ACC/AHA 2008 Guideline Update on Valvular Heart Disease: Focused Update on Infective Endocarditis

2007 Focused update of the ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention

Infective endocarditis prophylaxis for the 21st century: end of an error?

Guidelines for the prevention and management of infective endocarditis (IE) in children with congenital heart disease (CHD) have not been established, so the aim of this study was to clarify the incidence, practical prevention and management of IE in patients with CHD in Japan through a nationwide survey. A written questionnaire was sent to members of the Japanese Society of Pediatric Cardiology and Cardiac Surgery and information was obtained from 236 cardiologists in 228 institutions. Four hundred and eight patients with IE were hospitalized during 1997 to 2001 (1/173 admissions with CHD including those hospitalized for cardiac catheterization or surgery). Prevention of IE for CHD was undertaken by 92% of cardiologists, usually oral penicillins (73%) and less frequently cephems (18%) were prescribed. The Duke criteria were used as clinical criteria by 38%. Blood culture was performed once only by 40%. Penicillins and aminoglycosides (38%) were frequently administered for management of culture-negative IE. There were variations in the dose and duration of antibiotics for prevention and management of IE. It appears that the prevalence of IE in CHD is rising and the nationwide survey revealed more variations in practical prevention and management of IE in patients with CHD than expected. The results should be helpful in making future guidelines for management of IE in CHD.

Sir, The use of antibiotics to prevent infective endocarditis (IE) has generated extensive debate between dentists, microbiolo- gists, cardiologists and cardiothoracic surgeons. Up to 16 million of the UK population 1 may potentially be required to take antibiotic prophylaxis based on past guidelines produced by various specialist societies. In addition, several differing recommendations exist which perpetuates confusion among clinicians who are dealing directly with those at risk. However, more recently, national and international guidelines have recommended significant changes in the use of antibiotic prophylaxis for the prevention of IE which may facilitate rationalization. 2 patients at risk of IE 3 and recommended that antibiotic prophy- laxis should not be given to any patients at risk of IE undergoing dental, upper and lower gastrointestinal (GI) tract, genitourinary (GU) or respiratory tract procedures. NICE concluded that for dental procedures 'the evidence does not show a causal relation- ship between having an interventional procedure and the development of IE' and 'it is biologically implausible that a dental procedure would lead to a greater risk of IE than regular tooth brushing'. This was based on increasing evidence of cumulative bacteraemia from every day oral activities. 4 Included was a de novo UK relevant analysis of cost-effectiveness of those at risk of IE undergoing dental procedures. The economic evaluation was based upon a Markov model and replicated a pre- viously published American analysis but applied costs from the perspective of the NHS. The outcome, based on prophylactic options set out in BNF 54, suggested that even applying the most optimistic assumptions with regard to efficacy and anaphylaxis risk, a strategy of no prophylaxis, leads to fewer deaths, especially when using a penicillin-based regimen. The NICE guideline development group reasoned that pro- cedures involving the GI or GU tract are being increasingly undertaken in the UK with only a small number of associated IE cases being reported; therefore, logically there can be no causal relationship with IE. In contrast to dental procedures, there is a lack of data regarding non-dental intervention and subsequent IE risk, and no published studies show a conclusive link between procedures of the GU and GI tract and the development of IE. Consequently, NICE did not recommend antibiotic prophylaxis for any patient at risk of IE undergoing GU or GI procedures in a non-infected site. NICE defined the patients who should receive antibiotic pro- phylaxis to prevent IE as those undergoing GI or GU procedures at 'infected' or 'potentially infected' sites. A potentially infected site was not clearly defined and is therefore open to clinical interpretation. Specific indications could include endoscopic retrograde chologio-pancreaticography in the presence of biliary disorders or urethral instrumentation associated with urinary sepsis. These details need to be clarified by specialist advisory groups to prevent misinterpretation. Similarly, NICE does not give specific recommendation regarding those patients who are already being treated with anti- biotics for ongoing infection and who are due to have a pro- cedure local to that site, for example, a dental abscess or cholecystitis, or those who are already on long-term antibiotic prophylaxis for other reasons including asplenia and recurrent urinary tract infections. NICE recommended, based on the expert opinion of the guideline development group, that anti- biotics should be given to cover microorganisms which have been known to cause IE under these circumstances; again specific recommendations for these patients need to be produced by the relevant advisory groups. In view of the publication from NICE regarding antibiotic prophylaxis in IE, the BSAC Working Party considered that the current BSAC guidelines should be updated to bring them in line with the recommendations from NICE and also the BNF. We considered that the guidance from NICE should be accepted and endorsed by all interested UK groups so that a single national guideline can be achieved. The BSAC Working Party are now drawing up specific recommendations for those patients who are infected or potentially infected at the operative site and who are at risk of IE.

Background— The purpose of this statement is to update the recommendations by the American Heart Association (AHA) for the prevention of infective endocarditis that were last published in 1997. Methods and Results— A writing group was appointed by the AHA for their expertise in prevention and treatment of infective endocarditis, with liaison members representing the American Dental Association, the Infectious Diseases Society of America, and the American Academy of Pediatrics. The writing group reviewed input from national and international experts on infective endocarditis. The recommendations in this document reflect analyses of relevant literature regarding procedure-related bacteremia and infective endocarditis, in vitro susceptibility data of the most common microorganisms that cause infective endocarditis, results of prophylactic studies in animal models of experimental endocarditis, and retrospective and prospective studies of prevention of infective endocarditis. MEDLINE database searches from 1950 to 2006 were done for English-language papers using the following search terms: endocarditis, infective endocarditis, prophylaxis, prevention, antibiotic, antimicrobial, pathogens, organisms, dental, gastrointestinal, genitourinary, streptococcus, enterococcus, staphylococcus, respiratory, dental surgery, pathogenesis, vaccine, immunization, and bacteremia. The reference lists of the identified papers were also searched. We also searched the AHA online library. The American College of Cardiology/AHA classification of recommendations and levels of evidence for practice guidelines were used. The paper was subsequently reviewed by outside experts not affiliated with the writing group and by the AHA Science Advisory and Coordinating Committee. Conclusions— The major changes in the updated recommendations include the following: (1) The Committee concluded that only an extremely small number of cases of infective endocarditis might be prevented by antibiotic prophylaxis for dental procedures even if such prophylactic therapy were 100% effective. (2) Infective endocarditis prophylaxis for dental procedures is reasonable only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis. (3) For patients with these underlying cardiac conditions, prophylaxis is reasonable for all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa. (4) Prophylaxis is not recommended based solely on an increased lifetime risk of acquisition of infective endocarditis. (5) Administration of antibiotics solely to prevent endocarditis is not recommended for patients who undergo a genitourinary or gastrointestinal tract procedure. These changes are intended to define more clearly when infective endocarditis prophylaxis is or is not recommended and to provide more uniform and consistent global recommendations.

For over a half century, guidelines for the prevention of infective endocarditis (IE) have recommended antibiotic prophylaxis for certain patients receiving dental care. Much emphasis has been attributed historically on the baseless concept that dental procedures are main cause of cases of IE and dentistry carried the blame for induce endocarditis without much supporting evidence. In 2007, the American Heart Association (AHA) and British Society for Antimicrobial Chemotherapy (BSAC) updated the recommendations for IE prophylaxis before dental procedures and those recommendations are clearly evidencebased 9 . The dental treatment is a very rarely cause of IE and antibiotic prophylaxis do not give assurances as preventive. So, the value of antibiotic prophylaxis in prevention of IE has been questioned for over 20 years 3 . In reviewing the literature 2 , we did not find support that antibiotic prophylaxis actually prevents endocarditis from dental procedure only an extremely small number of cases of IE might be prevented by antibiotic prophylaxis for dental procedure. There is increasing evidence that spontaneous bacteremia are more likely to cause IE in at risk patients than specific episodes of dental treatment 568 . The majority of infective endocarditis cases caused by oral bacteria result from chewing, flossing, tooth brushing and others daily activities, and the presence of dental disease may increase the risk of bacteremia associated with these daily events 8 . Anyway the role of dental procedures in the production of infective endocarditis has probably been overestimated in relation to oral health condition thus more attention should be given to the importance of good oral hygiene and control of dental biofilm in the prevention of IE. In short, the care of the oral health must be the first step in the prevention of infective endocarditis from dental origin than antibiotic prophylaxis. Almost a year after the issued of new recommendations for prevention of IE, we still seeing most patients and health care professionals resistant to adopt this new recommendations and persisting to prescribe antibiotic prophylaxis when the need no longer exists. Only a few patients will be elected to receive antibiotic prophylaxis according to the AHA and BSAC, thus only employ in the very highest risk patients 8 . (Tables 1, 2, 3) The prescription of antibiotics carries the risk for both, patient and community, through the undesirable effects and the fact of introducing microorganisms mutants or genetically transfer the microbial resistance, respectively. The scientific community has focused the link between the overuse of antibiotics and the increasing prevalence of the drug resistant organisms 14710 . This concern is overt when evaluating ambulatory patients wich receiving short courses of antibiotics and they became an important reservoir of resistant microorganisms 7 . Antibiotic resistance is a serious incident and capable to be prevented through common sense and clinical judgment. Health care professionals have misused antibiotics for too long and carry the blame of antibiotic resistance. The risks associated with widespread antibiotic use and lack of efficacy data take us back to rethink our practice The new guidelines should be seen as great progress based on evidence that currently exists and must be followed until more evidence arise. We need further debate, especially as there are increasing environmental concerns over the misuse of antibiotics. We are now experiencing a shift thus we need time to change this scenario. Antimicrobial prophylaxis against infective endocarditis for dental procedure. A brief commentary

The incidence of infective endocarditis (IE), a rare disease with high morbidity and mortality, has not undergone a great change over the past decades, despite the advances in diagnosis and treatment. Thus, much effort should be done to reduce the probability of its occurrence. Previously a predominantly streptococcal disease of patients with long-term heart conditions, IE has changed to be a staphylococcal disease of elderly patients suffering from many comorbidities or having intracardiac devices1. The principles of IE antibiotic prophylaxis (IEAP) were developed based on observational studies at the beginning of the twentieth century2. More than half a century ago, the first recommendation of the American Heart Association (AHA) for IE prevention was headed by Thomas Duckett Jones (1899-1954), and was published months after his death3. The AHA recommendation published in 2008, which replaces the one included in the general guidelines of valvular heart diseases, is currently used4,5. The European Society of Cardiology, with its guidelines published in 2012, endorses the new trends6. According to the new concepts, the use of antibiotics for IE prophylaxis before starting dental interventional procedures involving the manipulation of gingival tissue or the periapical region of teeth, or perforation of the oral mucosa, should be indicated only for patients at higher risk for the adverse outcome of an episode of IE; thus, their use is not necessary for patients solely at risk for IE. If on the one hand there was a dramatic change in the IEAP proposition - for example, the National Institute for Health and Care Excellence (NICE) recommended the complete cessation of IEAP in Great Britain7 - consequent to reinterpretation of known data, on the other, there was a reduction in the emphasis on the heart condition, chronic rheumatic heart disease, which is highly valued in Brazil. We should, therefore, reflect about the strict adhesion to that renovation. Those proposing a significant restriction justify their position with the scarcity of scientific conclusions about the benefit of preventing the development of IE, reserving IEAP to a minority of cases understood as of preoccupying clinical course. It is worth noting that the new recommendations were not based on new research; thus, a prospective assessment of the real impact of prophylaxis - known to be complex due to the need to include a large number of patients - will be welcome8. A primordial factor that was overvaluing, especially by the AHA, was the risk of anaphylaxis to amoxicillin over its possible prophylactic effect. In Brazil, we cannot ignore rheumatic fever - still the major etiology of valvular heart disease, with its peculiar structural and immunological characteristics -, nor the poor oral health of the general Brazilian population, which has not improved significantly over the past decades. Brazilian adults have recently shown a mean CPO-D (oral health index that translates the cavity experience of an individual over life) greater than 20 teeth, and a component of lost teeth (with no possibility of recovery) greater than 60%9. Therefore, it is not wise to ignore our epidemiological peculiarity of valvular heart diseases, tolerating interpretations of other cultures of a disease, whose bedside experience recommends thoughtfulness in preventing complications. That is why the Brazilian/Inter-American guidelines for valvular heart diseases, as published in 201110, recommends classic and expanded IEAP. The Brazilian Society of Cardiology and the Inter-American Society of Cardiology recommend antibiotic prophylaxis before starting dental interventional procedures that bear a high probability of significant bacteremia to patients who have either valvular or congenital heart diseases that represent a risk for IE, regardless of assumptions on differences of disease course. In addition, they reinforce the need for prospective and controlled studies to support the probability of the effect of IEAP. In conclusion, in face of the Brazilian reality and although we want to be globalized physicians with no cultural frontiers, it is difficult for us to comfortably rule out IEAP to a patient with native valvular lesion, endorsing the comprehensive recommendation of the Brazilian guidelines. That is despite the literature binomial of low incidence of IE and high probability of anaphylaxis to amoxicillin, the latter irrelevant in the Brazilian experience, and, thus, not even mentioned in our guidelines. Those with real bedside experience with IE patients will agree.

Prevention of infective endocarditis: Guidelines from the American Heart Association: A guideline from the American Heart Association Rheumatic Fever, Endocarditis and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group

Prevention of infective endocarditis: Guidelines from the American Heart Association: A guideline from the American Heart Association Rheumatic Fever, Endocarditis and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group

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2009;53;1343-1382; originally published online Mar 26, 2009; J. Am. Coll. Cardiol. Rahko, Marc A. Silver, Lynne Warner Stevenson, and Clyde W. Yancy Francis, Theodore G. Ganiats, Marvin A. Konstam, Donna M. Mancini, Peter S. Mariell Jessup, William T. Abraham, Donald E. Casey, Arthur M. Feldman, Gary S. Heart and Lung Transplantation Developed in Collaboration With the International Society for Guidelines Cardiology Foundation/American Heart Association Task Force on Practice Management of Heart Failure in Adults: A Report of the American College of 2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and This information is current as of August 30, 2010 http://content.onlinejacc.org/cgi/content/full/53/15/1343 located on the World Wide Web at: The online version of this article, along with updated information and services, is

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Cardiology| February 01 2008 Endocarditis Prophylaxis: Do We Have It Right This Time? AAP Grand Rounds (2008) 19 (2): 13–14. https://doi.org/10.1542/gr.19-2-13 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Twitter LinkedIn Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Endocarditis Prophylaxis: Do We Have It Right This Time?. AAP Grand Rounds February 2008; 19 (2): 13–14. https://doi.org/10.1542/gr.19-2-13 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search nav search search input Search input auto suggest search filter All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: endocarditis prophylaxis, bacterial endocarditis Source: Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis. Guidelines from the American Heart Association. A guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care Outcomes Research Interdisciplinary Working Group. Circulation. 2007;116(15):1736–1754; doi:10.1161/circulationaha.106.183095 A writing group appointed by the American Heart Association (AHA) with expertise in prevention and treatment of infective endocarditis worked with representatives of the American Dental Association, the Infectious Diseases Society of America, and the AAP to update the recommendations by the AHA for the prevention of infective endocarditis (IE) that were last published in 1997. The panel reviewed the published literature, drew upon its own expertise, and consulted with international experts on IE. The major changes in the updated recommendations include the following: The writing group concluded that fewer patients will be candidates for IE prophylaxis. The new guideline is intended to define more clearly when IE prophylaxis is or is not recommended and to provide more uniform and consistent global recommendations. Dr. Danford has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device. Although we will not necessarily say this aloud, pediatric cardiologists of a certain age understand that we do not know now, and may never know, the best way to prevent IE. We have practiced our way through a remarkable evolution in our approach to the problem, and each time the rules change we have mustered the authoritative tone of the true believer as we counsel our patients at risk. In 1977 we were warning our patients of the dangers of IE, and urging them to take antibiotics prior to seeing the dentist and take a two-day antibiotic course after that. If the cardiac lesion was thought to be particularly high-risk, there were shots, and even aminoglycoside administration. Sometimes our patients protested, so we invoked the authority of the AHA.1 “This is for your own good,” we would say, “A committee of renowned experts has studied the matter in detail, and they say this is how to prevent IE. Fail to follow these instructions at your peril,” or words to that effect. Abruptly, in 1984, according to a consensus of experts, this rather lengthy prophylaxis protocol was no longer necessary.2 We were down to a dose prior to the dental visit, and a dose six hours later. At the time I wondered if our patients and their parents, who had become so accustomed to our reminders about prophylaxis, were going to wonder about the effectiveness of ‘IE prophylaxis – lite,’ perhaps even balk at this change. I began to say things like, “If you receive antibiotics for a period of days, it just makes the organisms in the mouth resistant – better to just blast them at the time... You do not currently have access to this content.

### A. Organization of Committee and Evidence Review The American College of Cardiology/American Heart Association (ACC/AHA) Task Force on Practice Guidelines was formed to make recommendations regarding the diagnosis and treatment of patients with known or suspected cardiovascular disease. Ischemic heart disease is the single leading cause of death in the United States. The most common manifestation of this disease is chronic stable angina. Recognizing the importance of the management of this common entity and the absence of national clinical practice guidelines in this area, the task force formed the Committee on Management of Patients With Chronic Stable Angina to develop guidelines for the management of stable angina. Because this problem is frequently encountered in the practice of internal medicine, the task force invited the American College of Physicians–American Society of Internal Medicine (ACP–ASIM) to serve as a partner in this effort by identifying 3 general internists to serve on the committee. The guidelines are arbitrarily divided into 4 sections: diagnosis, risk stratification, treatment, and patient follow-up. Experienced clinicians will quickly recognize that the distinctions between these sections may be arbitrary and unrealistic for individual patients. However, for most clinical decision making, these divisions are helpful and facilitate the presentation and analysis of the available evidence. Detailed evidence was developed whenever possible. The weight of the evidence was ranked highest (A) if the data were derived from multiple randomized clinical trials involving large numbers of patients and intermediate (B) if the data were derived from a limited number of randomized trials involving small numbers of patients or careful analyses of nonrandomized studies or observational regis-tries. A low rank (C) was given when expert consensus was the primary basis for the recommendation. The customary ACC/AHA classifications I, II, and III are used in tables that summarize both the evidence and expert opinion and provide final recommendations for both patient …

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