Preventing Infectious Endocarditis: Pill or No Pill?

From day one in dental school forty years ago there was an emphasis on knowing if your patient had a history of rheumatic fever. That was a red flag because of the potential sequelae of heart valve disease that could result in infectious endocarditis (IE) following dental care. This resonated with me because I had an aunt that died from cardiac complications after having rheumatic fever. On occasion all dentists must deal with issues related to bacteremia created by dental care. But current thought is that we should pay equal if not more attention to bacteremia caused by everyday patient activities.

It is in a dentist’s DNA to protect our patients with heart disease from developing infectious endocarditis after dental care. But the question of when to prescribe prophylactic antibiotics to prevent this and which antibiotic to use has had an evolving answer. Fortunately, antibiotic prophylaxis protocols have become more easily delivered with the use of oral medications and an easier dosing regimen. That wasn’t always true especially for patients allergic to penicillin. I remember years ago sending a patient to a hospital for IV infusion of antibiotics before my dental care.  

Just recently I re-read the 2008 report from JADA – Prevention of IE:  Guidelines from the American Heart Association. It succinctly covers the history of the issues surrounding the subject noting that the evidence supporting immediate pre-operative antibiotic use to prevent IE is not strong.

Currently antibiotic prophylaxis is recommended for patients with a history of IE, those with unrepaired cyanotic congenital heart defects, repaired congenital heart defects within the past six months and patients with repaired congenital defects with residual defects.  It is also recommended for heart transplant patients who develop valvulopathy. But gone are guidelines that suggested antibiotic prophylaxis for a history of rheumatic fever, mitral valve prolapse, murmurs, stents and other conditions which we had to consider in the past. Decreasing the use of antibiotics is reportedly good for several reasons, not the least of which are problems related to resistant bacteria in the general population.

One of the questions that the report addressed:  How often is a bacteremia created from a dental procedure compared to events in every-day life?  One researcher has estimated a cumulative exposure of 5,370 minutes of bacteremia over a one-month period in dentulous patients resulting from random bacteremia from chewing food and from oral hygiene measures, such as tooth brushing and flossing, and compared that to a duration of bacteremia lasting six to 30 minutes associated with a single tooth extraction.

Another estimated that tooth brushing two times daily for one year had a 154,000 times greater risk of exposure to bacteremia than that resulting from a single tooth extraction. The cumulative exposure during one year to bacteremia from routine, daily activities may be as high as 5.6 million times greater than that resulting from a single tooth extraction, the dental procedure reported to be most likely to cause a bacteremia. This emphasizes the need for focusing on good oral hygiene to lessen the degree of bacteremia associated with daily life activities rather than focusing too much on a non-proven antibiotic prophylaxis regimen.

It was pointed out to me by a pediatric infectious disease specialist that our pediatric cardiologists and surgeons are very effective in helping people live into adulthood with congenital heart disease history.  And yet while the criteria for antibiotic prophylaxis is narrowed, the number of candidates is growing and the likelihood of dentists seeing more patients meeting criteria for antibiotic prophylaxis.

The same pediatric infectious disease specialist also said, “It’s really hard to get someone well from IE.  Give the antibiotics.”  And there’s the rub.

What is decreasing is the patient population for which antibiotic prophylaxis is recommended to protect from the a serious infection – IE.  What is not decreasing is the need to consider all patients individually and applying the best evidence, experience and intuition to clinical decision making.

 

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