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Perspectives on the 2007 AHA guidelines for the prevention of infective endocarditis Nelson L. Rhodus, DMD, MPH, FACD Professor Academy of Distinguished Professors. Director, Division of Oral Medicine, Dental School Adjunct Professor, Otolaryngology, Medical School

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slide1
Perspectives on the 2007 AHA guidelines for the prevention of infective endocarditisNelson L. Rhodus, DMD, MPH, FACDProfessorAcademy of Distinguished Professors

Director, Division of Oral Medicine, Dental School

Adjunct Professor, Otolaryngology, Medical School

Diplomate, American Board of Oral Medicine

University of Minnesota

slide2
Dr. Robert Gorlin

1923-2006

50 yrs. at UM

basis for past aha guidelines
Basis for Past AHA Guidelines

1. True or false

  • Dental procedures were the source of the bacteremias leading to IE
basis for past aha guidelines1
Basis for Past AHA Guidelines
  • Dental procedures were the source of the bacteremias leading to IE
  • (False, Daily activities much more likely the source)
basis for past aha guidelines2
Basis for Past AHA Guidelines
  • 2. True or false
  • Magnitude of dental procedure bacteremias were far greater than daily activities
basis for past aha guidelines3
Basis for Past AHA Guidelines
  • Magnitude of dental procedure bacteremias were far greater than daily activities
  • (False, they are about the same, both relatively low magnitude)
basis for past aha guidelines4
Basis for Past AHA Guidelines
  • 3. True or false
  • Bleeding is the indication for bacteremia occurring
basis for past aha guidelines5
Basis for Past AHA Guidelines
  • Bleeding is the indication for bacteremia occurring
  • (False, it is not a reliable predictor for bacteremia)
basis for past aha guidelines6
Basis for Past AHA Guidelines
  • 4. True or false Prophylaxis reduces the risk of IE from occurring
basis for past aha guidelines7
Basis for Past AHA Guidelines
  • Prophylaxis reduces the risk of IE from occurring
  • (False, antibiotics may reduce the magnitude of the bacteremia, no evidence they will reduce the incidence of IE)
basis for past aha guidelines8
Basis for Past AHA Guidelines
  • 5. True or false The new 2007 guidelines are significantly different than any previous guidelines
basis for past aha guidelines9
Basis for Past AHA Guidelines
  • The new 2007 guidelines are significantly different than any previous guidelines
  • TRUE !
basis for past aha guidelines10
Basis for Past AHA Guidelines
  • Based on unproven assumptions
  • Dental procedures were the source of the bacteremias leading to IE (False, Daily activities much more likely the source)
  • Magnitude of dental procedure bacteremias were far greater than daily activities (False, they are about the same, both relatively low magnitude)
  • Bleeding is the indication for bacteremia occurring (False, it is not a reliable predictor for bacteremia)
  • Prophylaxis reduces the risk of IE from occurring (antibiotics may reduce the magnitude of the bacteremia, no evidence they will reduce the incidence of IE)
rational for 2007 guidelines
Rational for 2007 Guidelines
  • Previous 9 AHA Guidelines – Based on the lifetime risk for IE
  • New Guidelines – Based on the risk for an adverse outcome
2007 aha guidelines
2007 AHA Guidelines
  • First made public at the annual American Academy of Oral Medicine meeting on May 19, 2007 in San Diego, CA. www.aaom.com
  • Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et al. Prevention of Infective Endocarditis: Guidelines From The American Heart Association. Circulation 2007; 115:1-17. Available at http://www.circulationaha.org, DOI:10.1116/circulationAHA.106.18309.
  • Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et al. Prevention of Infective Endocarditis: Guidelines From The American Heart Association. J Am Dent Assoc 2007:138 (6): 739-760.
conditions recommended for prophylaxis in 1997 vs 2007
High-risk lesions

Prosthetic heart valves

Previous endocarditis

Cyanotic CHD

Aortic valve disease

Mitral regurgitation

Patent ductus arteriosus

Ventricular septal defect

Coarctation of aorta

Intermediate-risk

MVP with regurgitation

Mitral stenosis

Tricuspid valve disease

Pulmonary stenosis

Septal hypertrophy

Degenerative valvular disease in older patients

Nonvalvular intracardiac prosthetic implants

Conditions Recommended for Prophylaxis in 1997 vs 2007
the aha cites the following reasons for revision of the 1997 guidelines
The AHA cites the following reasons for revision of the 1997 guidelines:
  • IE is much more likely to result from frequent exposure to random bacteremias associated with daily activities than from bacteremia caused by a dental procedure
  • Prophylaxis may prevent an exceedingly small number, if any, cases of IE in individuals who undergo a dental procedure
  • The risk of antibiotic associated adverse eventsexceeds the benefit, if any, from prophylactic antibiotic therapy
  • 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
slide22
~40 %

morbidity-mortality

acute IE ( staph aureus)- aortic v.

infective endocarditis hypothetical association with dental treatment
Infective Endocarditis: hypothetical association with dental treatment ?
  • Invasive dental procedures>>>>transient systemic bacteremia (6 min.)
  • transient systemic bacteremia (6 min.) >>>>> colonization of susceptible endocardial surfaces ??????
  • colonization of susceptible endocardial surfaces ??????>>>>>>>>IE ??????
infective endocarditis hypothetical association with dental treatment1
Infective Endocarditis: hypothetical association with dental treatment ?
  • J. Antimicrobial Chemotherapy, 4-19-2006
  • A study of 273 patients = no link between dental treatment and IE (Strom BL., Ann Int Med 1998 129:761-9)
  • Cochrane review: no evidence to support antimicrobial prophylaxis to prevent IE in invasive dental procedures( Oliver R. 2006)
  • Evidence-based…doesn’t exist
rheumatic heart disease
Rheumatic Heart Disease
  • immune reaction to Streptococci or products
  • fibrosis, calcification, scarring on valve ( usually mitral or aortic)
  • damaged & dysfunctional valve leaflets
  • murmur
  • ventricular dilatation and hypertrophy
  • CHF
rheumatic heart disease concerns
Rheumatic Heart Disease: concerns
  • angina
  • Arrhythmia
  • dyspnea
  • epistaxis
  • CHF
  • PV
  • IE
prosthetic heart valve

Prosthetic heart valve

usually mitral dysfunction

RF...RHD……... CHF

synthetic replacement = PV

tissue prosthetic heart valve
Tissue Prosthetic Heart Valve

Little JW, Dental Management of the Medically Compromised Patient, Mosby, 2007, p 21

slide29
Prosthetic valve

endocarditis ( PVE)

slide30
Prosthetic valve

endocarditis ( PVE)

infective endocarditis
Infective endocarditis
  • fever, murmur, weakness, fatigue, malaisse, anemia,visual problems, GI, weight loss, fever, chills, night sweats, arthralgia, ngina, hematuria, paresthesias or paralysis, petechiae, Osler nodes, Janeway lesions, retinal hemorrhages
infective endocarditis1
Infective endocarditis
  • Has the risk changed ?
  • Dx (Duke) criteria
  • The use of antibiotic prophylaxis has not changed the incidence of IE in > 50 years!
infective endocarditis2
Infective endocarditis
  • Risk of a brain abcess resulting from extracting a tooth is 1: 10 million !
  • Risk of a LPJRI resulting from extracting a tooth is 1: 2.5 million !
  • Risk of IE resulting with a MVP-r from extracting a tooth is 1: 1 million !
  • Risk of IE resulting with RHD from extracting a tooth is 1: 150,000 !
  • Risk of IE resulting with PVR from extracting a tooth is 1: 95,000 !
infective endocarditis3
Infective endocarditis
  • Risk of IE resulting with PVR from extracting a tooth is 1: 95,000 !
  • Risk of IE resulting with any heart condition from any dental procedure is 1:14 million !
  • If 10 million patients at risk undergo dental treatment without prophylaxis 20 will get IE and 2 will die, but more than 10 will die from acute anaphylaxis from the PCN !

Agha Z, et.al. Med. Dec. Mak. 2005 25:308-320.

rheumatic fever and rheumatic heart disease
Rheumatic Fever and Rheumatic Heart Disease
  • mitral valve damaged 60% of those defects
  • as many as 30-40 % of cases are un-diagnosed
  • Signs-symptoms
  • pharyngitis, athralgia,carditis, chorea, fever, erythema marginatum, sub-q nodules, dyspnea
  • lab values: ESR, EKG( PR interval), strep Ab
reported frequency of bacteremias associated with various dental procedures and daily activities
Procedure

Tooth extraction

Periodontal surgery

Scaling and root planing

Teeth cleaning

Rubber dam matrix/wedge placement

Endodontic procedures

Daily Activities

Tooth brushing and flossing

Use of wooden toothpicks

Use of water irrigation devices

Chewing food

Frequency of bacteremia

10-100%

36-88%

8-80%

≤ 40%

9-32%

≤ 20%

20-68%

20-40%

7-50%

7-51%

Reported Frequency of Bacteremias Associated With Various Dental Procedures and Daily Activities
initiating bacteremia
Initiating Bacteremia
  • Dental Procedures
  • Most (if not all) are not associated with the onset of IE.
  • If a dental procedure is possibly associated with the cause of IE, the symptoms of IE should appear within less than 2 weeks.

(2:300 law suits…Pallasch)

endocarditis prophylaxis recommended
Endocarditis prophylaxis recommended
  • The new guidelines recommend that only individuals who are at the highest risk of an adverse outcome receive antibiotic prophylaxis, and they include:
endocarditis prophylaxis recommended1
Endocarditis prophylaxis recommended
  • *Prosthetic cardiac valve
  • * Previous infective endocarditis (IE)
  • * Congenital heart disease (CHD) with :
endocarditis prophylaxis recommended2
Endocarditis prophylaxis recommended
  • - Unrepaired cyanotic CHD, including palliative shunts and conduits
  • - Completely repaired CHD defect with prosthetic material or device for first 6 months after procedure - Repaired CHD with residual defects at the site or adjacent to site of prosthetic patch/ device which inhibit endothelializtion
  • - Cardiac transplantation recipients who develop cardiac valvulopathy
endocarditis prophylaxis
Endocarditis prophylaxis
  • Compared with previous AHA guidelines, far fewer patients will receive IE prophylaxis. Consequently, many patients who previously were premedicated for dental procedures are no longer recommended for prophylactic antibiotic coverage.
endocarditis prophylaxis1
Endocarditis prophylaxis
  • * The AHA committee feels that IE is much more likely to result form frequent exposure to transient bacteremia associated with daily activities (brushing, chewing food) than from bacteremia caused by a dental procedures..
  • * Prophylaxis may prevent an exceedingly small number of cases of IE (if any) in individuals who undergo a dental procedure.
endocarditis prophylaxis2
Endocarditis prophylaxis
  • * The risk of antibiotic-associated adverse events exceeds the benefit (if any) from prophylactic antibiotic therapy.
  • * 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 in reducing the risk of IE.
conditions recommended for coverage in 2007
Conditions Recommended for Coverage in 2007
  • Based on greatest risk for adverse outcome
  • Prosthetic Cardiac Valve
  • Previous Infective Endocarditis
  • Congenital Heart Disease (CHD)
    • Unrepaired cyanotic CHD including those with palliative shunts and conduits
    • Completely repaired CHD with prosthetic material or device for first 6 months
    • Repaired CHD with residual defects at the site
  • Cardiac Transplantation Recipients who Develop Cardiac Valvulopathy
endocarditis prophylaxis not recommended 1997 vs 2007
Endocarditis prophylaxis NOT recommended (1997 vs 2007)
  • functional heart murmurs
  • post-coronary surgeries > 6 mos.
  • RF, RHD, most congential defects
  • MVP with or without regurgitation
  • pacemakers
conditions recommended for prophylaxis in 1997 vs 20071
High-risk lesions

Prosthetic heart valves

Previous endocarditis

Cyanotic CHD

Aortic valve disease

Mitral regurgitation

Patent ductus arteriosus

Ventricular septal defect

Coarctation of aorta

Intermediate-risk

MVP with regurgitation

Mitral stenosis

Tricuspid valve disease

Pulmonary stenosis

Septal hypertrophy

Degenerative valvular disease in older patients

Nonvalvular intracardiac prosthetic implants

Conditions Recommended for Prophylaxis in 1997 vs 2007
1997 endocarditis prophylaxis not recommended
1997 : Endocarditis prophylaxis NOT recommended
  • routine restorative procedures
  • placement of rubber dams
  • routine local anesthetic injections
  • intracanal endo; suture removal
  • impressions, fluoride, radiographs
  • insertion or adjustment of removable prosthetic or ortho appliances
1997 endocarditis prophylaxis recommended
1997 : Endocarditis prophylaxis recommended
  • extractions
  • perio surgery-scaling-probing-prophy
  • implants( or re-implantation)
  • endo(only beyond apex)
  • subgingival manipulation( antibiotic fibers)
  • initial placement of ortho bands
  • intraligamentary injections
2007 endocarditis prophylaxis recommended
2007 : Endocarditis prophylaxis recommended
  • Any procedure which abrogates the mucosal barrier and causes ANY bleeding !
  • The amount of bleeding has no impact upon the risk for IE !
2007 aha guidelines dental procedures recommended for prophylaxis
2007 AHA Guidelines – Dental Procedures recommended for Prophylaxis
  • All Dental Procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa. (Includes many procedures that in the 1997 guidelines were not recommended for coverage)
prevention of infective endocarditis note
Prevention of Infective Endocarditis : NOTE
  • The MOST important factor is to maximize oral health and reduce oral microflora
  • minimize oral tissue trauma
  • periodontal and plaque control
  • antimicrobial mouthrinses
  • proper AHA prophylactic regimen ONLY when indicated
prevention of infective endocarditis
Prevention of Infective Endocarditis :
  • standard : Amoxicillin- 2 g; 30-60 min. pre-op
  • IM or IV: Ampicillin-2g; 30 min. pre-op
  • allergic : Clindamycin- 600mg; 30-60 min. pre-op Cephalexin- 2 g one-hour pre-op
    • Cefadroxil
    • Azithromycin or Clarithromycin- 500mg-1 hr.
  • aller-npo: Clindamycin- 600mg -IV;
    • - or Cefazolin- 1 g; 30 min. pre-op
antibiotic prophylaxis
Antibiotic prophylaxis
  • Does it really do any good ?
amoxicillin
Amoxicillin
  • Bioavailability > 95 %
  • Rapid GI absorption from po
  • Works fast
  • Resistance ( >95 % K. pneumoniae in Japan)
antibiotic prophylaxis1
Antibiotic Prophylaxis
  • Antibiotic Resistance

About 17% to 50% of the viridans group of streptococci are resistant to penicillin and 13% to 27% are resistant to clindamycin.

Impact on IE prevention is unknown.

infective endocarditis4
Infective endocarditis
  • 2007…..there is no evidence that dental treatment causes infective endocarditis or that antibiotic prophylaxis is preventive
  • >95% of IE = no relation at all to dental Tx
  • physiologic bacteremias regular toothbrushing = 0-40% chewing = 17-51 % cleaning-irrigating devices = 7-50% random periodontal disese = 11-20%
infective endocarditis5
Infective endocarditis
  • Toothbrushing 2 x daily = 150,000 times risk if IE than extracting a tooth !
  • All daily activities= 5 million times risk if IE than extracting a tooth !
endocarditis prophylaxis issues
Endocarditis prophylaxis issues
  • already on previous regimen
  • already on an antibiotic ( lower dose)
  • how much dental treatment (appt. length)
  • interval between appointments
  • Patient forgot to take the antibiotic
  • IBD( colitis) and clindamycin
  • not the same as prevention of late prosthetic joint infections
antibiotic prophylaxis2
Antibiotic prophylaxis
  • If prophylaxis is not possible, administering the antibiotic within 2 hours may help prevent IE
  • time between prophylaxis coverage periods = 10 days ! Do as much treatment as possible during coverage period
  • Rx’d antibiotics (not sufficient type or dose)
  • Pre-op antimicrobial mouthrinses have not shown any benefit
  • monitor for signs-symptoms of IE
2007 aha guidelines1
2007 AHA Guidelines
  • Patients who undergo cardiac surgery
  • A careful dental evaluation is recommended so that requireddental treatment may be completed whenever possible before cardiacvalve surgery or replacement or repair of CHD.
endocarditis prevention
Endocarditis Prevention
  • Current practice
  • Identify the susceptible patient and use antibiotic prophylaxis for indicated dental procedures
  • Medical referral to establish current status may be needed to for patients with CHD corrected with prosthetic material or devices.
  • Within 6 months of corrective surgery
  • Residual defect (leakage)
nonvalvular cardiovascular devices aha does not recommend prophylaxis
Pacemakers

Defibrillators

Left ventricular assist devices

Total artificial hearts

Arteriovenous fistulae

Closure devices for ASD, PDA, AVF

Hemodialysis grafts

Vascular grafts

Intra-aortic balloon pumps

Dacron grafts and patches

Vena caval filters

Vascular closure devices

Ventriculoatrial shunts

Coronary artery stents

Nonvalvular Cardiovascular DevicesAHA does not recommend prophylaxis

AHA, Scientific statement on Nonvalvular Cardiovascular Devices. Circulation, 108: 2015, 2003.

nonvalvular cardiovascular devices
Nonvalvular Cardiovascular Devices
  • AHA does recommend Prophylaxis
  • Incision and Drainage of infection at other sites (I & D of dental abscess)
  • Extraction of teeth or surgical procedures performed in areas of acute infection
  • Residual leak following closure of PDA, ASD, VSD (follow AHA guidelines)

AHA, Scientific statement on Nonvalvular Cardiovascular Devices. Circulation, 108: 2015, 2003.

impact of 2007 guidelines
Impact of 2007 Guidelines
  • Patients who have taken antibiotics for years to prevent IE and now no longer are recommended to do such.
  • Patients who are still recommended to be covered but now for just about all dental procedures.
  • Explain rational for new guidelines, answer questions, consult with patient’s physician – informed consent (record in progress notes).
impact of 2007 guidelines pallasch tj cdaj 2007 35 7 507 11
Impact of 2007 GuidelinesPallasch TJ. CDAJ 2007:35(7): 507-11
  • MD or patient non-acceptance: they can provide the Rx “upon their own authority “
  • “ Based upon the best current scientific evidence as published by the AHA, and my best clinical judgement. “
congenital heart disease dental concerns
Congenital heart disease-dental concerns
  • Endocarditis
  • Congestive heart failure
  • Endarteritis
  • Excessive bleeding
  • Cyanosis
  • Infection
what is next
What is Next
  • 2007 Guidelines – Foundation set
  • Dental procedures not cause
  • No evidence that prophylaxis is effective
  • Adverse reactions to antibiotics
  • Increasing rate of resistance to antibiotics
  • The next set of AHA guidelines will not recommend prophylaxis for any dental procedure even in patients with cardiac lesions with the greatest risk for adverse outcomes
prevention of endocarditis
Prevention of Endocarditis
  • General concepts
  • Goal of “infection free” oral cavity
  • Follow the current (2007) AHA guidelines for selection of cardiac conditions and dental procedures needing prophylaxis
  • Reduce gingival inflammation before performing restorative procedures
  • Establish effective home care practices
  • Chlorhexidine mouth rinse can be used prior to periodontal or surgical procedures, however several studies suggest no real benefit
prevention of endocarditis1
Prevention of Endocarditis
  • General principles Cont.
  • Coverage is effective for 4-6 hours
  • Do as much dental treatment as possible during each coverage period
  • Allow at least 9 days to elapse between coverage periods. If this is not possible select an alternant antibiotic
  • Be alert for signs and symptoms of IE in patients receiving antibiotic prophylaxis and those with cardiac lesions at risk for IE
slide73
plasma levels of prophylactic antibiotics

µg/ml

3g Amox

7

2 g Amox

1.5 g Amox

5

1 g PenVK

------------------------------------------------

3

hours

1 4 6 10

late prosthetic joint infections
Late Prosthetic Joint Infections
  • Wahl’s myths: #1: There are similarities between IE (PVE) and LPJI. NO. #2: Dental treatment is a probable cause of LPJI. NO. #3: Animal experiments document dental bacteremias as cause of LPJI. NO. #4: To protect patients DDS should always cover patients with PJ. NO.
prevention of late prosthetic joint infections 1997 changes
Prevention of late Prosthetic joint infections: 1997 changes
  • ADA/AAOS advisory statement
  • medical consultation with Orthopod
  • No prophylaxis for pins, rods, screws, plates, wires, implants, etc.
  • healthy patient: < 2 yrs. after TJR
  • chronic RA or other infection of TJR
  • immunocompromised patients
prevention of late prosthetic joint infections 1997 changes1
Prevention of late Prosthetic joint infections: 1997 changes
  • Cephalexin ( Keflex) 2g ; po ; 1 hr. pre-op
  • Cephazolin; 1 g; IM/IV; 1 hr. pre-op
  • Clindamycin; 600mg.; po; 1 hr. pre-op
antibiotics
ANTIBIOTICS
  • Other indications for antibiotic prophylaxis:
  • HIV
  • ESRD : hemodialysis
  • IDDM
  • Autoimmune diseases; SLE
  • Splenectomy
  • CHF, CVA; thromboemboli
  • Liver disease
  • Organ transplants
congenital heart disease dental concerns1
Congenital heart disease-dental concerns
  • Endocarditis
  • Congestive heart failure
  • Endarteritis
  • Excessive bleeding
  • Cyanosis
  • Infection
rheumatic heart disease1
Rheumatic Heart Disease
  • DETECTION historyechocardiography chest radiographs EKG auscultation
basis for 2007 guidelines
Basis for 2007 Guidelines
  • Adverse Outcomes
  • Valvular dysfunction
  • Congestive heart failure
  • Need for valvular replacement
  • Multiple embolic events
  • Death
ad