Infective Endocarditis Prophylaxis Research Articles

Valvular Heart Disease: Diagnosis and Management

Valvular heart disease (VHD) encompasses a number of common cardiovascular conditions that account for 10% to 20% of all cardiac surgical procedures in the United States. A better understanding of the natural history coupled with the major advances in diagnostic imaging, interventional cardiology, and surgical approaches have resulted in accurate diagnosis and appropriate selection of patients for therapeutic interventions. A thorough understanding of the various valvular disorders is important to aid in the management of patients with VHD. Appropriate work-up for patients with VHD includes a thorough history for evaluation of causes and symptoms, accurate assessment of the severity of the valvular abnormality by examination, appropriate diagnostic testing, and accurate quantification of the severity of valve dysfunction and therapeutic interventions, if necessary. It is also important to understand the role of the therapeutic interventions vs the natural history of the disease in the assessment of outcomes. Prophylaxis for infective endocarditis is no longer recommended unless the patient has a history of endocarditis or a prosthetic valve.

Endocardite infectieuse : quoi de neuf ? Recommandations de l’ European Society of Cardiology (ESC) 2009

Infective endocarditis (IE) is a severe form of valve disease still associated with a high mortality (10-26 % in-hospital mortality). IE is a rare disease, with reported incidences ranging from 3 to 10 episodes/100,000 people per year. The epidemiological profile of IE has changed over the last few years, with newer predisposing factors - valve prostheses, degenerative valve sclerosis, intravenous drug abuse (IVDA), associated with the increased use of invasive procedures at risk for bacteremia. Health care-associated IE represents up to 30 % cases of IE, justifying aseptic measures during venous catheters manipulation and during any invasive procedures. There is a lack of scientific evidence for the efficacy of infective endocarditis prophylaxis. Thus, antibiotic prophylaxis is recommended only for patients with the highest risk of IE undergoing the highest risk dental procedures. Good oral hygiene and regular dental review have a very important role in reducing the risk of IE. Echocardiography and blood cultures are the cornerstone of diagnosis of IE. TTE must be performed first, but both TTE and TEE should ultimately be performed in the majority of cases of suspected or definite IE. The treatment of IE relies on the combination of prolonged antimicrobial therapy and - in about half patients - surgical eradication of the infected tissues. The 3 main complications of IE indicating early surgery are heart failure (HF), uncontrolled infection, and prevention of embolic events. HF is the most frequent and severe complication of IE. Unless severe comorbidity exists, the presence of HF indicates early surgery. The new guidelines give for the first time informations not only on the indications of surgery, but also on the timing of surgery.

Infective endocarditis: Updated guidelines

The most recent revision of the American Heart Association guidelines on infective endocarditis prophylaxis occurred in 2007. These revisions were based on the fact that current data have brought into question the benefit of previous recommendations for infective endocarditis prophylaxis. It was noted that the bacteremia that occurs following dental procedures represents only a fraction of the episodes of bacteremia that occur with activities of daily living (such as chewing, brushing teeth and other oral hygiene measures). The target groups and the procedures for which prophylaxis is reasonable have been significantly reduced in number. The focus is now on patients who are most likely to have adverse outcomes from infectious endocarditis. The present article is targeted at practicing Canadian physicians and provides the rationale for the current recommendations. In addition to a summary of the indications for prophylaxis, information is provided on the conditions for which prophylaxis is not recommended.

Treatment strategies for infective endocarditis

Importance of the field: Despite significant advances in medical, surgical, and critical care interventions, infective endocarditis (IE) remains a disease associated with considerable morbidity and mortality. Estimates from the American Heart Association place the incidence of IE in the US at 10,000 – 15,000 new cases each year. This may be due to the changing epidemiology of IE, including increasing antimicrobial resistance, increasing heart surgeries, prosthetic valve implantation, and widespread use of intravenous drugs. Furthermore, a new form of the disease, healthcare-associated IE, which is associated with new therapeutic modalities such as intravenous catheters, hyperalimentation lines, pacemakers, and dialysis shunts, has emerged.Areas covered in this review: We present the latest therapeutic and preventive strategies for IE caused by a variety of bacterial and fungal pathogens. The general methods employed included an extensive literature search, confined to the last 10 years, using key words such as ‘infective endocarditis’, ‘culture-negative endocarditis’, ‘treatment guidelines for IE’, and ‘prophylaxis for IE’.What the reader will gain: Comprehensive information regarding the changing epidemiology of IE is provided. The latest guidelines with respect to therapy and prophylaxis of IE are reviewed.Take home message: Successful management of IE depends on maintaining a high index of suspicion for the disease and, when IE is diagnosed, close cooperation of medical and surgical disciplines is required. Further research is needed to better understand and provide optimal therapy for complex situations such as multidrug-resistant and polymicrobial IE.

Infective Endocarditis: Updated Guidelines

The most recent revision of the American Heart Association guidelines on infective endocarditis prophylaxis occurred in 2007. These revisions were based on the fact that current data have brought into question the benefit of previous recommendations for infective endocarditis prophylaxis. It was noted that the bacteremia that occurs following dental procedures represents only a fraction of the episodes of bacteremia that occur with activities of daily living (such as chewing, brushing teeth and other oral hygiene measures). The target groups and the procedures for which prophylaxis is reasonable have been significantly reduced in number. The focus is now on patients who are most likely to have adverse outcomes from infectious endocarditis. The present article is targeted at practicing Canadian physicians and provides the rationale for the current recommendations. In addition to a summary of the indications for prophylaxis, information is provided on the conditions for which prophylaxis is not recommended.

Infective endocarditis following gastrointestinal and genitourinary procedures: An argument in favour of prophylaxis

In the 2007 American Heart Association guidelines, gastrointestinal (GI) and genitourinary (GU) procedures were removed from the indications for infective endocarditis (IE) prophylaxis. The purpose of this study was to estimate the contribution of GI and GU procedures to the occurrence of IE in order to appreciate whether this removal was justified. Among 212 episodes of IE prospectively collected during 7 y, 20 cases (9%) had invasive GI and GU procedures and 17 (8%) had dental interventions within 3 months before IE diagnosis. Enteric organisms (predominantly Enterococcus faecalis) were significantly more common in the GI and GU group than in all other patients, whereas viridans streptococci, the most common pathogen in the dental group, were absent from the GI and GU group. This unique combination of pathogens in the GI and GU group is highly suggestive of a true association between the procedure and IE. Hence, GI and GU procedures pose a non-negligible risk of acquisition of IE. Consequently, it is proposed here, that adults at high risk of IE who undergo surgical GI and GU procedures, receive prophylaxis that includes an anti-enterococcal agent.

Prevention of Bacterial Endocarditis

Infective endocarditis (IE) is a rare but severe disease with high mortality, and results most often from the combination of bacteraemia and a predisposing cardiac condition. American Heart Association (AHA) and other national and international organizations have made recommendations for the prevention of IE, although no randomised clinical trial has confirmed its efficacy. The current tendencies of IE prophylaxis, based on 2007 AHA guidelines and recent medical bibliography are presented in our review.

Infective endocarditis and antibiotic prophylaxis—what do our Cardiac colleagues think? A national survey

Introduction: The National Institute of Clinical Excellence (NICE) guidelines introduced in 2008 have significantly altered the practice of performing exodontia on patients potentially at risk of developing infective endocarditis (IE). Referrals suggest however, that the cardiac care services continue to make recommendations contradictory to NICE.

Antibiotic prophylaxis for infective endocarditis: is there a missing link?

Antibiotic prophylaxis for infective endocarditis: is there a missing link?

Infective endocarditis and antibiotic prophylaxis prior to dental/oral procedures: latest revision to the guidelines by the American Heart Association published April 2007

This article reviews and analyzes the recently updated guidelines for the prevention of infective endocarditis (IE) through antibiotic prophylaxis established by the American Heart Association (AHA). Various articles studying methods of preventing IE were reviewed, primarily the AHA's revised guidelines published in April 2007. Lists of reference articles were examined to cross reference relevant information regarding antibiotic prophylaxis for the prevention of IE. A major influence for revisions to the guidelines is that studies show a very small fraction of IE cases are preventable with prophylaxis with antibiotic therapy prior to dental procedures. IE is more likely to result from daily activities, such as brushing and flossing teeth, than from bacteremia caused by dental procedures. Patients with underlying cardiac conditions, who are associated with the most detrimental outcome if IE develops, should receive prophylaxis prior to dental procedures. Maintenance of oral health is more effective in reducing the risk of IE than prophylactic antibiotics for dental procedures. An increased lifetime risk of developing IE alone is not a basis for prophylaxis, especially considering that adverse events stemming from antibiotic use exceed the benefit of antibiotic prophylaxis.

Nagt Joghurt an den Herzklappen?

A 22-year-old man with pre-existing aortic valve disease contracted acute lactobacillus endocarditis six weeks after a dental procedure despite adequate prophylaxis. We discuss the limitations of prophylaxis for infective endocarditis in use until the end of 2008 and describe the new updated guidelines. We also explain the treatment of lactobacillus endocarditis and speculate on possible health risks of the increasing use of lactobacillus-containing dairy products, especially in immune-compromised patients.

Comment on: New guidance from NICE regarding antibiotic prophylaxis for infective endocarditis - response by the BSAC Working Party

Comment on: New guidance from NICE regarding antibiotic prophylaxis for infective endocarditis - response by the BSAC Working Party

Antimicrobial prophylaxis against infective endocarditis for dental procedure. - A brief commentary

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

New guidance from NICE regarding antibiotic prophylaxis for infective endocarditis - response by the BSAC working party

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.

An infective endocarditis audit illustrates why dental guidelines in general need to be kept clear, simple and unambiguous

To test the effect complex, multiple dental guidelines have on establishing compliance with ideal clinical practice. A questionnaire was used to determine the level of knowledge of the British Cardiac Society and Royal College of Physicians 2004 infective endocarditis prophylaxis guidelines which were contemporary at the time the study was initiated, as well as to identify the existence of any written departmental policies on the safe management of patients at risk of developing this disease. Hospital Orthodontic Departments in the East of England. Fourteen consultant and nine training grade group hospital orthodontists in the East of England initially answered the questionnaire in November 2005. The results of the survey were then discussed at a subsequent regional audit meeting after which standards were agreed. The original questionnaire was then reissued in June 2006 to 13 and eight of the original consultants and training grade group orthodontists respectively. This was coincidently three months after the publication of further new infective endocarditis prophylaxis guidance from the working party of the British Society for Antimicrobial Chemotherapy. The initial results indicated a number of significant deficiencies in the knowledge of which dental procedures either did or did not need antibiotic prophylaxis that the subsequent audit then improved to a variable extent. Nevertheless, the general finding was one of persistent confusion regarding the multiple conflicting contemporaneous guidelines. This lends further support to the concept of converging guidelines which remain disunified, complex and non-evidence based. The results of this audit confirm that compliance with preferred clinical practice is noticeably compromised when complex conflicting guidelines from either different national or international authoritative bodies exist for the same condition. With particular regard to the dental guidance for infective endocarditis prophylaxis, this has now been largely circumvented in the United Kingdom by the publication of a single, unambiguous guideline from the National Institute of Health and Clinical Excellence (NICE) in March 2008.

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

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

A change of heart: the new infective endocarditis prophylaxis guidelines

New Australian guidelines for the prevention of infective endocarditis were published in July 2008. The guidelines were revised by a multidisciplinary group to reflect recent changes in international recommendations regarding antibiotic prophylaxis for infective endocarditis. The reasons for the changes are explored in this review and the implications for dental practice are discussed.

Continuing professional development self‐assessment quiz: A change of heart: the new infective endocarditis prophylaxis guidelines

Continuing professional development self‐assessment quiz: A change of heart: the new infective endocarditis prophylaxis guidelines

Safety of intrauterine contraceptive device (copper T 200 B) in women with cardiac disease

Background Women with cardiac disease have need for effective long-lasting reversible contraception. Women with cardiac disease are at increased risk for bacterial endocarditis. There is limited research regarding the use of intrauterine contraceptive devices (IUD) in women with cardiac disease. Study Design In a prospective study, the IUD copper (Cu T200B) was inserted in 40 women with cardiac disease. Infective endocarditis prophylaxis was given 1 h before IUD insertion. The IUD was inserted under aseptic conditions. Ten milliliters of venous blood was obtained for culture of aerobic and anerobic bacteria within 1 h of insertion of the copper T IUD. Women were contacted for follow-up at frequent intervals. Results There was no incidence of uterine perforation, hemorrhage or spontaneous expulsion of the IUD. All blood cultures were sterile. There were no cases of infective endocarditis. Four women (10%) had menorrhagia at the 6-month follow-up which responded to medical management. One woman had PID for which antibiotics were given. Five women had mild cramps and five had spotting after insertion of the IUD. Patient adherence was excellent as none returned for removal for reasons other than desire for another pregnancy. Conclusion The Cu T200B IUD is a reasonably safe and effective method of temporary contraception in women with cardiac disease who are not receiving anticoagulant therapy.

New British and American guidelines for the antibiotic prophylaxis of infective endocarditis: do the changes make sense? A critical review

New British and American guidelines for the antibiotic prophylaxis of infective endocarditis: do the changes make sense? A critical review