Presentation on theme: "Perspectives on the 2007 AHA guidelines for the prevention of infective endocarditis Nelson L. Rhodus, DMD, MPH, FACD Professor Academy of Distinguished."— Presentation transcript:
1Perspectives on the 2007 AHA guidelines for the prevention of infective endocarditis Nelson L. Rhodus, DMD, MPH, FACD Professor Academy of Distinguished ProfessorsDirector, Division of Oral Medicine, Dental SchoolAdjunct Professor, Otolaryngology, Medical SchoolDiplomate, American Board of Oral MedicineUniversity of Minnesota
7Basis for Past AHA Guidelines 1. True or falseDental procedures were the source of the bacteremias leading to IE
8Basis for Past AHA Guidelines Dental procedures were the source of the bacteremias leading to IE(False, Daily activities much more likely the source)
9Basis for Past AHA Guidelines 2. True or falseMagnitude of dental procedure bacteremias were far greater than daily activities
10Basis for Past AHA Guidelines Magnitude of dental procedure bacteremias were far greater than daily activities(False, they are about the same, both relatively low magnitude)
11Basis for Past AHA Guidelines 3. True or falseBleeding is the indication for bacteremia occurring
12Basis for Past AHA Guidelines Bleeding is the indication for bacteremia occurring(False, it is not a reliable predictor for bacteremia)
13Basis for Past AHA Guidelines 4. True or false Prophylaxis reduces the risk of IE from occurring
14Basis for Past AHA Guidelines Prophylaxis reduces the risk of IE from occurring(False, antibiotics may reduce the magnitude of the bacteremia, no evidence they will reduce the incidence of IE)
15Basis for Past AHA Guidelines 5. True or false The new 2007 guidelines are significantly different than any previous guidelines
16Basis for Past AHA Guidelines The new 2007 guidelines are significantly different than any previous guidelinesTRUE !
17Basis for Past AHA Guidelines Based on unproven assumptionsDental procedures were the source of the bacteremias leading to IE (False, Daily activities much more likely the source)Magnitude of dental procedure bacteremias were far greater than daily activities (False, they are about the same, both relatively low magnitude)Bleeding is the indication for bacteremia occurring (False, it is not a reliable predictor for bacteremia)Prophylaxis reduces the risk of IE from occurring (antibiotics may reduce the magnitude of the bacteremia, no evidence they will reduce the incidence of IE)
18Rational for 2007 Guidelines Previous 9 AHA Guidelines – Based on the lifetime risk for IENew Guidelines – Based on the risk for an adverse outcome
192007 AHA GuidelinesFirst made public at the annual American Academy of Oral Medicine meeting on May 19, 2007 in San Diego, CA.Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et al. Prevention of Infective Endocarditis: Guidelines From The American Heart Association. Circulation 2007; 115:1-17. Available at DOI: /circulationAHAWilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et al. Prevention of Infective Endocarditis: Guidelines From The American Heart Association. J Am Dent Assoc 2007:138 (6):
20Conditions Recommended for Prophylaxis in 1997 vs 2007 High-risk lesionsProsthetic heart valvesPrevious endocarditisCyanotic CHDAortic valve diseaseMitral regurgitationPatent ductus arteriosusVentricular septal defectCoarctation of aortaIntermediate-riskMVP with regurgitationMitral stenosisTricuspid valve diseasePulmonary stenosisSeptal hypertrophyDegenerative valvular disease in older patientsNonvalvular intracardiac prosthetic implants
21The AHA cites the following reasons for revision of the 1997 guidelines: IE is much more likely to result from frequent exposure to random bacteremias associated with daily activities than from bacteremia caused by a dental procedureProphylaxis may prevent an exceedingly small number, if any, cases of IE in individuals who undergo a dental procedureThe risk of antibiotic associated adverse events exceeds the benefit, if any, from prophylactic antibiotic therapyMaintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of IE
22acute IE ( staph aureus)- aortic v. ~40 %morbidity-mortalityacute IE ( staph aureus)- aortic v.
23Infective Endocarditis: hypothetical association with dental treatment ? Invasive dental procedures>>>>transient systemic bacteremia (6 min.)transient systemic bacteremia (6 min.) >>>>> colonization of susceptible endocardial surfaces ??????colonization of susceptible endocardial surfaces ??????>>>>>>>>IE ??????
24Infective Endocarditis: hypothetical association with dental treatment ? J. Antimicrobial Chemotherapy,A study of 273 patients = no link between dental treatment and IE (Strom BL., Ann Int Med :761-9)Cochrane review: no evidence to support antimicrobial prophylaxis to prevent IE in invasive dental procedures( Oliver R. 2006)Evidence-based…doesn’t exist
25Rheumatic Heart Disease immune reaction to Streptococci or productsfibrosis, calcification, scarring on valve ( usually mitral or aortic)damaged & dysfunctional valve leafletsmurmurventricular dilatation and hypertrophyCHF
32Infective endocarditis Has the risk changed ?Dx (Duke) criteriaThe use of antibiotic prophylaxis has not changed the incidence of IE in > 50 years!
33Infective endocarditis Risk of a brain abcess resulting from extracting a tooth is 1: 10 million !Risk of a LPJRI resulting from extracting a tooth is 1: 2.5 million !Risk of IE resulting with a MVP-r from extracting a tooth is 1: 1 million !Risk of IE resulting with RHD from extracting a tooth is 1: 150,000 !Risk of IE resulting with PVR from extracting a tooth is 1: 95,000 !
34Infective endocarditis Risk of IE resulting with PVR from extracting a tooth is 1: 95,000 !Risk of IE resulting with any heart condition from any dental procedure is 1:14 million !If 10 million patients at risk undergo dental treatment without prophylaxis 20 will get IE and 2 will die, but more than 10 will die from acute anaphylaxis from the PCN !Agha Z, et.al. Med. Dec. Mak :
35Rheumatic Fever and Rheumatic Heart Disease mitral valve damaged 60% of those defectsas many as % of cases are un-diagnosedSigns-symptomspharyngitis, athralgia,carditis, chorea, fever, erythema marginatum, sub-q nodules, dyspnealab values: ESR, EKG( PR interval), strep Ab
36Reported Frequency of Bacteremias Associated With Various Dental Procedures and Daily Activities Tooth extractionPeriodontal surgeryScaling and root planingTeeth cleaningRubber dam matrix/wedge placementEndodontic proceduresDaily ActivitiesTooth brushing and flossingUse of wooden toothpicksUse of water irrigation devicesChewing foodFrequency of bacteremia10-100%36-88%8-80%≤ 40%9-32%≤ 20%20-68%20-40%7-50%7-51%
37Initiating Bacteremia Dental ProceduresMost (if not all) are not associated with the onset of IE.If a dental procedure is possibly associated with the cause of IE, the symptoms of IE should appear within less than 2 weeks.(2:300 law suits…Pallasch)
38Endocarditis prophylaxis recommended The new guidelines recommend that only individuals who are at the highest risk of an adverse outcome receive antibiotic prophylaxis, and they include:
40Endocarditis prophylaxis recommended - Unrepaired cyanotic CHD, including palliative shunts and conduits- Completely repaired CHD defect with prosthetic material or device for first 6 months after procedure Repaired CHD with residual defects at the site or adjacent to site of prosthetic patch/ device which inhibit endothelializtion- Cardiac transplantation recipients who develop cardiac valvulopathy
41Endocarditis prophylaxis Compared with previous AHA guidelines, far fewer patients will receive IE prophylaxis. Consequently, many patients who previously were premedicated for dental procedures are no longer recommended for prophylactic antibiotic coverage.
42Endocarditis prophylaxis * The AHA committee feels that IE is much more likely to result form frequent exposure to transient bacteremia associated with daily activities (brushing, chewing food) than from bacteremia caused by a dental procedures..* Prophylaxis may prevent an exceedingly small number of cases of IE (if any) in individuals who undergo a dental procedure.
43Endocarditis prophylaxis * The risk of antibiotic-associated adverse events exceeds the benefit (if any) from prophylactic antibiotic therapy.* Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure in reducing the risk of IE.
44Conditions Recommended for Coverage in 2007 Based on greatest risk for adverse outcomeProsthetic Cardiac ValvePrevious Infective EndocarditisCongenital Heart Disease (CHD)Unrepaired cyanotic CHD including those with palliative shunts and conduitsCompletely repaired CHD with prosthetic material or device for first 6 monthsRepaired CHD with residual defects at the siteCardiac Transplantation Recipients who Develop Cardiac Valvulopathy
45Endocarditis prophylaxis NOT recommended (1997 vs 2007) functional heart murmurspost-coronary surgeries > 6 mos.RF, RHD, most congential defectsMVP with or without regurgitationpacemakers
46Conditions Recommended for Prophylaxis in 1997 vs 2007 High-risk lesionsProsthetic heart valvesPrevious endocarditisCyanotic CHDAortic valve diseaseMitral regurgitationPatent ductus arteriosusVentricular septal defectCoarctation of aortaIntermediate-riskMVP with regurgitationMitral stenosisTricuspid valve diseasePulmonary stenosisSeptal hypertrophyDegenerative valvular disease in older patientsNonvalvular intracardiac prosthetic implants
471997 : Endocarditis prophylaxis NOT recommended routine restorative proceduresplacement of rubber damsroutine local anesthetic injectionsintracanal endo; suture removalimpressions, fluoride, radiographsinsertion or adjustment of removable prosthetic or ortho appliances
481997 : Endocarditis prophylaxis recommended extractionsperio surgery-scaling-probing-prophyimplants( or re-implantation)endo(only beyond apex)subgingival manipulation( antibiotic fibers)initial placement of ortho bandsintraligamentary injections
492007 : Endocarditis prophylaxis recommended Any procedure which abrogates the mucosal barrier and causes ANY bleeding !The amount of bleeding has no impact upon the risk for IE !
502007 AHA Guidelines – Dental Procedures recommended for Prophylaxis All Dental Procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa. (Includes many procedures that in the 1997 guidelines were not recommended for coverage)
51Prevention of Infective Endocarditis : NOTE The MOST important factor is to maximize oral health and reduce oral microfloraminimize oral tissue traumaperiodontal and plaque controlantimicrobial mouthrinsesproper AHA prophylactic regimen ONLY when indicated
52Prevention of Infective Endocarditis : standard : Amoxicillin- 2 g; min. pre-opIM or IV: Ampicillin-2g; 30 min. pre-opallergic : Clindamycin- 600mg; min pre-op Cephalexin- 2 g one-hour pre-opCefadroxilAzithromycin or Clarithromycin- 500mg-1 hr.aller-npo: Clindamycin- 600mg -IV;- or Cefazolin- 1 g; 30 min. pre-op
53Antibiotic prophylaxis Does it really do any good ?
54Amoxicillin Bioavailability > 95 % Rapid GI absorption from po Works fastResistance ( >95 % K. pneumoniae in Japan)
55Antibiotic Prophylaxis Antibiotic ResistanceAbout 17% to 50% of the viridans group of streptococci are resistant to penicillin and 13% to 27% are resistant to clindamycin.Impact on IE prevention is unknown.
56Infective endocarditis 2007…..there is no evidence that dental treatment causes infective endocarditis or that antibiotic prophylaxis is preventive>95% of IE = no relation at all to dental Txphysiologic bacteremias regular toothbrushing = 0-40% chewing = % cleaning-irrigating devices = 7-50% random periodontal disese = 11-20%
57Infective endocarditis Toothbrushing 2 x daily = 150,000 times risk if IE than extracting a tooth !All daily activities= 5 million times risk if IE than extracting a tooth !
58Endocarditis prophylaxis issues already on previous regimenalready on an antibiotic ( lower dose)how much dental treatment (appt. length)interval between appointmentsPatient forgot to take the antibioticIBD( colitis) and clindamycinnot the same as prevention of late prosthetic joint infections
59Antibiotic prophylaxis If prophylaxis is not possible, administering the antibiotic within 2 hours may help prevent IEtime between prophylaxis coverage periods = 10 days ! Do as much treatment as possible during coverage periodRx’d antibiotics (not sufficient type or dose)Pre-op antimicrobial mouthrinses have not shown any benefitmonitor for signs-symptoms of IE
602007 AHA Guidelines Patients who undergo cardiac surgery A careful dental evaluation is recommended so that required dental treatment may be completed whenever possible before cardiac valve surgery or replacement or repair of CHD.
61Endocarditis Prevention Current practiceIdentify the susceptible patient and use antibiotic prophylaxis for indicated dental proceduresMedical referral to establish current status may be needed to for patients with CHD corrected with prosthetic material or devices.Within 6 months of corrective surgeryResidual defect (leakage)
62Nonvalvular Cardiovascular Devices AHA does not recommend prophylaxis PacemakersDefibrillatorsLeft ventricular assist devicesTotal artificial heartsArteriovenous fistulaeClosure devices for ASD, PDA, AVFHemodialysis graftsVascular graftsIntra-aortic balloon pumpsDacron grafts and patchesVena caval filtersVascular closure devicesVentriculoatrial shuntsCoronary artery stentsAHA, Scientific statement on Nonvalvular Cardiovascular Devices. Circulation, 108: 2015, 2003.
63Nonvalvular Cardiovascular Devices AHA does recommend ProphylaxisIncision and Drainage of infection at other sites (I & D of dental abscess)Extraction of teeth or surgical procedures performed in areas of acute infectionResidual leak following closure of PDA, ASD, VSD (follow AHA guidelines)AHA, Scientific statement on Nonvalvular Cardiovascular Devices. Circulation, 108: 2015, 2003.
64Impact of 2007 GuidelinesPatients who have taken antibiotics for years to prevent IE and now no longer are recommended to do such.Patients who are still recommended to be covered but now for just about all dental procedures.Explain rational for new guidelines, answer questions, consult with patient’s physician – informed consent (record in progress notes).
65Impact of 2007 Guidelines Pallasch TJ. CDAJ 2007:35(7): 507-11 MD or patient non-acceptance: they can provide the Rx “upon their own authority ““ Based upon the best current scientific evidence as published by the AHA, and my best clinical judgement. “
68What is Next 2007 Guidelines – Foundation set Dental procedures not causeNo evidence that prophylaxis is effectiveAdverse reactions to antibioticsIncreasing rate of resistance to antibioticsThe next set of AHA guidelines will not recommend prophylaxis for any dental procedure even in patients with cardiac lesions with the greatest risk for adverse outcomes
71Prevention of Endocarditis General conceptsGoal of “infection free” oral cavityFollow the current (2007) AHA guidelines for selection of cardiac conditions and dental procedures needing prophylaxisReduce gingival inflammation before performing restorative proceduresEstablish effective home care practicesChlorhexidine mouth rinse can be used prior to periodontal or surgical procedures, however several studies suggest no real benefit
72Prevention of Endocarditis General principles Cont.Coverage is effective for 4-6 hoursDo as much dental treatment as possible during each coverage periodAllow at least 9 days to elapse between coverage periods. If this is not possible select an alternant antibioticBe alert for signs and symptoms of IE in patients receiving antibiotic prophylaxis and those with cardiac lesions at risk for IE
73plasma levels of prophylactic antibiotics µg/ml3g Amox72 g Amox1.5 g Amox51 g PenVK3hours
75Late Prosthetic Joint Infections Wahl’s myths: #1: There are similarities between IE (PVE) and LPJI. NO. #2: Dental treatment is a probable cause of LPJI. NO. #3: Animal experiments document dental bacteremias as cause of LPJI. NO. #4: To protect patients DDS should always cover patients with PJ. NO.
76Prevention of late Prosthetic joint infections: 1997 changes ADA/AAOS advisory statementmedical consultation with OrthopodNo prophylaxis for pins, rods, screws, plates, wires, implants, etc.healthy patient: < 2 yrs. after TJRchronic RA or other infection of TJRimmunocompromised patients
77Prevention of late Prosthetic joint infections: 1997 changes Cephalexin ( Keflex) 2g ; po ; 1 hr. pre-opCephazolin; 1 g; IM/IV; 1 hr. pre-opClindamycin; 600mg.; po; 1 hr. pre-op
78ANTIBIOTICS Other indications for antibiotic prophylaxis: HIV ESRD : hemodialysisIDDMAutoimmune diseases; SLESplenectomyCHF, CVA; thromboemboliLiver diseaseOrgan transplants