Introduction
Since 1995 the AHA has been developing recommendations on how to use antibiotics to prevent infective endocarditis before certain surgical procedures such as dental, genitourinary tract, and gastrointestinal tract.
However, many scholars, academic groups, and experimental results have questioned the effectiveness of using antibiotics to prevent infective endocarditis in most cases!!!
5 changes from the 2006 edition of the guideline – 1
The committee concluded that infective endocarditis can be prevented by prophylactic use of antibiotics in only a very few cases in dental practice, even if this prophylactic treatment is 100% effective. — Only a few are effective! Sun Zongquan, Department of Cardiac Surgery, Wuhan Union Medical College Hospital
5 points of change from the 2006 edition of the guidelines — 2
Prophylactic use of antibiotics prior to dental operations is only justified when there is an underlying cardiac disease state that would lead to serious adverse outcomes if infective endocarditis were to develop. —- is only partially justified!!!
5 changes from the 2006 edition of the guideline – 3
Prophylactic treatment of all dental operations involving gingival tissue, apical areas of teeth, and oral mucosal penetration is justified in patients with an underlying cardiac disease state.
5-point change from the 2006 edition of the guideline – 4
Prophylaxis is not recommended based solely on the degree of increased lifetime risk of infective endocarditis.
5 changes from the 2006 edition of the guideline – 5
Do not recommend antibiotics for prophylaxis of infective endocarditis in patients undergoing genitourinary and gastrointestinal procedures.
Rationale for guideline changes.
Infective endocarditis is more commonly associated with bacteremia resulting from exposure to daily activities rather than bacteremia resulting from dental, genitourinary, or gastrointestinal procedures.
Prophylaxis can only prevent infective endocarditis in a very small number (if any) of patients who perform oral, GI, and GU procedures.
The adverse effects associated with antibiotics outweigh the benefits, if any, of prophylaxis.
Maintaining optimal oral hygiene reduces bacteremia from daily activities and reduces the risk of infective endocarditis more than prophylactic use of antibiotics in dental practices.
Therefore, the AHA Committee on Prevention of Infective Endocarditis recommends prophylactic antibiotics only for high-risk (infective endocarditis) patients undergoing dental procedures involving gingival tissue, the apical region of the teeth, and oral mucosal penetration. (IIa)
Supplementation.
Prophylaxis will no longer be recommended for patients performing respiratory operations, except in high-risk patients undergoing or involving incisions of the respiratory mucosa such as tonsillectomy, adenoidectomy.
Prophylaxis will no longer be recommended for patients with gastrointestinal and genitourinary tract operations, including diagnostic esophagogastroduodenoscopy, colonoscopy, and transesophageal cardiac ultrasound.
However, antibiotic therapy is required to prevent wound infection or sepsis in patients at high risk for pre-existing gastrointestinal and genitourinary tract infections.
For high-risk patients preparing for elective cystoscopy or other urinary tract operations with pre-existing E. coli urinary tract infection or colonization, antibiotics are required to eradicate E. coli prior to the operation.
High-risk patients
Patients with an underlying cardiac disease state that would lead to serious adverse outcomes if infective endocarditis were to develop.
Not those patients at increased lifetime risk of acquiring infective endocarditis.
This includes
Use of an artificial heart valve or repair of the valve using artificial tissue.
A prior history of infective endocarditis.
Heart valve disease that developed after a heart transplant.
Special types of congenital heart disease.
Summary: 2008 Edition of the IE Guidelines for the Prevention of Heart Valve Disease
Prophylaxis of infective endocarditis is warranted for the following high-risk patients who undergo dental procedures involving gingival tissue, the apical region of the teeth, and oral mucosal penetration (IIa)
(I) Use of a prosthetic heart valve or repair of the valve using artificial tissue. (Level of evidence: C)
(ii) Prior history of infective endocarditis. (Level of Evidence: B)
(iii) Heart valve disease after heart transplantation. (Level of Evidence: C)
Summary: 2008 Edition of IE Guidelines for the Prevention of Heart Valve Disease
(iv) Specific types of congenital heart disease. (Level of Evidence: B)
Unrepaired cyanotic congenital heart disease, including palliative bypass. (Level of evidence: B)
Completely repaired congenital heart disease using artificial materials or devices, whether by interventional or surgical route, in the first 6 months after their procedure. (Level of Evidence: B)
Congenital heart disease that has been repaired but a residual defect remains in or adjacent to the location of the artificial patch or device. (Level of Evidence: C)
Summary: 2008 Edition of IE Guidelines for the Prevention of Heart Valve Disease
For nonoral operations, prevention of infective endocarditis is not recommended if no active infection is present. (III, Level of Evidence: B)
E.g., esophagogastroduodenoscopy, colonoscopy, transesophageal cardiac ultrasound.
Summary: 2006 Edition of IE Guidelines for Prevention of Heart Valve Disease
Prevention of infective endocarditis is recommended for the following patients (I)
(I) use a prosthetic heart valve or have a previous history of infective endocarditis. (Level of evidence: C)
(ii) Complex cyanotic congenital heart disease, such as single ventricle, transposition of great vessels, and tetralogy of Fallot. (Level of evidence: C)
(iii) Surgically constructed systemic pulmonary shunt or bypass. (Level of evidence: C)
(iv) Congenital valvular malformations, particularly of the mitral aortic valve, or acquired valvular insufficiency, such as rheumatic valve disease. (Level of Evidence: C)
Summary: 2006 Edition of IE Guidelines for the Prevention of Heart Valve Disease
⑤ Valve repair has been performed. (Level of Evidence: C)
⑥Patients with hypertrophic cardiomyopathy with underlying or resting obstruction. (Level of Evidence: C)
(vii) Mitral valve prolapse with auscultatory findings of valve regurgitation and or ultrasonographic findings of leaflet thickening. (Level of evidence: C)
Summary: 2006 Edition of the IE Guidelines for the Prevention of Heart Valve Disease
Prophylaxis of infective endocarditis is not recommended for the following patients (III)
(I) Solitary secondary empty atrial defect . (Level of evidence: C)
② Atrial defect, ventricular defect, and patent ductus arteriosus successfully repaired by intervention or surgery more than 6 months after the procedure . (Level of evidence: C)
(iii) Mitral valve prolapse without regurgitation or no leaflet thickening on ultrasound. (Level of evidence: C)
④Physiological, functional, harmless murmur. (Level of evidence: C)
⑤ Physiologic mitral regurgitation with normal leaflet structure and no murmur on auscultation is found on cardiac ultrasound. (Level of evidence: C)
(vi) Physiologic tricuspid and pulmonary regurgitation with normal leaflet structure and no murmur on auscultation is found on cardiac ultrasound. (Level of evidence: C)
Specific dental procedures to prevent infective endocarditis.
Required: Not required.
Gingival tissue After routine injection of numbing of non-infected tissue
Tooth apical area Dental radiographs
Penetration of oral mucosa Placement or removal of restorative, orthodontic molds
Adjustment of orthodontic molds
Placement of orthodontic brackets
Bleeding of the lip or oral mucosa
Loss of baby teeth
Antibiotic regimen