciences, Augusta University, Augusta, Georgia
| | - Kununya Pimolbutr
- Department of Oral Medicine and Periodontology, Mahidol University, Bangkok, Thailand
| | - Haly Holmes
- Department of Oral Medicine and Periodontology, University of the Western Cape, Cape Town, South Africa
| | - Luis Monteiro
- UNIPRO, Oral Pathology and Rehabilitation Research Unit, University Institute of Health Sciences (IUCS-CESPU), Gandra, Portugal
| | - Laurel Graham
- Dental Medicine Library, University of Pennsylvania, Philadelphia
| | | | | | - Giovanni Lodi
- Dipartimento di Scienze Biomediche, Chirurgiche e Odontoiatriche, Università degli Studi di Milano, Milan, Italy
| | - Peter B. Lockhart
- Department of Otolaryngology, Wake Forest University School of Medicine, Atrium Health, Charlotte, North Carolina
| | - Martin Thornhill
- Department of Oral and Maxillofacial Medicine, Surgery and Pathology, University of Sheffield School of Clinical Dentistry, Sheffield, United Kingdom
| | - Pedro Diz Dios
- Medical-Surgical Dentistry Research Group, Health Research Institute of Santiago de Compostela, School of Medicine and Dentistry, Santiago de Compostela University, Santiago de Compostela, Spain
| | - Federica Turati
- Branch of Medical Statistics, Biometry, and Epidemiology G.A. Maccacaro, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Valeria Edefonti
- Fondazione IRCCS, Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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Goycochea-Valdivia WA, Aboza-García M, Moreno-Pérez de Tudela R, Carazo-Gallego B, Roldan-Tormo E, Ruiz-Sáez B, Vázquez-Pérez Á, Peromingo-Matute E, Croche-Santander B, Obando-Pacheco P, Obando-Santaella I. Infective endocarditis in paediatric patients from Andalusia (Spain), 2008-2020. ENFERMEDADES INFECCIOSAS Y MICROBIOLOGIA CLINICA (ENGLISH ED.) 2023; 41:549-558. [PMID: 36464618 DOI: 10.1016/j.eimce.2022.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 05/11/2022] [Accepted: 05/16/2022] [Indexed: 06/17/2023]
Abstract
INTRODUCTION Paediatric infective endocarditis (IE) is a serious condition associated with significant mortality. Information in Spain is limited and comes from case series from single centres. The aim was to describe the epidemiology, clinical features, microbiology and outcome of paediatric IE in Andalusia. PATIENTS AND METHODS Multi-centre descriptive observational retrospective study of patients <18 years old with a diagnosis of IE who were admitted to six Andalusian hospitals during 2008-2020. RESULTS 44 episodes of IE (41 patients) with a median age of 103 months (IQR 37-150 months) were identified. Congenital heart disease (CHD) was the main predisposing factor, identified in 34 cases (77%). A total of 21 (48%) episodes of IE occurred in patients with prosthetic material. These had higher rate of CHD (p = 0.002) and increased end organ dysfunction (p = 0.04) compared to those with native valve. Fever was an almost universal symptom, associated in 23% of the episodes with heart failure. Staphylococcus aureus (25%) followed by coagulase-negative staphylococci (18%) and Streptococcus viridans (14%) were the most frequently isolated microorganisms, and three (7%) patients with central venous catheters had a fungal infection. Thromboembolic events were observed in 30% of the episodes, surgical intervention was required in 48% of cases. Mortality rate was 9%. Prosthetic material and CRP > 140 mg/L were independent predictors of complicated IE. CONCLUSIONS Our findings emphasize the high morbidity of paediatric IE. The information provided could be useful for the identification of epidemiological and clinical profiles of children with IE and complicated forms.
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Affiliation(s)
| | - Marta Aboza-García
- Unidad de Infectología e Inmunopatologías Pediátricas, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | | | - Begoña Carazo-Gallego
- Sección de Infectología Pediátrica, Unidad de Gestión Clínica de Pediatría, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Elena Roldan-Tormo
- Sección de Infectología Pediátrica, Unidad de Gestión Clínica de Pediatría, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Beatriz Ruiz-Sáez
- Unidad de Infecciosas Pediátricas, Hospital Universitario Reina Sofía, Córdoba, Spain
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Delgado V, Ajmone Marsan N, de Waha S, Bonaros N, Brida M, Burri H, Caselli S, Doenst T, Ederhy S, Erba PA, Foldager D, Fosbøl EL, Kovac J, Mestres CA, Miller OI, Miro JM, Pazdernik M, Pizzi MN, Quintana E, Rasmussen TB, Ristić AD, Rodés-Cabau J, Sionis A, Zühlke LJ, Borger MA. 2023 ESC Guidelines for the management of endocarditis. Eur Heart J 2023; 44:3948-4042. [PMID: 37622656 DOI: 10.1093/eurheartj/ehad193] [Citation(s) in RCA: 186] [Impact Index Per Article: 186.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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Horsley W, Srinivasan S, Hokanson JS. Antibiotic Prophylaxis for Infective Endocarditis: A Survey of Practice Among Pediatric Cardiology Providers. Clin Pediatr (Phila) 2022; 61:859-868. [PMID: 35854631 DOI: 10.1177/00099228221106552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The 2007 American Heart Association (AHA) guidelines limited antibiotic prophylaxis (AP) for infective endocarditis (IE) to fewer patients with predisposing cardiac conditions (PCC). We surveyed the American Academy of Pediatrics Section on Cardiology and Cardiac Surgery (AAP SOCCS) on their recommendations for AP for a number of PCC and procedures. We report on those 173 respondents who follow the 2007 AHA guidelines. AP rates for high-risk PCCs clearly meeting AHA criteria ranged from 70.5-89.8%. Conversely, for PCCs which did not meet AHA criteria, prescribing rates varied from <1% to 29.5%. PCC for which AP indication was unclear per guidelines, AP rates similarly varied from 9.9-39.8%. Similar variability is noted in AP for various procedures in setting of high-risk PCC. There is variability in AP prescribing practices among pediatric cardiologists based on both underlying PCC and noncardiac procedures in the setting of underlying cardiac disease.
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Affiliation(s)
- Whitney Horsley
- Mid-Valley Children's Clinic, Samaritan Health Services, Albany, OR, USA
| | - Shardha Srinivasan
- Division of Pediatric Cardiology, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - John S Hokanson
- Division of Pediatric Cardiology, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Endocarditis infecciosa en pacientes pediátricos de Andalucía (España), 2008-2020. Enferm Infecc Microbiol Clin 2022. [DOI: 10.1016/j.eimc.2022.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Wilson WR, Gewitz M, Lockhart PB, Bolger AF, DeSimone DC, Kazi DS, Couper DJ, Beaton A, Kilmartin C, Miro JM, Sable C, Jackson MA, Baddour LM. Adapted from: Prevention of Viridans Group Streptococcal Infective Endocarditis: A Scientific Statement From the American Heart Association. J Am Dent Assoc 2021; 152:886-902.e2. [PMID: 34711348 DOI: 10.1016/j.adaj.2021.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND In 2007, the American Heart Association published updated evidence-based guidelines on the recommended use of antibiotic prophylaxis to prevent viridans group streptococcal (VGS) infective endocarditis (IE) in cardiac patients undergoing invasive procedures. The 2007 guidelines significantly scaled back the underlying conditions for which antibiotic prophylaxis was recommended, leaving only 4 categories thought to confer the highest risk of adverse outcome. The purpose of this update is to examine interval evidence of the acceptance and impact of the 2007 recommendations on VGS IE and, if needed, to make revisions based on this evidence. METHODS AND RESULTS A writing group was formed consisting of experts in prevention and treatment of infective endocarditis including members of the American Dental Association, the Infectious Diseases Society of America, and the American Academy of Pediatrics, in addition to the American Heart Association. MEDLINE database searches were done for English language articles on compliance with the recommendations in the 2007 guidelines and the frequency of and morbidity or mortality from VGS IE after publication of the 2007 guidelines. Overall, there was good general awareness of the 2007 guidelines but variable compliance with recommendations. There was no convincing evidence that VGS IE frequency, morbidity, or mortality has increased since 2007. CONCLUSIONS On the basis of a review of the available evidence, there are no recommended changes to the 2007 VGS IE prevention guidelines. We continue to recommend VGS IE prophylaxis only for categories of patients at highest risk for adverse outcome while emphasizing the critical role of good oral health and regular access to dental care for all. Randomized controlled studies to determine whether antibiotic prophylaxis is effective against VGS IE are needed to further refine recommendations.
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Mahony M, Lean D, Pham L, Horvath R, Suna J, Ward C, Veerappan S, Versluis K, Nourse C. Infective Endocarditis in Children in Queensland, Australia: Epidemiology, Clinical Features and Outcome. Pediatr Infect Dis J 2021; 40:617-622. [PMID: 33902079 DOI: 10.1097/inf.0000000000003110] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Infective endocarditis (IE) is a rare entity in children associated with significant morbidity and mortality. To optimize management, it is important to understand local epidemiology, risk factors, clinical features and outcome. These are investigated in this retrospective 10-year study of endocarditis in children in Queensland. METHODS Children <18 years with IE were identified from the state-wide pediatric cardiology center (Mater Children's Hospital, 2009-2014; Queensland Children's Hospital, 2014-2018) through International Classification of Diseases codes and local cardiology database. Clinical records were assessed by a clinician and echocardiograms by a cardiologist. Incidence was calculated using Australian Bureau of Statistics Queensland Estimated Resident Population data, 2019. RESULTS Fifty-one children were identified, with an overall estimated incidence of 0.84 per 100,000 per year; 0.69 per 100,000 in 2009-2013 and 0.99 per 100,000 in 2014-2018, respectively. Twenty-four (47.1%) children were male and 10 (19.6%) were identified as Aboriginal or Torres Strait Islander peoples. Underlying cardiac conditions were present in 29 (56.9%): 25 congenital heart disease, 3 rheumatic heart disease and 1 cardiomyopathy. A causative pathogen was identified in 46 (90.2%) children with Staphylococcus aureus most common. Thirty-six (70.6%) met criteria for "Definite IE" as per modified Duke criteria, with the remainder "Possible IE." Surgery was required in 26 (51%). Median duration of antibiotics was 42 (interquartile range = 32-51) days and hospitalization 49 (interquartile range = 34-75) days. One child died due to IE. CONCLUSIONS IE in children in Queensland is increasing in incidence and is higher than the reported incidence in New Zealand and the United States. Congenital heart disease is the most common risk factor and S. aureus is the commonest responsible organism. Aboriginal or Torres Strait Islander children are over-represented. Mortality remains low.
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Affiliation(s)
- Michelle Mahony
- From the Infection Management and Prevention Service, Queensland Children's Hospital, Brisbane, Australia
| | - David Lean
- Paediatric Department, Nazarene General Hospital, Papua New Guinea
| | - Lily Pham
- Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Robert Horvath
- Faculty of Medicine, University of Queensland, Brisbane, Australia
- Infective Endocarditis Queensland [ieQ], Brisbane, Australia
- The Prince Charles Hospital, Brisbane, Australia
- Pathology Queensland, Brisbane, Australia
| | - Jessica Suna
- Queensland Paediatric Cardiac Service
- Queensland Paediatric Cardiac Research, Queensland Children's Hospital, Brisbane, Australia
| | - Cameron Ward
- Faculty of Medicine, University of Queensland, Brisbane, Australia
- Queensland Paediatric Cardiac Service
- Queensland Paediatric Cardiac Research, Queensland Children's Hospital, Brisbane, Australia
| | | | - Kathryn Versluis
- Queensland Paediatric Cardiac Research, Queensland Children's Hospital, Brisbane, Australia
| | - Clare Nourse
- From the Infection Management and Prevention Service, Queensland Children's Hospital, Brisbane, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Australia
- Infective Endocarditis Queensland [ieQ], Brisbane, Australia
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Difficulties in Diagnosis and Therapy of Infective Endocarditis in Children and Adolescents-Cohort Study. Healthcare (Basel) 2021; 9:healthcare9060760. [PMID: 34205298 PMCID: PMC8235031 DOI: 10.3390/healthcare9060760] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 06/13/2021] [Accepted: 06/15/2021] [Indexed: 01/22/2023] Open
Abstract
Despite the progress in management and prophylaxis measures, infective endocarditis (IE) is still a condition associated with high mortality rates and severe complications. Fortunately, the incidence of IE is much lower in children and adolescents, with only 0.05–0.12/1000 cases being reported in hospitalized pediatric patients. According to recent data, IE is, in most cases, a complication of pre-existing congenital heart disorders, in up to 75–90% of cases. About 8–10% of all IE cases occur in children without a pre-existing heart condition, due to the widespread use of catheters and invasive procedures, or are associated with immunosuppression. The overall mortality rate due to IE among children and adolescents is 16–25%, a fairly high incidence despite advances made in management and treatment methodologies. We present a retrospective case study conducted in the Pediatric Cardiology Department of ‘St. Maria’ Emergency Children’s Hospital of Iași between February 2007 and February 2020, including 54 children aged between 23 days and 17 years. Our study was aimed at revealing the evolution of IE in recent years in the pediatric population, at identifying the main causes leading to the onset and progress of the disease, at assessing the incidence of clinical and paraclinical manifestations and at determining efficient diagnosis and therapy approaches for the population under survey.
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9
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Wilson WR, Gewitz M, Lockhart PB, Bolger AF, DeSimone DC, Kazi DS, Couper DJ, Beaton A, Kilmartin C, Miro JM, Sable C, Jackson MA, Baddour LM. Prevention of Viridans Group Streptococcal Infective Endocarditis: A Scientific Statement From the American Heart Association. Circulation 2021; 143:e963-e978. [PMID: 33853363 DOI: 10.1161/cir.0000000000000969] [Citation(s) in RCA: 100] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND In 2007, the American Heart Association published updated evidence-based guidelines on the recommended use of antibiotic prophylaxis to prevent viridans group streptococcal (VGS) infective endocarditis (IE) in cardiac patients undergoing invasive procedures. The 2007 guidelines significantly scaled back the underlying conditions for which antibiotic prophylaxis was recommended, leaving only 4 categories thought to confer the highest risk of adverse outcome. The purpose of this update is to examine interval evidence of the acceptance and impact of the 2007 recommendations on VGS IE and, if needed, to make revisions based on this evidence. METHODS AND RESULTS A writing group was formed consisting of experts in prevention and treatment of infective endocarditis including members of the American Dental Association, the Infectious Diseases Society of America, and the American Academy of Pediatrics, in addition to the American Heart Association. MEDLINE database searches were done for English language articles on compliance with the recommendations in the 2007 guidelines and the frequency of and morbidity or mortality from VGS IE after publication of the 2007 guidelines. Overall, there was good general awareness of the 2007 guidelines but variable compliance with recommendations. There was no convincing evidence that VGS IE frequency, morbidity, or mortality has increased since 2007. CONCLUSIONS On the basis of a review of the available evidence, there are no recommended changes to the 2007 VGS IE prevention guidelines. We continue to recommend VGS IE prophylaxis only for categories of patients at highest risk for adverse outcome while emphasizing the critical role of good oral health and regular access to dental care for all. Randomized controlled studies to determine whether antibiotic prophylaxis is effective against VGS IE are needed to further refine recommendations.
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Williams ML, Doyle MP, McNamara N, Tardo D, Mathew M, Robinson B. Epidemiology of infective endocarditis before versus after change of international guidelines: a systematic review. Ther Adv Cardiovasc Dis 2021; 15:17539447211002687. [PMID: 33784909 PMCID: PMC8020745 DOI: 10.1177/17539447211002687] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Introduction: All major international guidelines for the management of infective endocarditis (IE) have undergone major revisions, recommending antibiotic prophylaxis (AP) restriction to high-risk patients or foregoing AP completely. We performed a systematic review to investigate the effect of these guideline changes on the global incidence of IE. Methods: Electronic database searches were performed using Ovid Medline, EMBASE and Web of Science. Studies were included if they compared the incidence of IE prior to and following any change in international guideline recommendations. Relevant studies fulfilling the predefined search criteria were categorized according to their inclusion of either adult or pediatric patients. Incidence of IE, causative microorganisms and AP prescription rates were compared following international guideline updates. Results: Sixteen studies were included, reporting over 1.3 million cases of IE. The crude incidence of IE following guideline updates has increased globally. Adjusted incidence increased in one study after European guideline updates, while North American rates did not increase. Cases of IE with a causative pathogen identified ranged from 62% to 91%. Rates of streptococcal IE varied across adult and pediatric populations, while the relative proportion of staphylococcal IE increased (range pre-guidelines 16–24.8%, range post-guidelines 26–43%). AP prescription trends were reduced in both moderate and high-risk patients following guideline updates. Discussion: The restriction of AP to only high-risk patients has not resulted in an increase in the incidence of streptococcal IE in North American populations. The evidence of the impact of AP restriction on IE incidence is still unclear for other populations. Future population-based studies with adjusted incidence of IE, AP prescription rates and accurate pathogen identification are required to delineate findings further in these other regions.
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Affiliation(s)
- Michael L Williams
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, 50 Missenden Road, Camperdown, NSW 2050, Australia
| | - Mathew P Doyle
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Centre for Human and Applied Physiology, School of Medicine, University of Wollongong, Keiraville, Australia
| | - Nicholas McNamara
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - Daniel Tardo
- Department of Medicine, St Vincents Hospital, Sydney, NSW, Australia.,School of Medicine, University of Notre Dame, Sydney, NSW, Australia
| | - Manish Mathew
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - Benjamin Robinson
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia
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CANDAN M. INFECTIVE ENDOCARDITIS PROPHYLAXIS IN DENTISTRY : CURRENT PERSPECTIVE. CUMHURIYET DENTAL JOURNAL 2020. [DOI: 10.7126/cumudj.825256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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12
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Time-trend population analysis of the clinical and epidemiologic effect on pediatric infective endocarditis after change of antibiotic prophylaxis guidelines. Infection 2020; 48:671-678. [PMID: 32356253 DOI: 10.1007/s15010-020-01433-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 04/23/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE In 2007, antibiotic prophylaxis (AP) guidelines for infective endocarditis (IE) changed, but the possible influence on the annual incidences of pediatric IE is unclear. METHODS We studied the clinical and epidemiologic impact of AP change by comparing two time periods before and after change of AP guidelines in a tertiary care center as referral center for a total population of more than 4,500,000 inhabitants. RESULTS After change of AP guidelines, twenty-five patients were diagnosed for IE at a median age of 6.9 years (range 0.1-19.4, female 48%). Modified Duke criteria were fulfilled for definite (12/25; 48%), or probable IE (13/25; 52%). The frequency of IE (cases per 1000 hospitalized patients) increased from 0.37% (1995-2005) to 0.59% (2006-2017) [p = 0.152], the annual incidence of IE (cases per 1000 CHD patients, < 20 years of age) increased from 0.195 ‰ to 0.399 ‰ [p = 0.072]. Postoperative IE (13/25; 52%), was associated mostly with prosthetic pulmonary valves (12/13; 92%). Pathogens were staphylococci spp. (8/25; 32%), streptococci spp. (7/25; 28%), HACEK (3/25; 12%), other (4/25; 16%), or culture-negative (3/25; 12%). Treatment included antibiotics (25/25; 100%), and cardiac surgery (16/25; 64%). The clinical findings and complications of pediatric IE including mortality (2/25; 8%) did not differ between the two time periods. CONCLUSIONS Pediatric IE remains a severe cardiac disease with a comparable clinical picture. Unless increasing absolute case numbers of IE, the relative case number of IE remains stable despite AP change. The high number of prosthetic pulmonary valve associated IE needs further evaluation and therapeutic alternatives.
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Quan TP, Muller-Pebody B, Fawcett N, Young BC, Minaji M, Sandoe J, Hopkins S, Crook D, Peto T, Johnson AP, Walker AS. Investigation of the impact of the NICE guidelines regarding antibiotic prophylaxis during invasive dental procedures on the incidence of infective endocarditis in England: an electronic health records study. BMC Med 2020; 18:84. [PMID: 32238164 PMCID: PMC7114779 DOI: 10.1186/s12916-020-01531-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 02/13/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Infective endocarditis is an uncommon but serious infection, where evidence for giving antibiotic prophylaxis before invasive dental procedures is inconclusive. In England, antibiotic prophylaxis was offered routinely to patients at risk of infective endocarditis until March 2008, when new guidelines aimed at reducing unnecessary antibiotic use were issued. We investigated whether changes in infective endocarditis incidence could be detected using electronic health records, assessing the impact of inclusion criteria/statistical model choice on inferences about the timing/type of any change. METHODS Using national data from Hospital Episode Statistics covering 1998-2017, we modelled trends in infective endocarditis incidence using three different sets of inclusion criteria plus a range of regression models, identifying the most likely date for a change in trends if evidence for one existed. We also modelled trends in the proportions of different organism groups identified during infection episodes, using secondary diagnosis codes and data from national laboratory records. Lastly, we applied non-parametric local smoothing to visually inspect any changes in trend around the guideline change date. RESULTS Infective endocarditis incidence increased markedly over the study (22.2-41.3 per million population in 1998 to 42.0-67.7 in 2017 depending on inclusion criteria). The most likely dates for a change in incidence trends ranged from September 2001 (uncertainty interval August 2000-May 2003) to May 2015 (March 1999-January 2016), depending on inclusion criteria and statistical model used. For the proportion of infective endocarditis cases associated with streptococci, the most likely change points ranged from October 2008 (March 2006-April 2010) to August 2015 (September 2013-November 2015), with those associated with oral streptococci decreasing in proportion after the change point. Smoothed trends showed no notable changes in trend around the guideline date. CONCLUSIONS Infective endocarditis incidence has increased rapidly in England, though we did not detect any change in trends directly following the updated guidelines for antibiotic prophylaxis, either overall or in cases associated with oral streptococci. Estimates of when changes occurred were sensitive to inclusion criteria and statistical model choice, demonstrating the need for caution in interpreting single models when using large datasets. More research is needed to explore the factors behind this increase.
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Affiliation(s)
- T Phuong Quan
- National Institute for Health Research (NIHR) Health Protection Research Unit on Healthcare Associated Infections and Antimicrobial Resistance, John Radcliffe Hospital, Microbiology Level 7, Headley Way, Oxford, OX3 9DU, UK. .,Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK. .,NIHR Biomedical Research Centre, Oxford, OX3 9DU, UK.
| | | | - Nicola Fawcett
- National Institute for Health Research (NIHR) Health Protection Research Unit on Healthcare Associated Infections and Antimicrobial Resistance, John Radcliffe Hospital, Microbiology Level 7, Headley Way, Oxford, OX3 9DU, UK.,Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK.,Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK
| | - Bernadette C Young
- Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK
| | - Mehdi Minaji
- National Infection Service, Public Health England, Colindale, London, UK
| | - Jonathan Sandoe
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust and University of Leeds, Leeds, LS1 3EX, UK
| | - Susan Hopkins
- National Infection Service, Public Health England, Colindale, London, UK
| | - Derrick Crook
- National Institute for Health Research (NIHR) Health Protection Research Unit on Healthcare Associated Infections and Antimicrobial Resistance, John Radcliffe Hospital, Microbiology Level 7, Headley Way, Oxford, OX3 9DU, UK.,Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK.,NIHR Biomedical Research Centre, Oxford, OX3 9DU, UK.,Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK
| | - Timothy Peto
- National Institute for Health Research (NIHR) Health Protection Research Unit on Healthcare Associated Infections and Antimicrobial Resistance, John Radcliffe Hospital, Microbiology Level 7, Headley Way, Oxford, OX3 9DU, UK.,Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK.,NIHR Biomedical Research Centre, Oxford, OX3 9DU, UK.,Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK
| | - Alan P Johnson
- National Infection Service, Public Health England, Colindale, London, UK
| | - A Sarah Walker
- National Institute for Health Research (NIHR) Health Protection Research Unit on Healthcare Associated Infections and Antimicrobial Resistance, John Radcliffe Hospital, Microbiology Level 7, Headley Way, Oxford, OX3 9DU, UK.,Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK.,NIHR Biomedical Research Centre, Oxford, OX3 9DU, UK
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Fawcett N, Young B, Peto L, Quan TP, Gillott R, Wu J, Middlemass C, Weston S, Crook DW, Peto TEA, Muller-Pebody B, Johnson AP, Walker AS, Sandoe JAT. 'Caveat emptor': the cautionary tale of endocarditis and the potential pitfalls of clinical coding data-an electronic health records study. BMC Med 2019; 17:169. [PMID: 31481119 PMCID: PMC6724235 DOI: 10.1186/s12916-019-1390-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 07/12/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Diagnostic codes from electronic health records are widely used to assess patterns of disease. Infective endocarditis is an uncommon but serious infection, with objective diagnostic criteria. Electronic health records have been used to explore the impact of changing guidance on antibiotic prophylaxis for dental procedures on incidence, but limited data on the accuracy of the diagnostic codes exists. Endocarditis was used as a clinically relevant case study to investigate the relationship between clinical cases and diagnostic codes, to understand discrepancies and to improve design of future studies. METHODS Electronic health record data from two UK tertiary care centres were linked with data from a prospectively collected clinical endocarditis service database (Leeds Teaching Hospital) or retrospective clinical audit and microbiology laboratory blood culture results (Oxford University Hospitals Trust). The relationship between diagnostic codes for endocarditis and confirmed clinical cases according to the objective Duke criteria was assessed, and impact on estimations of disease incidence and trends. RESULTS In Leeds 2006-2016, 738/1681(44%) admissions containing any endocarditis code represented a definite/possible case, whilst 263/1001(24%) definite/possible endocarditis cases had no endocarditis code assigned. In Oxford 2010-2016, 307/552(56%) reviewed endocarditis-coded admissions represented a clinical case. Diagnostic codes used by most endocarditis studies had good positive predictive value (PPV) but low sensitivity (e.g. I33-primary 82% and 43% respectively); one (I38-secondary) had PPV under 6%. Estimating endocarditis incidence using raw admission data overestimated incidence trends twofold. Removing records with non-specific codes, very short stays and readmissions improved predictive ability. Estimating incidence of streptococcal endocarditis using secondary codes also overestimated increases in incidence over time. Reasons for discrepancies included changes in coding behaviour over time, and coding guidance allowing assignment of a code mentioning 'endocarditis' where endocarditis was never mentioned in the clinical notes. CONCLUSIONS Commonly used diagnostic codes in studies of endocarditis had good predictive ability. Other apparently plausible codes were poorly predictive. Use of diagnostic codes without examining sensitivity and predictive ability can give inaccurate estimations of incidence and trends. Similar considerations may apply to other diseases. Health record studies require validation of diagnostic codes and careful data curation to minimise risk of serious errors.
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Affiliation(s)
- Nicola Fawcett
- National Institute for Health Research (NIHR) Health Protection Research Unit on Healthcare Associated Infections and Antimicrobial Resistance, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK. .,Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK. .,Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK. .,Microbiology Level 7, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK.
| | - Bernadette Young
- Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK.,Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK
| | - Leon Peto
- National Institute for Health Research (NIHR) Health Protection Research Unit on Healthcare Associated Infections and Antimicrobial Resistance, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK.,Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK.,Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK
| | - T Phuong Quan
- National Institute for Health Research (NIHR) Health Protection Research Unit on Healthcare Associated Infections and Antimicrobial Resistance, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK.,Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK.,NIHR Biomedical Research Centre, Oxford, OX3 9DU, UK
| | - Richard Gillott
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust and University of Leeds, Leeds, LS1 3EX, UK
| | - Jianhua Wu
- School of Dentistry, University of Leeds, Leeds, LS2 9LU, UK
| | - Chris Middlemass
- Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK
| | - Sheila Weston
- Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK
| | - Derrick W Crook
- National Institute for Health Research (NIHR) Health Protection Research Unit on Healthcare Associated Infections and Antimicrobial Resistance, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK.,Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK.,Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK.,NIHR Biomedical Research Centre, Oxford, OX3 9DU, UK
| | - Tim E A Peto
- National Institute for Health Research (NIHR) Health Protection Research Unit on Healthcare Associated Infections and Antimicrobial Resistance, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK.,Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK.,Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK.,NIHR Biomedical Research Centre, Oxford, OX3 9DU, UK
| | | | - Alan P Johnson
- National Institute for Health Research (NIHR) Health Protection Research Unit on Healthcare Associated Infections and Antimicrobial Resistance, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK.,National Infection Service, Public Health England, Colindale, London, UK
| | - A Sarah Walker
- National Institute for Health Research (NIHR) Health Protection Research Unit on Healthcare Associated Infections and Antimicrobial Resistance, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK.,Nuffield Department of Medicine, University of Oxford, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK.,NIHR Biomedical Research Centre, Oxford, OX3 9DU, UK
| | - Jonathan A T Sandoe
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust and University of Leeds, Leeds, LS1 3EX, UK
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Abstract
BACKGROUND Infective endocarditis (IE) remains a diagnostic and therapeutic challenge associated with high morbidity and mortality. We evaluated the microbial profile and clinical manifestation of IE in children. METHODS A retrospective study examining pediatric IE cases treated between 2000 and 2017 at the Department of Pediatric Cardiology, KU Leuven, was conducted. Clinical presentation, treatment, complications, outcome of IE, underlying microorganisms and congenital heart defects were reviewed. RESULTS Fifty-three patients were diagnosed with IE. Overall, 19 patients (36%) required cardiac surgery. Seven patients (13%) died. Eighty-seven percent of patients had an underlying congenital cardiac defect. Eighteen (34%) children presented with prosthetic graft IE. A causative organism was found in 49 (92%) cases: viridans group streptococci were identified in 17 (32%), Staphylococcus aureus in 13 (25%) and coagulase-negative staphylococci in 11 (20%) children. Community-acquired (CA) IE increased significantly from 8 (33%) cases in 2000-2007 to 20 (74%) cases in 2008-2017 (P < 0.01). Even with viridans streptococci being significantly more prevalent in the CA group (P < 0.01), we did not observe an increase of streptococcal IE from 2008 to 2017. Seventeen (32%) patients presented with hospital-acquired IE during the first year of life with 14 (82%) children after surgery and a prevalence of coagulase-negative staphylococci (53%). CONCLUSIONS The incidence of pediatric IE was similar over the investigated time period with a shift toward CA IE. Streptococci and staphylococci accounted for the majority of cases in both periods. Awareness of IE and its prevention is crucial in patients after implantation of prosthetic grafts.
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Dolgner SJ, Arya B, Kronman MP, Chan T. Effect of Congenital Heart Disease Status on Trends in Pediatric Infective Endocarditis Hospitalizations in the United States Between 2000 and 2012. Pediatr Cardiol 2019; 40:319-329. [PMID: 30415379 DOI: 10.1007/s00246-018-2020-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 11/01/2018] [Indexed: 02/06/2023]
Abstract
The purpose of this study was to create national estimates for the incidence of pediatric infective endocarditis (IE) in the United States and to determine if these changed after the implementation of the 2007 American Heart Association IE guidelines. It also sought to determine the effect of congenital heart disease (CHD) status on outcomes in IE. Hospital discharges with the diagnosis of IE in patients < 18 years old from the Kids' Inpatient Database were identified from the years 2000, 2003, 2006, 2009, and 2012. Discharges were grouped into Pre- and Post-2007 groups to facilitate analysis surrounding the implementation of the guidelines in 2007. Patients were categorized by age, underlying CHD, and etiologic organism. Descriptive comparisons and changes in categorical variables were made between groups. Average annual IE hospitalization rates before and after the 2007 guidelines were 10.8 and 9.3 per 1,000,000 children, respectively. The proportion of IE patients with CHD was stable between time periods, (45% vs. 47%, p = 0.50). Mortality was higher in the Post-2007 time period for CHD patients than non-CHD patients (11.1% vs. 2.4%, respectively; p < 0.001), while there was no difference noted during the Pre-2007 time period (6.5% vs. 6.6%, respectively; p = 0.95). Streptococcus was more common among CHD patients than non-CHD patients (27% vs. 17%), while Staphylococcus was more common among non-CHD patients than CHD patients (34% vs. 24%, p < 0.001). Even though the incidence of IE was stable over time, mortality was higher in CHD patients after the implementation of the 2007 AHA IE prophylaxis guidelines.
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Affiliation(s)
- Stephen J Dolgner
- Seattle Children's Hospital, RC.2.820, PO Box 5371, Seattle, WA, 98145-5005, USA.
- Department of Pediatrics, University of Washington, Seattle, WA, USA.
| | - Bhawna Arya
- Seattle Children's Hospital, RC.2.820, PO Box 5371, Seattle, WA, 98145-5005, USA
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Matthew P Kronman
- Seattle Children's Hospital, RC.2.820, PO Box 5371, Seattle, WA, 98145-5005, USA
- Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Titus Chan
- Seattle Children's Hospital, RC.2.820, PO Box 5371, Seattle, WA, 98145-5005, USA
- Department of Pediatrics, University of Washington, Seattle, WA, USA
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Abstract
The pediatric cardiology field has developed rapidly over the past few decades. More children than ever born with congenital heart disease (CHD) are growing into adulthood. Primary care providers play a key role in diagnosis, management, and referral of children with CHD because many common cardiac complaints (eg, feeding intolerance, cyanosis, chest pain, palpitations, and syncope) are first addressed in the primary care setting. The spectrum of heart disease in children ranges from common complaints to complex single-ventricle physiology, acute myocarditis, and heart transplantation. This article reviews the pathophysiology and management of the most frequent cardiac conditions encountered in primary care.
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Affiliation(s)
- Richard U Garcia
- Division of Cardiac Critical Care Medicine, Departments of Pediatrics and Critical Care Medicine, The University of Pennsylvania and the Children's Hospital of Philadelphia, 34th Street, Civic Center Boulevard, Philadelphia, PA 19104, USA.
| | - Stacie B Peddy
- Division of Cardiac Critical Care Medicine, Departments of Pediatrics and Critical Care Medicine, The University of Pennsylvania and the Children's Hospital of Philadelphia, 34th Street, Civic Center Boulevard, Philadelphia, PA 19104, USA
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18
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Taubert KA, Wilson W. Is endocarditis prophylaxis for dental procedures necessary? HEART ASIA 2017; 9:63-67. [PMID: 28321267 PMCID: PMC5337686 DOI: 10.1136/heartasia-2016-010810] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/02/2017] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Our purpose is to address whether antimicrobial prophylaxis is necessary before certain dental procedures for patients at increased risk for acquiring infective endocarditis (IE). METHODS We reviewed recommendations for IE prophylaxis made by the American Heart Association (AHA) from 1995 to the present time. We also compared and contrasted the current recommendations from the AHA, European Society of Cardiology (ESC), United Kingdom's National Institute for Health and Care Excellence (NICE) and a consortium of French organisations. We further reviewed recent papers that have observed the incidence of IE since these current recommendations were published. RESULTS Beginning in the 1990s, questions were raised about the advisability of using antimicrobial prophylaxis before certain dental procedures to prevent IE. Various groups in Europe and the US were increasingly aware that there were not any clinical trials showing the effectiveness, or lack thereof, of such prophylaxis. In the early to mid-2000s, the AHA, ESC and French consortium published guidelines recommending restriction of prophylaxis before dental procedures to patients with highest risk for developing IE and/or the highest risk for an adverse outcome from IE. The NICE guidelines eliminated recommendations for prophylaxis before dental procedures. Studies published after these changes were instituted have generally shown that the incidence of IE has not changed, although two recent reports have observed some increased incidence (but not necessarily related to an antecedent dental procedure). CONCLUSION A multi-national randomised controlled clinical trial that would include individuals from both developed and developing countries around the world is needed to ultimately define whether there is a role for antibiotic prophylaxis administered before certain dental procedures to prevent IE.
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