The incidence of bacteremia in pediatric patients following tooth extraction

Bacteraemia of oral origin in children-A Systematic review and network meta-analysis

OBJECTIVES

To systematically review the prevalence of bacteraemia, triggered by dental intervention and home oral hygiene practices, in children. The network meta-analysis (NMA) quantitatively compared the risk of bacteraemia triggered by dental extractions and home and professional cleaning procedures.

MATERIALS AND METHODS

Clinical trials with the outcome "bacteraemia in children" were searched. The NMA was performed using the frequentist weighted least-squares approach comparing the odds ratios (OR) of different interventions.

RESULTS

Among 11 of 13 studies, dental treatment was performed under general anaesthesia. In 2,381 patients, bacteraemia occurred in 38.7%-56% patients following single-tooth extractions, in 22%-46% after manual toothbrushing (MTB), and in 26%-78% after power toothbrushing (PTB). When MTB was set as the reference (OR 1), rubber cup polishing showed a slightly higher risk (OR 1.26) of bacteraemia. PTB presented a higher risk (OR 1.79-2.27) than with single-tooth extractions (OR 1.55) but lower than that with multiple extractions (OR 2.55).

CONCLUSION

Daily use of MTB and routine professional cleaning were associated with the lowest risk of developing bacteraemia in children with gingivitis, almost as much as with a single-tooth extractions. Improved plaque control with PTB increased the risk of bacteraemia. There is limited evidence on gingivitis-free and systemically-diseased children.

Bacteremia Associated With Oral Surgery: A Review

OBJECTIVES

Bacterial (infective) endocarditis, a microbial infection of the endocardium surfaces after bacteremia, causes significant morbidity and mortality. Recent epidemiologic studies have reported a prevalence of 2-8 cases per 100,000 individuals per year, with the highest incidence in those aged 70-80 years and those living in developed countries. We systematically reviewed the literature on several critical aspects regarding the development of bacteremia after oral surgery. The purpose of this work is to assess the controversy regarding antibiotic prophylaxis before oral surgery.

MATERIALS AND METHODS

Publications between 1976 and 2015 were included. Clinical studies focusing on oral surgery as the underlying cause were included.

RESULTS

Among the 32 clinical studies reviewed, 3564 cases, accounting for 12,839 blood cultures, were evaluated. In 10 of these studies, amoxicillin usefulness was studied. Antimicrobial prophylaxis before an invasive dental procedure does not prevent bacteremia, although it can decrease both its magnitude and its persistence.

CONCLUSIONS

The highly conflicting data and conclusions of the analyzed work highlight the need for new approaches to the study of bacteremia that would provide reliable evidence and thus appropriate prophylactic and therapeutic standards. Many reports have explored the occurrence of bacteremia after dental procedures, but the results have been conflicting.

An investigation of the frequency of bacteraemia following dental extraction, tooth brushing and chewing

Abstract

We conducted a study to determine the frequency of bacteraemias following dental extraction and common oral procedures, namely tooth brushing and chewing, and the relationship between bacteraemia and oral health in black patients. Positive blood cultures were detected in 29.6% of patients after dental extraction, in 10.8% of patients after tooth brushing and in no patients after chewing. No relationship between the state of oral health, which was assessed using the plaque and gingival indices, and the incidence of bacteraemia was found. The duration of bacteraemia was less than 15 minutes. One patient had a positive blood culture prior to dental extraction; his oral health status was poor. Our study confirmed that bacteraemia occurs after tooth brushing.

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

The Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures evidence-based clinical practice guideline was codeveloped by the American Academy of Orthopaedic Surgeons (AAOS) and the American Dental Association. This guideline replaces the previous AAOS Information Statement, "Antibiotic Prophylaxis in Bacteremia in Patients With Joint Replacement," published in 2009. Based on the best current evidence and a systematic review of published studies, three recommendations have been created to guide clinical practice in the prevention of orthopaedic implant infections in patients undergoing dental procedures. The first recommendation is graded as Limited; this recommendation proposes that the practitioner consider changing the long-standing practice of routinely prescribing prophylactic antibiotic for patients with orthopaedic implants who undergo dental procedures. The second, graded as Inconclusive, addresses the use of oral topical antimicrobials in the prevention of periprosthetic joint infections. The third recommendation, a Consensus statement, addresses the maintenance of good oral hygiene.

Prophylaxis against infective endocarditis for dental procedures--summary of the NICE guideline

The National Institute for Health and Clinical Excellence (NICE) has developed a guideline on 'Prophylaxis against infective endocarditis'. This paper details the recommendations from these guidelines which relate to dental practice and discusses the clinical and cost-effectiveness evidence pertaining to them. This is taken from the full NICE guideline, which also includes guidance relating to non-dental procedures (http://www.nice.org.uk/CG064).

Prevalence of bacteraemia following third molar surgery

OBJECTIVE

To investigate the prevalence and aetiology of bacteraemia following third molar extractions (B-TME), analysing the factors affecting its development.

METHODS

The study group was formed of 100 patients undergoing third molar extractions under general anaesthesia. Peripheral venous blood samples were collected at baseline, 30 s after a mandibular third molar extraction and 15 min after completing the final extraction. Samples were inoculated into BACTEC aerobic and anaerobic blood culture bottles and were processed in the BacT/Alert. Subculture and further identification of the bacteria isolated was performed using conventional microbiological techniques.

RESULTS

The prevalence of bacteraemia following third molar surgery was 62% at 30 s after the first dental extraction and 67% at 15 min after finishing the final extraction. The bacteria most frequently identified in the positive blood cultures were Streptococcus viridans (87.9%).

CONCLUSION

In our series, the prevalence of B-TME at 30 s after a single third molar extraction was high, principally being of streptococcal aetiology, and was independent of the oral health status and the magnitude of the surgical procedure. Positive blood cultures persisted for at least 15 min after three to four dental extractions in a higher number of patients, questioning the supposedly transient nature of bacteraemia following dental extractions.

The impact of oral disease and nonsurgical treatment on bacteremia in children

BACKGROUND

The authors examine the role of dental disease and nonsurgical dental procedures in the incidence and duration of bacteremia in children.

METHODS

The authors randomized a group of children to receive amoxicillin or a placebo before dental rehabilitation in an operating room setting. They collected eight blood draws at the following times: two minutes after intubation (draw 1); after dental restorations, pulp therapy and cleaning (draw 2); 10 minutes later (draw 3); and five draws during and after dental extractions (draws 4-8). The authors compared dental disease parameters and the type of dental procedures performed with the incidence and duration of bacteremia.

RESULTS

The authors enrolled 100 children (aged 1-8 years) in the study. The incidence of bacteremia from draw 2 was 20 percent in the placebo group and 6 percent in the amoxicillin group (P = .07), and the incidence from draw 3 was 16 percent in the placebo group and zero percent in the amoxicillin group (P = .03). Subjects with higher gingival scores were more likely to have a bacteremia for draw 2 (P = .01). The authors found that subjects in the group with bacteremia for draw 3 had undergone more pulpotomies than did subjects in the group without bacteremia for draw 3 (3 +/- 2.5 standard deviation [SD] versus 1.5 +/- 1.6 SD, P = .04), while they found almost no differences for draw 2.

CONCLUSIONS

This study suggests that gingival disease has an impact on bacteremia after dental restorations and prophylaxis. Although antibiotics have an impact, they do not eliminate bacteremia altogether.

Prevalence, duration and aetiology of bacteraemia following dental extractions

OBJECTIVE

To investigate the prevalence, duration and aetiology of bacteraemia following dental extractions, analysing the factors affecting its development.

SUBJECTS AND METHODS

The study group was composed of 53 patients undergoing dental extractions under general anaesthesia. Peripheral venous blood samples were collected at baseline and at 30 s, 15 min and 1 h after the dental extractions. Samples were inoculated into BACTEC PLUS aerobic and anaerobic blood culture bottles and were processed in Bactec 9240. Subculture and further identification of the bacteria isolated was performed by conventional microbiological techniques.

RESULTS

The prevalence of bacteraemia following dental extractions was 96.2% at 30 s, 64.2% at 15 min and 20% at 1 h after completing the surgical procedure. The bacteria most frequently identified in the positive blood cultures were Streptococcus spp. (63.8%), particularly Streptococcus viridans.

CONCLUSIONS

In our series, the majority of patients undergoing dental extractions developed bacteraemia, usually of a streptococcal nature, independently of the grade of oral health and of the number of extractions performed. Positive blood cultures persisted for at least 1 h after the dental procedure in a considerable number of patients, questioning the supposedly transient nature of bacteraemia following dental extractions.

Transfusion-transmitted bacterial infection: risks, sources and interventions

Records of the transmission of bacterial infections by transfusion date back to the beginning of organized blood banking. Despite tremendous strides in preventing viral infection through careful donor screening and viral testing, there has been little improvement in reducing the risk of bacterial sepsis since the introduction of closed collection systems. Based on the French Haemovigilance study, the British Serious Hazards of Transmission (SHOT) study and fatality reports to the United States Food and Drug Administration, the risk of clinically apparent sepsis exceeds the risk of HIV, HBV, and HCV transmission. Sources of contamination include the skin, blood, disposables, and the environment. Potential interventions to reduce transfusion-associated bacterial sepsis include improvements to donor arm preparation, diversion of the first aliquot of whole blood, introduction of bacterial testing and/or implementation of pathogen reduction methods.

Intravenous antibiotic regimens and prophylaxis of odontogenic bacteraemia

OBJECTIVES

This study retrospectively examines the efficacy of prophylactic intravenous antibiotic regimens in the prevention of odontogenic bacteraemia in children with severe congenital heart defects receiving comprehensive dental treatment under general anaesthesia.

PATIENTS AND METHODS

Blood cultures were taken from children with congenital cardiac defects 30 seconds after completion of dental treatment under general anaesthesia. Antibiotic prophylaxis had been given intravenously immediately before dental treatment. The choice of antibiotics and the extent of dental treatment were recorded. The percentage prevalence of bacteraemia was compared with published data following multiple dental extractions using the same clinical and microbiological methodology.

RESULTS

The overall percentage prevalence of positive cultures in children receiving intravenous prophylactic antibiotics was 16%. The percentage of positive blood cultures in cardiac children who received ampicillin alone was not significantly different from that in children having a combination of amikacin and teicoplanin (16.7% v 22.2%) respectively [Chi Square = 0.385, df = 1, P= 0.535]. When compared with multiple extractions, both ampicillin alone and amikacin with teicoplanin were effective in reducing the prevalence of odontogenic bacteraemia.

CONCLUSIONS

In children with cardiac defects, bacteraemia after dental treatment is reduced by antibiotics but is still detected on 16% of occasions. In comparison with children receiving ampicillin alone, the combination of amikacin and teicoplanin is as effective in reducing bacteraemia in children who are either allergic to penicillins or who have received them within the previous month.

An update on the controversies in bacterial endocarditis of oral origin

OBJECTIVES

The aim of this review was to evaluate the evidence implicating dental procedures in bacterial endocarditis (BE) development and the basis for antimicrobial prophylaxis (AP).

STUDY DESIGN

In this article, the literature is reviewed and meaningful findings about epidemiology, pathogenesis, and AP guidelines for BE of oral origin are highlighted. Available results are used to formulate clinical recommendations for the dental practitioner.

RESULTS

The nature of dental procedures that cause bacteremia, patients at risk for BE, and the effectiveness of AP guidelines, continue to be points of controversy. There appears to be further evidence to support the important role of oral health status in the prevention of BE of dental origin.

CONCLUSIONS

One objective of the dental practitioner in caring for patients at risk for BE should be to promote oral health care. There are no hard data on which to scientifically base the need for AP in patients at risk for BE. However, it would appear prudent, at least from the medicolegal perspective, to provide AP, at least to persons with previous BE or prosthetic heart valves and to those undergoing oral surgery, periodontal treatment, or implant placement.

Estudo comparativo da eficiência de três métodos de anti-sepsia intrabucal na redução do número de estreptococos do sulco gengival

Este trabalho foi feito com o objetivo de avaliar três métodos de anti-sepsia intrabucal na redução do número de estreptococos do sulco gengival. Os resultados obtidos demonstraram que os três tratamentos promoveram a redução do número de estreptococos do sulco gengival. A análise estatística mostrou que, ao nível de 1% de significância, o método que empregou um bochecho com clorexidina a 0,12% associado à limpeza das faces dentais com cotonete embebido nesta mesma solução foi semelhante àquele que empregou dois bochechos com cloreto de cetilpiridínio intercalados com a limpeza das faces dentais com cotonete embebido em peróxido de hidrogênio a 3%. Esses dois métodos foram mais eficientes na redução do número de estreptococos do que o que empregou apenas um bochecho com clorexidina.

Risks for and prevention of infective endocarditis

It is accepted medical practice to prevent bacterial endocarditis in patients with susceptible congenital or acquired cardiac malformations who are likely to experience predictable procedure-related bacteremia. Patients in general, those with congenital heart disease specifically, are insufficiently aware of the need for such prophylaxis. It is responsibility of the physician to determine which patients are susceptible to endocarditis and the need for endocarditis prophylaxis for each patient for any given instance and to educate the patient as to this need. The American Heart Association provides wallet-sized cards that may be given to each patient. Those patients not previously known to have heart disease are, of course, not eligible for chemoprophylaxis. Because these represent many of the patients with endocarditis each year, it can be argued that only a minority of patients have preventable cases. Regarding the clinical application of anti-infective endocarditis prophylaxis, the American Heart Association gives this perspective: This statement represents recommended guidelines to supplement practitioners in the exercise of their clinical judgement and is not intended as a standard of care for all cases.... Because no adequate, controlled clinical trials of antibiotic regimens for the prevention of bacteria endocarditis in humans have been done, recommendations are based on vitro studies, clinical experience, data from experimental animal models, and assessment of both the bacteria most likely to produce bacteremia from a given site and those most likely to result in endocarditis. Bacterial endocarditis is one of the few infectious disease that almost always result in death unless treated. The dramatic nature of the morbidity and mortality of infective endocarditis in those so afflicted makes the prevention of even a few cases worth the effort.

The incidence of bacteremia after orthodontic banding

This investigation assessed the incidence of bacteremia after orthodontic banding. Thirty adult volunteers with good oral health, who were not at risk from bacterial endocarditis, were included in this study. An orthodontic band was placed on a first molar of each subject. Venous blood samples were taken before, and 1 to 2 minutes after the molar band was fitted. Microbiologic tests performed on the blood samples revealed a comparatively low incidence of bacteremia (10%) after orthodontic banding.

Changing methods of preventing infective endocarditis following dental procedures: 1943 to 1993

The report by Northrop and Crowley in the inaugural issue of the Journal of Oral Surgery heralded the appearance of studies designed to confirm both the relationship between dental procedure-induced bacteremia and infective endocarditis and the best methods to interrupt this chain of causation. Their discovery that antibiotics can modulate bacteremias produced by dental procedures eventually led to the universal adoption of the prophylactic regimens to prevent cases of infective endocarditis following dental procedures. Advances since their work have involved a greater understanding of the role of adherence in the mechanism of action of prophylactic antibiotics, an appreciation of the ability to limit antibiotic administration to only the immediate preoperative period, the need to keep prophylactic regimens as uncomplicated as is safe, and greater knowledge about the interaction between dental procedures and bacteremias. Whether the widespread use of prophylactic antibiotics during dental procedures significantly decreases the incidence of endocarditis remains open to future investigation.

Optimum sampling time for detection of dental bacteraemia in children

A total of 458 blood cultures were taken from 229 children aged 2 to 16 yr. Each 6 ml sample was taken starting at one of the following times after the extraction of a single tooth: 10 s, 30 s, 60 s, 90 s, 120 s, 180 s, 600 s and continuously over 2.5 min. The samples were cultured in the BACTEC radiometric culture system and when positive the bacteria isolated were speciated. At 30 s 56% of the samples were positive, the highest proportion, in contrast to only 38% of positive samples at 90 s and 28% at 600 s. Over 50% of the organisms found were Viridans streptococci.

Bacteremia in children following dental extraction

The incidence and intensity of bacteremia following tooth extraction in children were measured by blood culture. The effects on bacteremia of the number and type of teeth extracted, oral hygiene, gingival health, presence of abscess, and antibiotic prophylaxis were assessed. Antibiotic prophylaxis reduced the incidence of bacteremia from 63% to 35%. The intensity of bacteremia was 2 cfu/mL of blood or less in 80% of the children. An agar pour-plate method of blood culture was significantly more effective than broth in culturing the small volumes of inoculum. Of 83 bacterial strains characterized, 39 were strict anaerobes or micro-aerophilic, and the remainder mainly streptococci. S. mitior and S. sanguis were most commonly isolated, often in pure culture, and were generally sensitive to antibiotics. No direct association was demonstrated between the plaque and gingival indices and incidence of bacteremia or between the number of teeth extracted and the incidence or intensity of bacteremia. It is concluded that all children at risk from infective endocarditis require antibiotic prophylaxis prior to tooth extraction, since it is impossible for the likelihood or intensity of transient bacteremia to be clinically predicted.

The interface between primary care and pediatric cardiology

Pediatricians and family practitioners share responsibility with pediatric cardiologists for providing these patients with comprehensive medical services. This article serves as a resource for primary care physicians when questions concerning the care of children with heart disease arise. Considered are questions on growth, development, infectious disease, psychosocial issues, pharmacology, contraception and pregnancy, genetic counseling, school, travel, minor surgery, and financial considerations.

How important are dental procedures as a cause of infective endocarditis?

Eighteen pediatric patients with infective endocarditis (IE) were reviewed for "failure" of chemoprophylaxis; none had had a previous dental procedure. Surprisingly, published reports reveal a similarly low prevalence of dental extractions preceding IE, only 3.6% for 1,322 cases. Although bacteremia was associated with 40% of 2,403 reported extractions, it also was found in 38% of patients after mastication, and in 11% of patients with oral sepsis and no intervention. In a hypothetical month, ending with a single dental extraction, the cumulative exposure to these "physiologic" sources of bacteremia is nearly 1,000 times greater than it is from extraction. The current American Heart Association recommendations for intramuscular or intravenous chemoprophylaxis are impractical, and the discomfort and inconvenience may impede good dental care. The Committee also implies that gingival bleeding allows bacterial access to the blood stream, whereas experimental studies establish the lymphatics as the only access. Although oral chemoprophylaxis for major dental procedures appears prudent, the British regimen of a single dose of amoxicillin administered orally is much simpler and probably more effective. However, scrupulous oral and dental hygiene is undoubtedly superior in preventing IE than any chemoprophylaxis regimen.

Value of antibiotic prophylaxis in periodontal surgery

THE MORBIDITY and incidence of bacteremia in periodontal surgery with or without cephalexin prophylaxis were assessed in adults on the basis of clinical evaluations and blood cultures. Cephalexin reduced the incidence of polymicrobic bacteremias. There was no correlation between objective signs of tissue healing and antibiotic coverage in treated or nontreated patients. In vitro antibiotic susceptibility data showed that cephalexin was active against the aerobic and anaerobic bacteria isolated from blood specimens taken during surgery.

Dental implications of brain abscess in children with congenital heart disease. Case report and review of the literature

There is a high morbidity and mortality associated with brain abscesses in children with congenital cyanotic heart disease. A case is reported here which implicated an endodontically treated primary molar in the etiology of a brain abscess in a boy with congenital cyanotic heart disease.

Is there bacteremia after suprapubic aspiration in children with urinary tract infections?

It has been shown that bacteremia may occur after bladder puncture in animals. Whether this also happens in man is not known. Thirty-three patients who were suspected to have urinary tract infection were examined for bacteremia after suprapubic bladder puncture. Of these children 19 had infection. There was no positive blood culture in any of these cases after suprapubic bladder puncture.