Dental providers must keep up to date

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1 Debte& o p i n i o n Which Antibiotic Prophylxis Guidelines for Infective Endocrditis Should Cndin Dentists Follow? Herve Y. Sroussi, DMD, PhD; Ashwin R. Prbhu, BDS; Joel B. Epstein, DMD, MSD, FRCD(C) Contct Author Dr. Epstein Emil: For cittion purposes, the electronic version is the definitive version of this rticle: Dentl providers must keep up to dte with ntibiotic prophylxis guidelines for infectious endocrditis (IE) s these guidelines represent stndrds of cre nd determine medicolegl stndrds. A survey of Cndin dentists reveled tht prctitioners tend to employ ntibiotic prophylxis ccording to the guidelines in plce t the time of their grdution from dentl school guidelines tht often do not meet the current stndrds, 1 s both the Americn Hert Assocition (AHA) 2 nd the British Society for Antimicrobil Chemotherpy (BSAC) 3 hve currently updted their recommendtions. Host fctors tht increse the risk of IE include specific crdic bnormlities, previous episode of IE nd the extent of the dentl procedure to be undertken (Tble 1). In the 2007 revision of its recommendtions, the AHA limited the conditions for which endocrditis prophylxis is recommended before dentl tretment to those ssocited with the highest risk (Tble 2). It is importnt to note tht vlvulr disese independent of regurgittion is not condition for which the AHA recommends prophylxis. 2 This will result in considerble reduction in the use of IE ntibcteril prophylxis. It is believed tht invsive dentl procedures ssocited with bleeding increse the risk of orl bcteri entering the blood circultion. Although there is evidence tht the risk of infection due to tretment-relted bcteremi my occur during short window of less thn 2 weeks following procedure, dentl procedures conducted even months erlier my be questioned s custive of IE. 4 Furthermore, periodontl nd dentl disese increse the risk of bcteremi with ctivities of dily living nd my more commonly cuse bcteremi; therefore, good orl cre is of prmount importnce in ptients with conditions tht plce them t risk for IE. To reduce the risk of IE following dentl procedures, prophylctic mesures hve been developed by experts in the fields of microbiology, epidemiology, crdiology nd dentistry. The principle preventive mesure recommended is the use of prophylctic ntibiotics before certin dentl procedures in ptients identified s t risk. The first AHA-recommended prophylxis regimen ws issued in 1955; the most current recommendtions were issued in The British Crdic Society 5 nd the BSAC 3 hve lso recently updted their recommendtions for IE prophylxis (in 2004 nd 2006, respectively). This rticle provides summry of those guidelines nd notes the differences mong them. The continuing evolution of IE prophylxis guidelines hs recognized the nturl history of the condition, risk fctors, niml reserch, epidemiology nd review of ntibiotic prophylxis filures. The guidelines lso reflect n incresing need to gurd ginst overuse of ntibiotics. In Cnd, using either the current British or Americn guidelines my JCDA June 2007, Vol. 73, No

2 Epstein Tble 1 Guidelines for the identifiction of ptients who my require prophylxis for infective endocrditis before dentl procedures Americn Hert Assocition 2 British Society for Antimicrobil Chemotherpy 3 British Crdic Society 5 Prosthetic crdic vlve Previous infective endocrditis Congenitl hert disese (CHD) if 1 of the 3 conditions listed below: 1. Unrepired cynotic CHD, including pllitive shunts nd conduits 2. Completely repired congenitl hert defect with prosthetic mteril or device, whether plced by surgery or by ctheter intervention, during the first 6 months fter the procedure 3. Repired CHD with residul defects t the site or djcent to the site of prosthetic ptch or prosthetic device (which inhibit endotheliliztion) Crdic trnsplnttion recipients who develop crdic vlvulopthy Previous infective endocrditis Crdic vlve replcement surgery, i.e., mechnicl or biologic prosthetic vlves Surgiclly constructed systemic or pulmonry shunt or conduit Prosthetic hert vlves Previous infective endocrditis Complex cynotic congenitl hert disese Trnsposition of gret rteries Fllot s tetrlogy Gerbode s effect Surgiclly constructed systemic pulmonry shunts or conduits Mitrl vlve prolpse with cliniclly significnt mitrl regurgittion or thickened vlve leflets Moderte risk Acquired vlvulr hert disese, e.g., rheumtic hert disese Aortic stenosis Aortic regurgittion Mitrl regurgittion Other structurl crdic defects, e.g., ventriculr septl defect Bicuspid ortic vlve Primum tril septl defect Ptent ductus rteriosus Aortic root replcement Corcttion of ort Atril septl neurysm/ptent formen ovle provide justifible ptient cre nd, therefore, my mnge the medicolegl necessities of prctice (Tbles 3 to 5). Providers must choose the most recent guidelines from recognized uthorities. In the United Sttes, this is limited to AHA guidelines, but in Cnd, either the AHA or one of the British societies could be chosen s the uthorittive body. Whichever guidelines re employed, it is impertive tht they be followed s promoted nd tht the most recent version be used. Before considering ntibcteril prophylxis, both the ptient nd the procedure should be defined s t risk (i.e., bleeding risk, bcteremi risk nd subject t risk). When dentl provider consults with physicin, it is importnt for the dentist to provide detiled informtion on the current guidelines to be used, s the dentl community my be more wre of these, the ptient s dentl condition nd the risk of bleeding or bcteremi nticipted with the procedure. 402 JCDA June 2007, Vol. 73, No. 5

3 Antibiotic Prophylxis Tble 2 Dentl procedures for which ntibiotic prophylxis is recommended Americn Hert Assocition 2 Mnipultion of gingivl, periodontl nd peripicl tissues; incision of mucos including: surgery periodontl procedures endodontic instrumenttion beyond the pex or picl surgery subgingivl plcement of ntibiotic fibres or strips initil plcement of orthodontic bnds but not brckets intrligmentry locl nesthetic injections prophylctic clening of teeth or implnts where bleeding is nticipted Excluding: locl nesthetic plcement (unless through site of infection) British Society for Antimicrobil Chemotherpy 3 British Crdic Society 5 Dentl procedures involving dentogingivl mnipultion nd endodontics. A risk ssessment, which involves the ptient, is importnt nd fctors like the orl hygiene sttus of the ptient re importnt considertions for deciding on prophylxis. Exmintion procedures periodontl probing Investigtion procedures silogrphy Anesthetic procedures intrligmentl locl nesthesi All surgicl procedures Restortive procedures rubber dm plcement mtrix bnd nd wedge plcement gingivl retrction cord plcement Periodontl procedures Professionl clening procedures polishing teeth with rubber cup orl irrigtion with wter jet scling, root plning ntibiotic fibres or strips plced subgingivlly b Endodontic procedures root cnl instrumenttion beyond the root pex Avulsed tooth reimplnttion c Orthodontic procedures tooth seprtion exposure or exposure nd bonding of tooth or teeth For multiple dentl visits, lternting ntibiotics re recommended, e.g., moxicillin clindmycin moxicillin. For young children the sequence would be moxicillin zithromycin moxicillin. If penicillin or penicillin-like ntibiotics re used, t lest 1 month must be llowed between visits. Dentists should provide s much tretment s is fesible ech visit. b No dt, but procedure is similr to gingivl retrction cord plcement. c The vulsed tooth cn be quickly wshed nd reimplnted immeditely by prent or other responsible person nd the ntibiotic prophylxis dministered fterwrd, provided this is within 2 hours of the reimplnttion. Antibiotic prophylxis my be successful if dministered shortly fter the bcteremic episode. Tble 3 Americn Hert Assocition regimens for infective endocrditis prophylxis 2 Ptient group Antibiotic Route Stndrd generl prophylxis for ptients t risk Adults Dose Children Timing before procedure Amoxicillin PO 2 g 50 mg/kg 1 hour Unble to tke orl mediction Allergic to penicillin/ moxicillin/mpicillin Ampicillin IV or IM 2 g 50 mg/kg Within 30 minutes Clindmycin PO 600 mg 20 mg/kg 1 hour Cephlexin or cephdroxil PO 2 g 50 mg/kg 1 hour Azithromycin or clrithromycin PO 500 mg 15 mg/kg 1 hour Allergic to penicillin/ moxicillin/mpicillin nd unble to tke orl medictions Clindmycin IV 600 mg 20 mg/kg Within 30 minutes Cefzolin IV 1 g 25 mg/kg Within 30 minutes Note: IV = intrvenous; PO = orl. Cephlosporins should not be used with penicillin or mpicillin in those with history of nphylxis, ngioedem or urticri. JCDA June 2007, Vol. 73, No

4 Epstein Tble 4 Recommendtions for infective endocrditis prophylxis regimen by the British Society for Antimicrobil Chemotherpy 3 Ptient group Antibiotic Route Dose ccording to ge of ptient; yers > < 5 Timing of dose before procedure Generl Amoxicillin PO 3 g 1.5 g 750 mg 1 hour Allergic to penicillin Clindmycin PO 600 mg 300 mg 150 mg 1 hour Allergic to penicillin nd unble to swllow cpsules Azithromycin PO 500 mg 300 mg 200 mg 1 hour IV regimen expedient Amoxicillin IV 1 g 500 mg 250 mg Just before the procedure or t induction of nesthesi IV regimen expedient nd llergic to penicillin Clindmycin IV 300 mg 150 mg 75 mg Just before the procedure or t induction of nesthesi Note: IV = intrvenous; PO = orl. Given over t lest 10 minutes before the dentl procedure. Preopertive mouth rinse my be used: chlorhexidine gluconte 0.2% (10 ml for 1 minute). Tble 5 British Society for Antimicrobil Chemotherpy recommendtions for infective endocrditis prophylxis for highest risk ptients (ptients with prosthetic hert vlves or previous infective endocrditis) 3 Age group; yers Antibiotic Route Dose After the procedure Adults nd children > 10 Amoxicillin nd IV 2 g 1 g PO or IV, 6 h fter procedure Children < 10 Adults nd children > 10 llergic to penicillin Children < 10 llergic to penicillin Amoxicillin nd Vncomycin nd Vncomycin nd IV 1 g 1 g PO IV 1 g None IV 20 mg/kg None Note: IV = intrvenous; PO = orl. 404 JCDA June 2007, Vol. 73, No. 5

5 Antibiotic Prophylxis THE AUTHORS Dr. Sroussi is ssistnt professor nd director of orl medicine, deprtment of orl medicine nd dignostic sciences nd Chicgo Cncer Center, University of Illinois, Chicgo, Illinois. Dr. Prbhu ws fellow, College of Dentistry, University of Illinois, Chicgo, Illinois. He is currently in privte prctice in Austrli. Dr. Epstein is professor nd hed, deprtment of orl medicine nd dignostic sciences, Chicgo Cncer Center, University of Illinois, Chicgo, Illinois. Correspondence to: Dr. Joel B. Epstein, Deprtment of Orl Medicine nd Dignostic Sciences, College of Dentistry, University of Illinois t Chicgo, 801 S. Pulin St., M/C 838, Chicgo, IL , USA. The views expressed re those of the uthors nd do not necessrily reflect the opinions or officil policies of the Cndin Dentl Assocition. References 1. Epstein JB, Chong S, Le ND. A survey of ntibiotic use in dentistry. J Am Dent Assoc 2000; 131(11): Wilson W, Tubert KA, Gewitz M, Lockhrt PB, Bddour LM, Levison M, nd others. Prevention of infective endocrditis. Guidelines from the Americn Hert Assocition. A Guideline From the Americn Hert Assocition Rheumtic Fever, Endocrditis, nd Kwski Disese Committee, Council on Crdiovsculr Disese in the Young, nd the Council on Clinicl Crdiology, Council on Crdiovsculr Surgery nd Anesthesi, nd the Qulity of Cre nd Outcomes Reserch Interdisciplinry Working Group. Circultion 2007; Apr 19 [Epub hed of print]. 3. Gould FK, Elliott TS, Fowerker J, Fulford M, Perry JD, Roberts GJ, nd others. Guidelines for the prevention of endocrditis: report of the Working Prty of the British Society for Antimicrobil Chemotherpy. J Antimicrob Chemother 2006; 57(6): Epstein JB. Infective endocrditis nd dentistry: outcome-bsed reserch. J Cn Dent Assoc 1999; 65(2): Roberts GJ, Rmsdle D, Lucs VS, British Crdic Society Working Group. Dentl spects of endocrditis prophylxis: new recommendtions from Working Group of the British Crdic Society Clinicl Prctice Committee nd Royl College of Physicins. London: Royl College of Surgeons of Englnd; Avilble from URL: (ccessed My 3, 2007). This rticle hs been peer reviewed. JCDA June 2007, Vol. 73, No

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