Perspectives on the 2007 AHA guidelines for the prevention of infective endocarditis Nelson L. Rhodus, DMD, MPH, FACD Professor Academy of Distinguished Professors Director, Division of Oral Medicine, Dental School Adjunct Professor, Otolaryngology, Medical School Diplomate, American Board of Oral Medicine University of Minnesota

Dr. Robert Gorlin 1923-2006 50 yrs. at UM

QUIZ

QUIZ

Basis for Past AHA Guidelines 1. True or false Dental procedures were the source of the bacteremias leading to IE

Basis for Past AHA Guidelines Dental procedures were the source of the bacteremias leading to IE (False, Daily activities much more likely the source)

Basis for Past AHA Guidelines 2. True or false Magnitude of dental procedure bacteremias were far greater than daily activities

Basis 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)

Basis for Past AHA Guidelines 3. True or false Bleeding is the indication for bacteremia occurring

Basis for Past AHA Guidelines Bleeding is the indication for bacteremia occurring (False, it is not a reliable predictor for bacteremia)

Basis for Past AHA Guidelines 4. True or false Prophylaxis reduces the risk of IE from occurring

Basis 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)

Basis for Past AHA Guidelines 5. True or false The new 2007 guidelines are significantly different than any previous guidelines

Basis for Past AHA Guidelines The new 2007 guidelines are significantly different than any previous guidelines TRUE !

Basis for Past AHA Guidelines Based on unproven assumptions Dental 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)

Rational for 2007 Guidelines Previous 9 AHA Guidelines – Based on the lifetime risk for IE New Guidelines – Based on the risk for an adverse outcome

2007 AHA Guidelines First made public at the annual American Academy of Oral Medicine meeting on May 19, 2007 in San Diego, CA. www.aaom.com 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 http://www.circulationaha.org, DOI:10.1116/circulationAHA.106.18309. Wilson 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): 739-760.

Conditions Recommended for Prophylaxis in 1997 vs 2007 High-risk lesions Prosthetic heart valves Previous endocarditis Cyanotic CHD Aortic valve disease Mitral regurgitation Patent ductus arteriosus Ventricular septal defect Coarctation of aorta Intermediate-risk MVP with regurgitation Mitral stenosis Tricuspid valve disease Pulmonary stenosis Septal hypertrophy Degenerative valvular disease in older patients Nonvalvular intracardiac prosthetic implants

The 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 procedure Prophylaxis may prevent an exceedingly small number, if any, cases of IE in individuals who undergo a dental procedure 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 to reduce the risk of IE

acute IE ( staph aureus)- aortic v. ~40 % morbidity-mortality acute IE ( staph aureus)- aortic v.

Infective 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 ??????

Infective Endocarditis: hypothetical association with dental treatment ? J. Antimicrobial Chemotherapy, 4-19-2006 A study of 273 patients = no link between dental treatment and IE (Strom BL., Ann Int Med 1998 129:761-9) Cochrane review: no evidence to support antimicrobial prophylaxis to prevent IE in invasive dental procedures( Oliver R. 2006) Evidence-based…doesn’t exist

Rheumatic Heart Disease immune reaction to Streptococci or products fibrosis, calcification, scarring on valve ( usually mitral or aortic) damaged & dysfunctional valve leaflets murmur ventricular dilatation and hypertrophy CHF

Rheumatic Heart Disease: concerns angina Arrhythmia dyspnea epistaxis CHF PV IE

Prosthetic heart valve usually mitral dysfunction RF...RHD……... CHF synthetic replacement = PV

Tissue Prosthetic Heart Valve Little JW, Dental Management of the Medically Compromised Patient, Mosby, 2007, p 21

Prosthetic valve endocarditis ( PVE)

Prosthetic valve endocarditis ( PVE)

Infective endocarditis fever, murmur, weakness, fatigue, malaisse, anemia,visual problems, GI, weight loss, fever, chills, night sweats, arthralgia, ngina, hematuria, paresthesias or paralysis, petechiae, Osler nodes, Janeway lesions, retinal hemorrhages

Infective endocarditis Has the risk changed ? Dx (Duke) criteria The use of antibiotic prophylaxis has not changed the incidence of IE in > 50 years!

Infective 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 !

Infective 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. 2005 25:308-320.

Rheumatic Fever and Rheumatic Heart Disease mitral valve damaged 60% of those defects as many as 30-40 % of cases are un-diagnosed Signs-symptoms pharyngitis, athralgia,carditis, chorea, fever, erythema marginatum, sub-q nodules, dyspnea lab values: ESR, EKG( PR interval), strep Ab

Reported Frequency of Bacteremias Associated With Various Dental Procedures and Daily Activities Tooth extraction Periodontal surgery Scaling and root planing Teeth cleaning Rubber dam matrix/wedge placement Endodontic procedures Daily Activities Tooth brushing and flossing Use of wooden toothpicks Use of water irrigation devices Chewing food Frequency of bacteremia 10-100% 36-88% 8-80% ≤ 40% 9-32% ≤ 20% 20-68% 20-40% 7-50% 7-51%

Initiating Bacteremia Dental Procedures Most (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)

Endocarditis 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:

Endocarditis prophylaxis recommended * Prosthetic cardiac valve * Previous infective endocarditis (IE) * Congenital heart disease (CHD) with :

Endocarditis 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

Endocarditis 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.

Endocarditis 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.

Endocarditis 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.

Conditions Recommended for Coverage in 2007 Based on greatest risk for adverse outcome Prosthetic Cardiac Valve Previous Infective Endocarditis Congenital Heart Disease (CHD) Unrepaired cyanotic CHD including those with palliative shunts and conduits Completely repaired CHD with prosthetic material or device for first 6 months Repaired CHD with residual defects at the site Cardiac Transplantation Recipients who Develop Cardiac Valvulopathy

Endocarditis prophylaxis NOT recommended (1997 vs 2007) functional heart murmurs post-coronary surgeries > 6 mos. RF, RHD, most congential defects MVP with or without regurgitation pacemakers

Conditions Recommended for Prophylaxis in 1997 vs 2007 High-risk lesions Prosthetic heart valves Previous endocarditis Cyanotic CHD Aortic valve disease Mitral regurgitation Patent ductus arteriosus Ventricular septal defect Coarctation of aorta Intermediate-risk MVP with regurgitation Mitral stenosis Tricuspid valve disease Pulmonary stenosis Septal hypertrophy Degenerative valvular disease in older patients Nonvalvular intracardiac prosthetic implants

1997 : Endocarditis prophylaxis NOT recommended routine restorative procedures placement of rubber dams routine local anesthetic injections intracanal endo; suture removal impressions, fluoride, radiographs insertion or adjustment of removable prosthetic or ortho appliances

1997 : Endocarditis prophylaxis recommended extractions perio surgery-scaling-probing-prophy implants( or re-implantation) endo(only beyond apex) subgingival manipulation( antibiotic fibers) initial placement of ortho bands intraligamentary injections

2007 : 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 !

2007 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)

Prevention of Infective Endocarditis : NOTE The MOST important factor is to maximize oral health and reduce oral microflora minimize oral tissue trauma periodontal and plaque control antimicrobial mouthrinses proper AHA prophylactic regimen ONLY when indicated

Prevention of Infective Endocarditis : standard : Amoxicillin- 2 g; 30-60 min. pre-op IM or IV: Ampicillin-2g; 30 min. pre-op allergic : Clindamycin- 600mg; 30-60 min. pre-op Cephalexin- 2 g one-hour pre-op Cefadroxil Azithromycin or Clarithromycin- 500mg-1 hr. aller-npo: Clindamycin- 600mg -IV; - or Cefazolin- 1 g; 30 min. pre-op

Antibiotic prophylaxis Does it really do any good ?

Amoxicillin Bioavailability > 95 % Rapid GI absorption from po Works fast Resistance ( >95 % K. pneumoniae in Japan)

Antibiotic Prophylaxis Antibiotic Resistance About 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.

Infective 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 Tx physiologic bacteremias regular toothbrushing = 0-40% chewing = 17-51 % cleaning-irrigating devices = 7-50% random periodontal disese = 11-20%

Infective 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 !

Endocarditis prophylaxis issues already on previous regimen already on an antibiotic ( lower dose) how much dental treatment (appt. length) interval between appointments Patient forgot to take the antibiotic IBD( colitis) and clindamycin not the same as prevention of late prosthetic joint infections

Antibiotic prophylaxis If prophylaxis is not possible, administering the antibiotic within 2 hours may help prevent IE time between prophylaxis coverage periods = 10 days ! Do as much treatment as possible during coverage period Rx’d antibiotics (not sufficient type or dose) Pre-op antimicrobial mouthrinses have not shown any benefit monitor for signs-symptoms of IE

2007 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.

Endocarditis Prevention Current practice Identify the susceptible patient and use antibiotic prophylaxis for indicated dental procedures Medical referral to establish current status may be needed to for patients with CHD corrected with prosthetic material or devices. Within 6 months of corrective surgery Residual defect (leakage)

Nonvalvular Cardiovascular Devices AHA does not recommend prophylaxis Pacemakers Defibrillators Left ventricular assist devices Total artificial hearts Arteriovenous fistulae Closure devices for ASD, PDA, AVF Hemodialysis grafts Vascular grafts Intra-aortic balloon pumps Dacron grafts and patches Vena caval filters Vascular closure devices Ventriculoatrial shunts Coronary artery stents AHA, Scientific statement on Nonvalvular Cardiovascular Devices. Circulation, 108: 2015, 2003.

Nonvalvular Cardiovascular Devices AHA does recommend Prophylaxis Incision and Drainage of infection at other sites (I & D of dental abscess) Extraction of teeth or surgical procedures performed in areas of acute infection Residual leak following closure of PDA, ASD, VSD (follow AHA guidelines) AHA, Scientific statement on Nonvalvular Cardiovascular Devices. Circulation, 108: 2015, 2003.

Impact of 2007 Guidelines Patients 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).

Impact 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. “

Congenital heart disease- dental concerns Endocarditis Congestive heart failure Endarteritis Excessive bleeding Cyanosis Infection

What is Next 2007 Guidelines – Foundation set Dental procedures not cause No evidence that prophylaxis is effective Adverse reactions to antibiotics Increasing rate of resistance to antibiotics The 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

USA Triathlon Series

Prevention of Endocarditis General concepts Goal of “infection free” oral cavity Follow the current (2007) AHA guidelines for selection of cardiac conditions and dental procedures needing prophylaxis Reduce gingival inflammation before performing restorative procedures Establish effective home care practices Chlorhexidine mouth rinse can be used prior to periodontal or surgical procedures, however several studies suggest no real benefit

Prevention of Endocarditis General principles Cont. Coverage is effective for 4-6 hours Do as much dental treatment as possible during each coverage period Allow at least 9 days to elapse between coverage periods. If this is not possible select an alternant antibiotic Be alert for signs and symptoms of IE in patients receiving antibiotic prophylaxis and those with cardiac lesions at risk for IE

plasma levels of prophylactic antibiotics µg/ml 3g Amox 7 2 g Amox 1.5 g Amox 5 1 g PenVK ------------------------------------------------ 3 hours 1 4 6 10

Late ProstheticJoint Infection

Late 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.

Prevention of late Prosthetic joint infections: 1997 changes ADA/AAOS advisory statement medical consultation with Orthopod No prophylaxis for pins, rods, screws, plates, wires, implants, etc. healthy patient: < 2 yrs. after TJR chronic RA or other infection of TJR immunocompromised patients

Prevention of late Prosthetic joint infections: 1997 changes Cephalexin ( Keflex) 2g ; po ; 1 hr. pre-op Cephazolin; 1 g; IM/IV; 1 hr. pre-op Clindamycin; 600mg.; po; 1 hr. pre-op

ANTIBIOTICS Other indications for antibiotic prophylaxis: HIV ESRD : hemodialysis IDDM Autoimmune diseases; SLE Splenectomy CHF, CVA; thromboemboli Liver disease Organ transplants

Congenital heart disease- dental concerns Endocarditis Congestive heart failure Endarteritis Excessive bleeding Cyanosis Infection

Rheumatic Heart Disease DETECTION history echocardiography chest radiographs EKG auscultation

Basis for 2007 Guidelines Adverse Outcomes Valvular dysfunction Congestive heart failure Need for valvular replacement Multiple embolic events Death