Monday, April 30, 2007

Updated AHA recommendations state that use of antibiotics prior to dental procedures rarely needed
by Julie McKeel

Chris Cabell

A recent update to the recommendations by the American Heart Association (AHA) for the prevention of infective endocarditis was issued this week by the American Heart Association (AHA) and published in the April 19, 2007 online issue of Circulation. [These recommendations were last published in 1997.] The update states that giving antibiotics to patients prior to dental procedures is unlikely to prevent many cases of infective endocarditis [inflammation of the lining of the heart and its valves].

The AHA appointed a writing group whose members have expertise in prevention and treatment of infective endocarditis. This group, along with members representing the American Dental Association, the Infectious Diseases Society of America, and the American Academy of Pediatrics, were instructed to review the original recommendations and make appropriate updates. The guidelines' writing group, which included the DCRI's Dr. Chris Cabell, concluded that the use of prophylactic (preventive) antibiotics should be restricted to patients at risk for infection, such as those with prosthetic valves or certain congenital heart defects.

According to the writing group, there was no evidence that the use of prophylactic antibiotics work, thus the use should be reserved only for those people who would have the worst outcomes if they get infective endocarditis. As stated in the press release, this newest update changes the whole philosophy of how researchers have constructed these recommendations for the past 50 years.

Based on an analysis of available literature and input from national and international experts on infective endocarditis, the writing group concluded that "random bacteremia" resulting from routine daily activities, such as chewing food or tooth brushing, is far more likely to cause infective endocarditis than bacteremia secondary to dental procedures.

The updated guidelines recommend greater emphasis on improved access to dental care and oral health in patients with underlying cardiac conditions that carry the highest risk of adverse outcome from infective endocarditis.

According to the report, preventive antibiotics are recommended for high-risk patients undergoing "procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa." Such "high-risk" patients include recipients of cardiac transplants who develop cardiac valvulopathy as well as patients with:

• Prior infective endocarditis.
• Prosthetic cardiac valves.
• Unrepaired cyanotic congenital heart defects, including palliative shunts and conduits.
• Congenital heart defects completely repaired with prosthetic material or a device, whether placed by surgery or by catheter intervention, during the first six months after the procedure.
• Repaired congenital defects with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device.

Preventive antibiotics are no longer appropriate for patients with mitral and aortic valve disease, rheumatic heart disease, or structural disorders like ventricular or atrial septal defects or hypertrophic cardiomyopathy, according to the AHA statement.

The revised guidelines were developed with the participation of and have been endorsed by the American Dental Association, the Infectious Diseases Society of America, and the American Academy of Pediatrics.