Antimicrobial prophylaxis for endocarditis: emotion or science?

Infective endocarditis: prevention strategy and risk factors in an animal model

INTRODUCTION

Infective endocarditis is a serious infection of the endocardium, especially the heart valves, which is associated with a high mortality rate. It generally occurs in patients with altered and abnormal cardiac architecture combined with exposure to bacteria from trauma and other potentially high-risk activities with transient bacteremia.

Methicillin-Resistant Staphylococcus aureus in the Oral Cavity: Implications for Antibiotic Prophylaxis and Surveillance

The oral cavity harbors a multitude of commensal flora, which may constitute a repository of antibiotic resistance determinants. In the oral cavity, bacteria form biofilms, and this facilitates the acquisition of antibiotic resistance genes through horizontal gene transfer. Recent reports indicate high methicillin-resistant Staphylococcus aureus (MRSA) carriage rates in the oral cavity. Establishment of MRSA in the mouth could be enhanced by the wide usage of antibiotic prophylaxis among at-risk dental procedure candidates. These changes in MRSA epidemiology have important implications for MRSA preventive strategies, clinical practice, as well as the methodological approaches to carriage studies of the organism.

Epidemiological and mortality trends in infective endocarditis, a 17-year population-based prospective study

BACKGROUND

The population at risk, the clinical and microbiological features of infective endocarditis (IE) have changed. Aim of our study was to evaluate the contemporary epidemiological trends, over a 17-year period in a definite region of Tuscany, Italy, to analyze the clinical outcomes and associated prognostic factors.

METHODS

From 1 January 1998 to 31 December 2014, all patients with a definite diagnosis of IE were prospectively entered in a data-base. The Health-Care system data-base was interrogated to capture patients who could have been missed. The final dataset derived by the merging of the two data-bases.

RESULTS

Incidence rate of IE was 4.6/100,000/y with a significant linear incidence increase. In hospitalized patients the incidence was 1.27/1,000 admissions. Over age 65 incidence rate was 11.7/100,000/y. Male/female ratio was 1.54:1. A temporal trend towards an increase in the mean population age was found (P=0.033). There was an increase in the incidence of Health-care associated IE, P=0.016. The most common microorganisms were staphylococcus aureus (25%) and coagulase-negative staphylococci (22%). In-hospital mortality was 24%. A trend towards an increase in mortality rate was found (P=0.055). Independent predictors of mortality were older age, S. aureus infection, heart failure, septic shock and persistent bacteremia.

CONCLUSIONS

Our study confirms an increasing mortality trend in IE, although with a borderline significance. Elderly forms are associated with poor prognosis and higher than 1-year mortality rate even in the multivariate analysis. Ageing population, increase in healthcare-associated and staphylococcal infections, may explain the rise of IE incidence and of the mortality trend.

Incidence and nature of adverse reactions to antibiotics used as endocarditis prophylaxis

OBJECTIVES

Antibiotic prophylaxis (AP) administration prior to invasive dental procedures has been a leading focus of infective endocarditis prevention. However, there have been long-standing concerns about the risk of adverse drug reactions as a result of this practice. The objective of this study was to identify the incidence and nature of adverse reactions to amoxicillin and clindamycin prophylaxis to prevent infective endocarditis.

METHODS

We obtained AP prescribing data for England from January 2004 to March 2014 from the NHS Business Services Authority, and adverse drug reaction data from the Medicines and Healthcare Products Regulatory Agency's Yellow Card reporting scheme for prescriptions of the standard AP protocol of a single 3 g oral dose of amoxicillin or a single 600 mg oral dose of clindamycin for those allergic to penicillin.

RESULTS

The reported adverse drug reaction rate for amoxicillin AP was 0 fatal reactions/million prescriptions (in fact 0 fatal reactions for nearly 3 million prescriptions) and 22.62 non-fatal reactions/million prescriptions. For clindamycin, it was 13 fatal and 149 non-fatal reactions/million prescriptions. Most clindamycin adverse drug reactions were Clostridium difficile infections.

CONCLUSIONS

AP adverse drug reaction reporting rates in England were low, particularly for amoxicillin, and lower than previous estimates. This suggests that amoxicillin AP is comparatively safe for patients without a history of amoxicillin allergy. The use of clindamycin AP was, however, associated with significant rates of fatal and non-fatal adverse drug reactions associated with C. difficile infections. These were higher than expected and similar to those for other doses, durations and routes of clindamycin administration.

Knowledge and Antibiotics Prescription Pattern among Ugandan Oral Health Care Providers: A Cross-sectional Survey

BACKGROUND AND AIMS

Irrational prescription of antibiotics by clinicians might lead to drug resistance. Clinicians do prescribe antibiotics for either prophylactic or therapeutic reasons. The decision of when and what to prescribe leaves room for misuse and therefore it is imperative to continuously monitor knowledge and pattern of prescription. The aim of the present study was to determine the knowledge of antibiotic use and the prescription pattern among dental health care practitioners in Uganda.

MATERIALS AND METHODS

A structured and pretested questionnaire was sent to 350 dental health care practitioners by post or physical delivery. All the questionnaires were sent with self-addressed and prepaid postage envelopes to enable re-spondents to mail back the filled questionnaires. Chi-squared test was used to test for any significant differences between groups of respondents based on qualitative variables.

RESULTS

The response rate was 40.3% (n=140). Of these 52.9 % were public health dental officers (PHDOs) and 47.1% were dental surgeons. The males constituted 74.3% of the respondents. There were statistically significant differences be-tween dental surgeons and (PHDOs) in knowledge on prophylactic antibiotic use (P = 0.001) and patient influence on pre-scription (P = 0.001). Amoxicillin, in combination with metronidazole, was the most common combination of antibiotics used followed by co-trimoxazole with metronidazole.

CONCLUSION

The knowledge of dental health care practitioners in antibiotic use in this study was generally low. A combi-nation of amoxicillin with metronidazole was the most commonly prescribed antibiotics subsequent to different dental pro-cedures.

Impact of the NICE guideline recommending cessation of antibiotic prophylaxis for prevention of infective endocarditis: before and after study

OBJECTIVE

To quantify the change in prescribing of antibiotic prophylaxis before invasive dental procedures for patients at risk of infective endocarditis, and any concurrent change in the incidence of infective endocarditis, following introduction of a clinical guideline from the National Institute for Health and Clinical Excellence (NICE) in March 2008 recommending the cessation of antibiotic prophylaxis in the United Kingdom.

DESIGN

Before and after study.

SETTING

England. Population All patients admitted to hospital in England with a primary or secondary discharge diagnosis of acute or subacute infective endocarditis.

MAIN OUTCOME MEASURES

Monthly number of prescriptions for antibiotic prophylaxis consisting of a single 3 g oral dose of amoxicillin or a single 600 mg oral dose of clindamycin, and monthly number of cases of infective endocarditis, infective endocarditis related deaths in hospital, or cases of infective endocarditis with a possible oral origin for streptococci.

RESULTS

After the introduction of the NICE guideline there was a highly significant 78.6% reduction (P < 0.001) in prescribing of antibiotic prophylaxis, from a mean 10,277 (SD 1068) prescriptions per month to 2292 (SD 176). Evidence that the general upward trend in cases of infective endocarditis before the guideline was significantly altered after the guideline was lacking (P = 0.61). Using a non-inferiority test, an increase in the number of cases of 9.3% or more could be excluded after the introduction of the guideline. Similarly an increase in infective endocarditis related deaths in hospital of 12.3% or more could also be excluded.

CONCLUSION

Despite a 78.6% reduction in prescribing of antibiotic prophylaxis after the introduction of the NICE guideline, this study excluded any large increase in the incidence of cases of or deaths from infective endocarditis in the two years after the guideline. Although this lends support to the guideline, ongoing data monitoring is needed to confirm this, and further clinical trials should determine if antibiotic prophylaxis still has a role in protecting some patients at particularly high risk.

[Fulfillment of the prevention of endocarditis guidelines after percutaneous closure of atrial septal defects]

INTRODUCTION

After the implantation of an intracardiac device for the closure of an atrial septal defect, most centres follow the guidelines for antibiotic prophylaxis to reduce the risk of infectious endocarditis, at least during the first 6 months after the implantation, if there is no evidence of residual shunt. The aim of this report is to evaluate the knowledge, fulfillment and adherence to the recommendations of our centre on the prevention of endocarditis, of the families of patients subjected to percutaneous closure of an ASD.

PATIENTS AND METHODS

We performed an observational retrospective study of 51 paediatric patients subjected to percutaneous closure of an ASD in the "Complejo Hospitalario Universitario de La Coruña", between 1999 and 2008.

RESULTS

A total of 51 procedures were performed, with an average of follow-up of 57.2 months. 75.7% of the families knew about the prophylaxis of endocarditis. This percentage was higher if less time had passed since the intervention and was also higher depending on the educational level of the parents. A total of 50% never stopped carrying out the endocarditis prophylaxis. In this case, a relationship was also observed, with the educational level of the parents and with the time passed since the intervention (P=0.004). The majority (73%) of the patients never had to carry out endocarditis prophylaxis.

CONCLUSIONS

The latest guidelines on antibiotic prophylaxis of endocarditis are increasingly restrictive in their indications in order to promote a more rational use of antibiotics. More studies are needed on the indications of antibiotic prophylaxis in endocarditis in patients with an intracardiac device, in order to establish concrete or evidence-based guidelines. Meanwhile, it is our responsibility to avoid the indiscriminate application of antibiotics, and involve the families and other health professionals.

[Prophylaxis of infective endocarditis: trends and new recommendations]

The rationale having led to the profound change in the guidelines on the prevention of endocarditis is presented. The current trend to abandoning systematic antibiotic prophylaxis in patients at risk for infective endocarditis is in fact based upon a sound scientific background. Systematic antibiotic prophylaxis remains necessary, however, in the category of patients at very high risk.

New recommendations for the prevention of infective endocarditis

PURPOSE OF REVIEW

A revision of the American Heart Association guidelines for the prevention of infective endocarditis was recently published in their journal Circulation. Pediatric practitioners as well as other primary care specialists and dentists will need to advise patients as to whether they require antibiotic prophylaxis prior to invasive procedures. Some patients who formerly received prophylaxis for certain procedures may need an explanation when they are told that antibiotic prophylaxis is no longer recommended for them.

RECENT FINDINGS

New research casts doubt on whether dental, surgical and invasive diagnostic procedures really are the cause of infective endocarditis. Events of daily life are more likely to cause bacteremia than planned procedures. Neither constant nor intermittent antibiotic prophylaxis has been proven to prevent endocarditis.

SUMMARY

The authors of the revised American Heart Association guidelines made significant changes from past guidelines restricting prophylaxis to only those individuals with cardiac conditions that pose the highest risk for bad outcome should infective endocarditis occur and only for dental procedures causing the highest bacteremia rates.

Prophylaxis of Infective Endocarditis: Prevention of the Perfect Storm

Despite the availability of endocarditis prophylaxis guidelines for more than five decades, no prospective, randomised trial has ever been conducted to evaluate the efficacy and safety of this practice. This fact, in combination with mixed results from case-control investigations and other factors, has prompted a re-evaluation of the appropriateness of the guidelines. The update provided herein highlights recent revisions in guidelines promulgated by different countries.

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

BACKGROUND

The purpose of this statement is to update the recommendations by the American Heart Association (AHA) for the prevention of infective endocarditis, which were last published in 1997.

METHODS AND RESULTS

A writing group appointed by the AHA for their expertise in prevention and treatment of infective endocarditis (IE) with liaison members representing the American Dental Association, the Infectious Diseases Society of America and the American Academy of Pediatrics. The writing group reviewed input from national and international experts on IE. The recommendations in this document reflect analyses of relevant literature regarding procedure-related bacteremia and IE; in vitro susceptibility data of the most common microorganisms, which cause IE; results of prophylactic studies in animal models of experimental endocarditis; and retrospective and prospective studies of prevention of IE. MEDLINE database searches from 1950 through 2006 were done for English language articles using the following search terms: endocarditis, infective endocarditis, prophylaxis, prevention, antibiotic, antimicrobial, pathogens, organisms, dental, gastrointestinal, genitourinary, streptococcus, enterococcus, staphylococcus, respiratory, dental surgery, pathogenesis, vaccine, immunization and bacteremia. The reference lists of the identified articles were also searched. The writing group also searched the AHA online library. The American College of Cardiology/AHA classification of recommendations and levels of evidence for practice guidelines were used. The article subsequently was reviewed by outside experts not affiliated with the writing group and by the AHA Science Advisory and Coordinating Committee.

CONCLUSIONS

The major changes in the updated recommendations include the following. (1) The committee concluded that only an extremely small number of cases of IE might be prevented by antibiotic prophylaxis for dental procedures even if such prophylactic therapy were 100 percent effective. (2) IE prophylaxis for dental procedures should be recommended only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from IE. (3) For patients with these underlying cardiac conditions, prophylaxis is recommended for all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa. (4) Prophylaxis is not recommended based solely on an increased lifetime risk of acquisition of IE. (5) Administration of antibiotics solely to prevent endocarditis is not recommended for patients who undergo a genitourinary or gastrointestinal tract procedure. These changes are intended to define more clearly when IE prophylaxis is or is not recommended and to provide more uniform and consistent global recommendations.

[Dental extraction and infective endocarditis prophylaxis: current recommendations]

PURPOSE

Antibiotic prophylaxis for infective endocarditis is still debated because of unproven efficacy and risk of side effects. French recommendations for infective endocarditis prophylaxis were revised in 2002 and its indications were restricted.

CURRENT KNOWLEDGE AND KEY POINTS

Several arguments plead against prophylaxis: the absence of scientific evidence of its efficacy, the very high number of antibiotic doses required to prevent a very small number of endocarditis, the possible failure of prophylaxis even if correctly administered and a lack of compliance with current recommendations. High-risk patients for whom dental extraction is required should receive prophylaxis. For moderate-risk patients, prophylaxis is optional and should be discussed for each case individually.

FUTURE PROSPECTS AND PROJECTS

Although prophylaxis is discussed, one should focus on prevention measures, such as dental hygiene and education of physicians, dentists and patients.

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

BACKGROUND

The purpose of this statement is to update the recommendations by the American Heart Association (AHA) for the prevention of infective endocarditis that were last published in 1997.

METHODS AND RESULTS

A writing group was appointed by the AHA for their expertise in prevention and treatment of infective endocarditis, with liaison members representing the American Dental Association, the Infectious Diseases Society of America, and the American Academy of Pediatrics. The writing group reviewed input from national and international experts on infective endocarditis. The recommendations in this document reflect analyses of relevant literature regarding procedure-related bacteremia and infective endocarditis, in vitro susceptibility data of the most common microorganisms that cause infective endocarditis, results of prophylactic studies in animal models of experimental endocarditis, and retrospective and prospective studies of prevention of infective endocarditis. MEDLINE database searches from 1950 to 2006 were done for English-language papers using the following search terms: endocarditis, infective endocarditis, prophylaxis, prevention, antibiotic, antimicrobial, pathogens, organisms, dental, gastrointestinal, genitourinary, streptococcus, enterococcus, staphylococcus, respiratory, dental surgery, pathogenesis, vaccine, immunization, and bacteremia. The reference lists of the identified papers were also searched. We also searched the AHA online library. The American College of Cardiology/AHA classification of recommendations and levels of evidence for practice guidelines were used. The paper was subsequently reviewed by outside experts not affiliated with the writing group and by the AHA Science Advisory and Coordinating Committee.

CONCLUSIONS

The major changes in the updated recommendations include the following: (1) The Committee concluded that only an extremely small number of cases of infective endocarditis might be prevented by antibiotic prophylaxis for dental procedures even if such prophylactic therapy were 100% effective. (2) Infective endocarditis prophylaxis for dental procedures is reasonable only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis. (3) For patients with these underlying cardiac conditions, prophylaxis is reasonable for all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa. (4) Prophylaxis is not recommended based solely on an increased lifetime risk of acquisition of infective endocarditis. (5) Administration of antibiotics solely to prevent endocarditis is not recommended for patients who undergo a genitourinary or gastrointestinal tract procedure. These changes are intended to define more clearly when infective endocarditis prophylaxis is or is not recommended and to provide more uniform and consistent global recommendations.

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

BACKGROUND

The purpose of this statement is to update the recommendations by the American Heart Association (AHA) for the prevention of infective endocarditis that were last published in 1997.

METHODS AND RESULTS

A writing group was appointed by the AHA for their expertise in prevention and treatment of infective endocarditis, with liaison members representing the American Dental Association, the Infectious Diseases Society of America, and the American Academy of Pediatrics. The writing group reviewed input from national and international experts on infective endocarditis. The recommendations in this document reflect analyses of relevant literature regarding procedure-related bacteremia and infective endocarditis, in vitro susceptibility data of the most common microorganisms that cause infective endocarditis, results of prophylactic studies in animal models of experimental endocarditis, and retrospective and prospective studies of prevention of infective endocarditis. MEDLINE database searches from 1950 to 2006 were done for English-language papers using the following search terms: endocarditis, infective endocarditis, prophylaxis, prevention, antibiotic, antimicrobial, pathogens, organisms, dental, gastrointestinal, genitourinary, streptococcus, enterococcus, staphylococcus, respiratory, dental surgery, pathogenesis, vaccine, immunization, and bacteremia. The reference lists of the identified papers were also searched. We also searched the AHA online library. The American College of Cardiology/AHA classification of recommendations and levels of evidence for practice guidelines were used. The paper was subsequently reviewed by outside experts not affiliated with the writing group and by the AHA Science Advisory and Coordinating Committee.

CONCLUSIONS

The major changes in the updated recommendations include the following: (1) The Committee concluded that only an extremely small number of cases of infective endocarditis might be prevented by antibiotic prophylaxis for dental procedures even if such prophylactic therapy were 100% effective. (2) Infective endocarditis prophylaxis for dental procedures is reasonable only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis. (3) For patients with these underlying cardiac conditions, prophylaxis is reasonable for all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa. (4) Prophylaxis is not recommended based solely on an increased lifetime risk of acquisition of infective endocarditis. (5) Administration of antibiotics solely to prevent endocarditis is not recommended for patients who undergo a genitourinary or gastrointestinal tract procedure. These changes are intended to define more clearly when infective endocarditis prophylaxis is or is not recommended and to provide more uniform and consistent global recommendations.