Continuing

Education Course
Prophylactic Antibiotics to Prevent Infective Endocarditis in High-
Risk Cardiac Patients during Invasive Dental Procedures
 Infective endocarditis is a rare, but potentially fatal disease. Antibiotics have traditionally been prescribed prior

to dental procedures for patients with congenital cardiac conditions to lower the risk of infective endocarditis.

Many people are at risk for the disease, but people undergoing dental procedures who have an underlying

cardiac condition have long been evaluated as having a greater risk. Between 25% and 40% of patients with

endocarditis have a history of recent dental manipulation (Imperiale et al., 1990). The issue of whether to

prescribe an antibiotic prophylactically is hotly debated, especially since the American Heart Association now

recommends only cardiac patients that are at highest risk for contracting infective endocarditis should receive

Background
prophylactic antibiotics. Prescribing antibiotics when unnecessary can lead to many unpleasant outcomes, such

as rash, anaphylaxis, and antibiotic resistance. The American Heart Association updated their clinical evidence

guidelines for prevention of infective endocarditis with antibiotics after reviewing multiple cases from varying

levels of evidence. They determined 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 (Wilson et al., 2007). As for cardiac patients at the highest risk of infective endocarditis, the

risks and benefits still need to be greatly evaluated prior to prescribing an antibiotic. Cardiac patients at the

highest risk are defined later in this course. The purpose of this course is to provide education on the current

literature on this topic that is published.

 • Infective Endocarditis (healthline.com, 2018)
• An infection in the heart valves or
endocardium
• The endocardium is the lining of the
interior surfaces of the chambers of the
heart.
• This condition is usually caused by bacteria
entering the bloodstream and infecting the

Definitions
heart. Bacteria may originate in the mouth,
skin, intestines, urinary tract, or respiratory
system.
• Invasive Dental Procedure (Levi, 2016)
• Those that involve manipulation of the gums
(gingival tissue) or perforation of the oral
mucosa
• Procedures like extractions, gum surgery
(gingivectomy/periodontal surgery), or dental
implants are considered invasive.
Infective Endocarditis
 • Cardiac Patients
• Anyone with a congenital heart disease undergoing a
dental procedure was recommended to receive
prophylactic antibiotics.
• In 2007, the American Heart Association changed
their recommendations. They now state that only
patients with the highest risk for contracting infective
endocarditis should receive antibiotics
prophylactically.
• Patients with the highest risk include patients with
Definitions, • Prosthetic cardiac valves, including
transcatheter-implanted prostheses and

continued
homografts.
• Prosthetic material used for heart valve repair,
such as annuloplasty rings, chords or clips.
• Previous IE.
• Unrepaired cyanotic congenital heart defect
(birth defects with oxygen levels lower than
normal) or repaired congenital heart defect, with
residual shunts or valvular regurgitation at the
site adjacent to the site of a prosthetic patch or
prosthetic device.
• Cardiac transplant with valve regurgitation due
to a structurally abnormal valve.
Conditions Where Antibiotics are No Longer Used

• The [American Heart Association] (AHA) guidelines say that many patients who have taken preventive antibiotics
regularly in the past no longer need them, including people with the following conditions:
• Mitral valve prolapse
• Rheumatic heart disease
• Bicuspid valve disease
• Calcified aortic stenosis
• Congenital heart conditions such as ventricular septal defect, atrial septal defect and hypertrophic
cardiomyopathy.
(New guidelines for taking antibiotics before dental procedures, 2012)
The AHA has been creating guidelines for the use of prophylactic antibiotics prior

to invasive dental procedures for 50+ years.

So…
 • The fundamental underlying principles that drove
the formulation of the AHA guidelines … were that:
• IE is an uncommon but life-threatening
disease, and prevention is preferable to
treatment of established infection

…What Drove • Certain underlying cardiac conditions

predispose to IE

Initial • Bacteremia with organisms known to cause IE

occurs commonly in association with invasive
dental, GI, or GU tract procedures
Guidelines for • Antimicrobial prophylaxis was proven to be
effective for prevention of experimental IE in
This Topic? animals
• Antimicrobial prophylaxis was thought to be
effective in humans for prevention of IE
associated with dental, GI, or GU tract
procedures
(Wilson, 2007)
 • IE is much more likely to result from frequent
exposure to random bacteremias associated with
daily activities than from bacteremia caused by a
dental, GI tract, or GU tract procedure
• Prophylaxis may prevent an exceedingly small
Then, What number of cases of IE, if any, in individuals who
undergo a dental, GI tract, or GU tract procedure
Reasons Caused • The risk of antibiotic-associated adverse events
exceeds the benefit, if any, from prophylactic
the Revision for antibiotic therapy

the Guidelines? • 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.
(Wilson, 2007)
 Infective Endocarditis Facts

• Most cases are caused by viridans streptococci, Streptococcus gallolyticus, Staphylococcus aureus,
coagulase-negative staphylococci, HACEK organisms (Haemophilus, Aggregatibacter,
Cardiobacterium, Eikenella, Kingella), and enterococci (Vilcant, 2020).
• Normal oral bacteria include streptococci, lactobacilli, staphylococci and corynebacteria, with a
great number of anaerobes, especially bacteroides.
• If oral streptococci are introduced into wounds created by invasive dental procedures, they may
adhere to heart valves and cause infective endocarditis. (Todar, 2020).
 More Infective Endocarditis Facts

• Signs & Symptoms • Headache • Petechiae • Brain abscess

• Fever • Myalgias • Splinter hemorrhages • Septic emboli leading to

infarction of the kidneys,
• Chills • Arthralgias Complications spleen, lungs and other
• Abdominal pain organs
• Night sweats • Congestive heart failure
• Dyspnea • Hematogenous spread of
• Anorexia • Conduction disease (first- infection leading to
• Cough degree atrioventricular vertebral osteomyelitis,
• Weight loss block, bundle branch block, septic arthritis, or psoas
• Loss of appetite • Pleuritic pain or complete heart block) abscess
• Malaise • Cardiac murmurs • Ischemia (emboli to the • Systemic immune reaction
coronary arteries) such as glomerulonephritis
• Embolic stroke
• Intracerebral hemorrhage
Although the mortality rate for infective endocarditis remains high, the incidence is
still low, making the prescribing of prophylactic antibiotics prior to invasive dental
procedures a controversial topic.
 • In-hospital mortality of 15 percent to 20 percent and 1-
year mortality of 40 percent for infective endocarditis
• In the United States alone, approximately 15,000 new cases
of infective endocarditis are diagnosed each year
• Non-fatal adverse reactions such as GI upset, rash, and
Issues with diarrhea can occur from the use of prophylactic antibiotics
• Prophylactic antibiotics are usually only 1 dose so

Infective adverse reactions are not as serve and usually self

limiting

Endocarditis vs • Fatal anaphylactic reactions [from antibiotics] were

estimated to occur in 15 to 25 individuals per 1 million
patients who receive a dose of penicillin

Antibiotics • Penicillin was the preferred choice for dental

procedure prophylaxis for IE
• These numbers seem small, and there is a big
issue with over-prescribing antibiotics, and
antibiotics leading to adverse effects, fatal
consequences, and antibiotic resistance…
 • Antibiotic resistance occurs when change their response to
a medication that is given to treat it and it becomes harder
or impossible to treat an infection
• This is mostly due to an over-prescription and over-
use of antibiotics
• Antibiotic resistance leads to higher medical costs,
prolonged hospital stays, and increased mortality
• There are ways to help prevent antibiotic resistance and in
2015 the World Health Organization created a world action
plan to help the issue
Antibiotic • It included 5 strategic objectives:
• To improve awareness and understanding of
Crisis antimicrobial resistance.
• To strengthen surveillance and research.
• To reduce the incidence of infection.
• To optimize the use of antimicrobial medicines.
• To ensure sustainable investment in countering
antimicrobial resistance.
(WHO, 2020)
 A Case Study

• One case study was done in Taiwan

• Data was collected from the Health Insurance Database
• Two case-only study designs were reviewed: a case-crossover and a self-controlled case series
• In total, 9120 and 8181 patients with IE (infective endocarditis) were included in case-crossover design and
self-controlled case series design, respectively
• In both study designs, a clinically larger risk for IE in the short periods after IDTs (invasive dental treatments) was
not observed
• Also, no association was found between IDTs and IE among patients with a high risk of I
• Although this is a small population it gives credibility to the reduction in prescribing prophylactic antibiotics for
invasive dental procedures
(Chen et al. 2018)
 Final Word

• Although there are issues with changing practices, the adverse effects of prophylactic antibiotics have
been proven to outweigh the benefits.
• You can reduce the risk of IE by maintaining good oral health through regular professional dental care
and the use of dental products such as manual, powered and ultrasonic toothbrushes; dental floss; and
other plaque-removal devices. 
 1. For which cardiac condition are prophylactic antibiotics still
prescribed?
o Mitral valve prolapse
o Unrepaired cyanotic congenital heart defect
o Ventricular septal defect
o Bicuspid valve disease
2. Select all that apply. Which of the following are symptoms
of infective endocarditis?
o Headache
o Petechiae
o Swollen lymph nodes
o Fever

Quiz
o Loss of taste and smell
3. What organization created a world action plan to help
combat the ongoing antibiotic crisis?
o American Heart Association
o American Dental Association
o Food and Drug Administration
o World Health Organization
4. What year did the American Heart Association revise their
guidelines on prophylactic antibiotics for invasive dental
procedures to include only patients at highest risk?
o 2007
o 2010
o 2011
o 2015
 5. Which type of surgery is not a risk factor for contracting
infective endocarditis?
o Genitourinary surgery
o Gastrointestinal surgery
o Foot and ankle surgery
o Dental surgery
6. Antibiotic resistance can lead to… (select all that apply)

Quiz
o More frequent surgical procedures
o Higher hospital costs
o Higher incidence of comorbidities
o Longer hospital stays
o Increased mortality
7. True/False: Good oral hygiene can reduce the risk of
infective endocarditis.
o True
o False
 8. Which of the following procedures is an invasive dental
procedure?
o Annual teeth cleaning
o Braces
o Tooth extraction
o Teeth whitening procedure

9. Which of the following is a complication of infective

endocarditis?
Quiz o
o
Retinopathy
Septic emboli
o Nerve damage
o Alzheimer’s disease
10. True/False: Staphylococcus aureus is a common
cause of infective endocarditis.
o True
o False
 Quiz Answers & Explanations

1. For which cardiac condition are prophylactic antibiotics still

prescribed?
o Mitral valve prolapse
o Unrepaired cyanotic congenital heart defect
o Ventricular septal defect 3. What organization created a world action plan to help combat the
o Bicuspid valve disease ongoing antibiotic crisis?
Explanation: unrepaired cyanotic congenital heart defect is listed o American Heart Association
as a condition of a high-risk cardiac patient. You would still o American Dental Association
prescribe antibiotics for this condition. o Food and Drug Administration
o World Health Organization
Explanation: The World Health Organization created a world
action plan to help prevent antibiotic resistance in 2015 with 5
strategic objectives in it.
2. Select all that apply. Which of the following are symptoms of
infective endocarditis?
o Headache
o Petechiae
o Swollen lymph nodes 4. What year did the American Heart Association revise their guidelines
o Fever on prophylactic antibiotics for invasive dental procedures to include
 Quiz Answers & Explanations

5. Which type of surgery is not a risk factor for contracting
infective endocarditis?
o Genitourinary surgery
o Gastrointestinal surgery
o Foot and ankle surgery
o Dental surgery
Explanation: GU, GI, and dental procedures are common
causes of bacteremia post procedure.
6. Antibiotic resistance can lead to… (select all that apply)
o More frequent surgical procedures
o Higher hospital costs
o Higher incidence of comorbidities
o Longer hospital stays
o Increased mortality
Explanation: More frequent procedures and higher incidence
of comorbidities are not caused by antibiotic resistance.
7. True/False: Good oral hygiene can reduce the risk of infective
endocarditis.
o True
o False
Explanation: 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.
 Quiz Answers & Explanations

8. Which of the following procedures is an invasive dental

procedure?
o Annual teeth cleaning
o Braces
o Tooth extraction Explanation: Congestive heart failure, conduction disease,
ischemia, embolic stroke, intracerebral hemorrhage, brain
o Teeth whitening procedure abscess, septic emboli, hematogenous spread of infection
Explanation: Procedures like extractions, gum surgery leading to vertebral osteomyelitis, septic arthritis, or psoas
(gingivectomy/periodontal surgery), or dental implants are abscess, and systemic immune reaction are all listed as
considered invasive. complications to infective endocarditis.

9. Which of the following is a complication of infective 10. True/False: Staphylococcus aureus is a common cause of
endocarditis? infective endocarditis.
o Retinopathy o True
o Septic emboli o False
o Nerve damage Explanation: Most cases of infective endocarditis are
caused by viridans streptococci, Streptococcus
 • Chen, T., Yeh, Y., Chien, K., Lai, M., Tu, Y., & Baddour, L. (2018, April 19). Risk of infective
endocarditis after invasive dental treatments. Retrieved March 28, 2021, from
https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.117.033131#:~:text=In%20the
%20self%2Dcontrolled%20case%20series%20design%2C%20we%20observed%20that,to
%204%20weeks%20after%20IDTs.
• Infective endocarditis. (2021, March 4). Retrieved March 16, 2021, from https://www.heart.org/en/health-
topics/infective-endocarditis
• Imperiale, T.F., & Horwitz, R. F. (1990). Does prophylaxis prevent postdental infective
endocarditis? A controlled evaluation of protective efficacy. The American Journal of
Medicine, 88(2), 131-136. doi:10.1016/0002-9343(90)90461-L
• Levi, L., Freuman, T., Brown, K., Clegg, H., & Morse, K. (2019, August 07). What are 'invasive' dental

References •
procedures? Retrieved March 16, 2021, from https://savorhealth.com/invasive-dental-procedures/
New guidelines for taking antibiotics before dental procedures. (2012). Retrieved March 21, 2021, from
https://www.deltadentalins.com/oral_health/antibiotics.html
• Todar, K. M. (2020). The normal bacterial flora of humans. Retrieved March 23, 2021, from
http://www.textbookofbacteriology.net/normalflora_3.html#:~:text=Normal%20Flora%20of%20the
%20Oral,number%20of%20anaerobes%2C%20especially%20bacteroides.
• Vilcant, V. (2020, August 10). Bacterial endocarditis. Retrieved March 23, 2021, from
https://www.ncbi.nlm.nih.gov/books/NBK470547/
• Wilson W., Taubert, K.A., Gewitz, M., Lockhart, P.B., Baddour, L. M., Levison, M., … Durack, D. T. (2007).
Prevention of infective endocarditis. Circulation, 116, 1736–1754.
doi:10.1161/CIRCULATIONAHA.106.183095
• World Health Organization, (2020, July 31). Antibiotic resistance. Retrieved March 28, 2021, from
https://www.who.int/news-room/fact-sheets/detail/antibiotic-resistance#:~:text=Antibiotic
%20resistance%20occurs%20when%20bacteria,caused%20by%20non%2Dresistant%20bacteria.