INFECTIVE ENDOCARDITIS

PROPHYLAXIS
(( UPDATED GUIDELINES))

Yaser O. Baroud
‫الجاهل يؤكد ‪ ...‬و العالم يشكك‪ ......‬و العاقل يتروى‬
‫ارسطو ( ‪ 384‬ق‪.‬م ‪ 322 -‬ق‪.‬م )‬
 HEADLINES

Infective endocarditis

Pathogenesis (mechanism)

Diagnosis

Treatment

Prophylaxis guidelines (latest guidelines)

Dental procedures for which prophylaxis is indicated.

CLINICAL SCENARIO

 52 year-old male patient, diabetic (on insulin 30,20 IU,

HbA1c =11% ) , hypertensive, with a history of kidney
transplant , catheterization and CABG (coronary artery
bypass graft) 4 months ago.
 The patient is in need of extraction of upper first molar.
Would you consider giving the patient prophylactic
antibiotic against infective endocarditis, and what is the
recommended dose ?
Yes No
MARRIED !!
SINGLE !!
 INFECTIVE ENDOCARDITIS
 Infective endocarditis is an inflammation of the inner lining
of the heart (endocardium), particularly affecting the heart
valves and caused mainly by bacterial infection.
 IE is associated with significant morbidity and mortality.
(40 %)*

*Bashore TM, Cabell C, Fowler V Jr. Update on infective endocarditis. Curr Probl Cardiol 2006

It is a life threatening condition !!

*

*http://www.heart.org/
PATHOPHYSIOLOGY OF IE

**http://www.nature.com/
 PATHOPHYSIOLOGY OF IE

 Platelet–fibrin deposits may accumulate along the free

margins of valves, where there is turbulent blood flow.
 Sterile vegetations are formed (Aseptic thrombotic
endocarditis)
 Bacterial proteins, called adhesins, recognize the fibrin and
platelet matrix of the ATE.
 Aseptic thrombotic endocarditis + infection = IE
 Large friable vegitations are formed.
 Bacteria are protected from phagocytosis by forming a
biofilm.
PATHOPHYSIOLOGY OF IE

So,,,, How??
1. Susceptible surface (damaged endocardium)
2. High bacterial loads
 CLINICAL FEATURES

 The interval between the presumed initiating bacteremia

and the onset of symptoms of IE is estimated to be less
than 2 weeks in more than 80% of patients *

 In many cases of IE that have been suggested to be

dentally induced bacteremia, the interval between the
dental appointment and the diagnosis of IE has been
much longer than 2 weeks !!

*Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine, 7th ed.

Philadelphia, Elsevier Saunders, 2005
 CLINICAL FEATURES OF IE

 Clinical features are highly variable, but should be

considered in any patient with fever, night sweat , and
new heart murmur.
 Anemia

 Light pigmentations (café-au-lait)

 Joint pain

 Hepatosplenomegaly

 Progressive heart damage (valve destruction)

 Kidneys , lung, brain (embolic damage)

CLINICAL FEATURES
 Embolic phenomena:
 Include haematuria, cerebrovascular occlusion, purpura
of skin and mucous membranes, and haemorrhages
under the fingernails.
 Roth spots

 Osler’s nodes
 DIAGNOSIS

 Clinical
 ECG (conduction abnormality)

 Echo ( valvular damage)

 Blood culture (3 samples,

before antimicrobial treatment)

Common blood culture isolates include Staphylococcus aureus,
viridans streptococci, enterococci and coagulase-negative
staphylococci.
 DUKE CRITERIA (1994)

Major criteria :
 Positive blood cultures
 Evidence of endocardial involvement (e.g., positive
echocardiography, presence of new valvular regurgitation)
Minor criteria :
 Predisposing heart condition or IV drug use
 Fever

 Vascular phenomena

 Immunologic phenomena

 Microbiologic evidence other than positive blood culture

 Definitive diagnosis of IE requires the presence of two major

criteria, one major and three minor criteria, or five minor criteria.
 TREATMENT

 Patient should be admitted to hospital for IV therapy.

 Iv penicilllin or gentamycin

 Vancomycin in cases of staphylococcal endocarditis.

 Prosthetic valve endocarditis : Removal of the valve and

repalcement.
INDIVIDUALS WHO NEED
PROPHYLAXIS
AHA 2007 guidelines :

1. Have a prosthetic cardiac valve

2. Have a history of previous IE
3. Are cardiac transplantation recipients who develop
cardiac valvulopathy
4. Have a history of CHD
HAVE A HISTORY OF CHD ?!!

 An unrepaired cyanotic congenital heart defect, including

palliative shunts and conduits
 A completely repaired congenital heart defect with prosthetic
material or prosthetic device, whether placed by surgery or by
catheter intervention, during the first 6 months after the
procedure
 A repaired congenital heart defect with residual defects at the
site or adjacent to the site of a prosthetic patch or prosthetic
device (which inhibit endothelialization)
TETRALOGY OF FALLOT
2021 !!
Clindamycin is no longer
recommended for antibiotic
prophylaxis for a dental
procedure.??
†Cephalosporins should not be
used in an individual with a history
of anaphylaxis, angioedema, or
urticarial with penicillin or
ampicillin.
 IN THE UK !!

 1992: the British Society for Antimicrobial Chemotherapy

(BSAC) recommended cover for all procedures associated
with bleeding.
 2004: The British Cardiac Society/Royal College of
Physicians (BCS/RCP) suggested in 2004 that antibiotic
prophylaxis be given for all bacteraemic dental procedures
and for a large range of cardiac defects and/or surgery
 2006: the BSAC recommended antibiotic prophylaxis in only
three (high-risk) circumstances.
 UK
NICE GUIDELINES 2008

 National institute of health and clinical excellence

(NICE) issued recommendations completely removing
the need for antibiotic prophylaxis in relation to
dentistry.!!

((Antibiotic prophylaxis is now not recommended for

patients at risk of endocarditis undergoing dental
procedures.))
 NICE recommended that patients at risk for endocarditis
should receive intensive preventive oral health care, to
try to minimize the need for dental intervention.
REASONS FOR ABANDONING USE OF
ANTIBIOTIC PROPHYLAXIS FOR
ENDOCARDITIS*

 There is no consistent association between dental

procedures and an increased risk of infective
endocarditis;
 Bacteraemia associated with dental procedures is not
greater than that from toothbrushing;
 Regular toothbrushing almost certainly presents a
greater risk of infective endocarditis than a single dental
procedure because of repetitive exposure to bacteraemia.

* NICE. Prophylaxis against infective endocarditis. March 2008

(NICE Clinical Guideline No.64)
 REASONS FOR ABANDONING USE OF
ANTIBIOTIC PROPHYLAXIS FOR
ENDOCARDITIS
Cont.,
 Antibiotics are not proven to reduce the risk of infective
endocarditis.
 Antibiotics are themselves not without risk and can cause
fatal anaphylaxis
 DENTAL ASPECTS
 Patients at risk of endocarditis should receive intensive
preventive dental care to minimize the need for dental
intervention.
 Patients at risk of infective endocarditis should be
discouraged from having procedures such as piercing or
tattooing.
 Patients at risk of infective endocarditis should be
advised to see a GP if they have flue symptoms for
longer than a week.*

*British Heart Foundation. Infective endocarditis: the facts. Accessed

on 8/4/2008
ROUTINELY !! 2016
 WHICH GUIDELINES SHOULD I FOLLOW ?

((Medico-legal and other considerations suggest that one

should err on the side of caution in relation to antibiotic
prophylaxis of IE.))
DENTAL PROCEDURES IN WHICH PROPHYLAXIS IS
RECOMMENDED

“All dental procedures that involve manipulation of

gingival tissue or the periapical region of teeth or
perforation of the oral mucosa”
 DENTAL PROCEDURES IN WHICH
PROPHYLAXIS IS
NOT RECOMMENDED

 Restorative dentistry
 Routine local anesthetic injection
 Intracanal endodontic therapy and placement of rubber dams
 Suture removal
 Placement of removable appliances
 Making of impressions
 Taking of oral radiographs
 Fluoride treatments
 Orthodontic appliance adjustment
 Shedding of primary teeth
 ANTIBIOTIC REGIMENS FOR PROPHYLAXIS OF
BACTERIAL ENDOCARDITIS
*

* Dental management of the medically compromised patient 7 th edition

*Total children’s dose should not exceed adult dose. !!

 If a particular patient requires a series of dental

treatments that requires antibiotic prophylaxis, a period
of 10 or more days between appointments is appropriate.
 IF YOU MISSED THE DOSE ??
 Prophylaxis given longer than 4 hours/ 2Hours after the
bacteremia may have limited prophylactic benefit.
 TAKE HOME MESSAGE
 Follow the guidelines
 Update your information

 When in doubt, consult the cardiologist !!!

CLINICAL SCENARIO

 52 year-old male patient, diabetic (on insulin 30,20 IU,

HbA1c =11% ) , hypertensive, with a history of kidney
transplant ( on immune suppressants), catheterization
and CABG (coronary artery bypass graft) 4 months
ago.
 The patient is in need of extraction of upper first molar.
Would you consider giving the patient prophylactic
antibiotics, and what is the recommended dose ?
CLINICAL SCENARIO

 52 year-old male patient, diabetic (on insulin 30,20 IU,

HbA1c =11% ) , hypertensive, with a history of kidney
transplant (on immune suppressants) , catheterization
and CABG (coronary artery bypass graft) 4 monthes
ago.
 The patient is in need of extraction of upper first molar.
Would you consider giving the patient prophylactic
antibiotic against infective endocarditis, and what is the
recommended dose ?
JORDAN UNIVERSITY HOSPITAL

Thank you