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Antibiotic Prophylaxis

for the Prevention of Infective Endocarditis

Risks to the dental patient

Treatment Planning for the At-Risk Patient

  • Complications of infective endocarditis:

    • Severe valvular dysfunction leading to heart failure and death

    • Myocardial infarction from emboli

    • Stroke from emboli

AHA 2007 Guidelines for Antibiotic Prophylaxis

High risk conditions and procedures for endocarditis

Antibiotic regimens recommended for prophylaxis

Other Methods to Decrease Bacteremia

  • Oral antimicrobial rinses (e.g., chlorhexidine, povidone-iodine) to reduce the frequency of bacteremia associated with dental procedures.

    •  Evidence shows that there is no clear benefit associated with its use.

  • The establishment and maintenance of optimal oral hygiene is the most effective way to decrease daily bacteremia

  • The antibiotic was inadvertantly not administered before the procedure

    • The dosage may be administered up to 2 hours after the procedure is completed

  • The patient is already taking penicillin or amoxicillin for eradication of an infection.  Resistance to these medications is likely.  

    • Clindamycin, azithromycin or clarithromycin should be used if prophylaxis is immediately necessary.  Cephalosporins exhibit cross-resistance and so should be avoided.

    • Or, wait at least 10 days after completion of antibiotic therapy.  The usual regimen can then be used.

  • The duration of the dental appointment is longer than 6 hours.

    • A second dose of the antibiotic should be administered.

  • How often can a patient requiring antibiotic prophylaxis be seen?

    • Every 10 days if the same antibiotic is to be used.  

  • What if a patient needs to be seen before this interval is up?

    • Use an alternate antibiotic

Special Conditions

 

  • A more aggressive strategy (i.e., extractions) for highly questionable teeth to reduce the bacterial load

  • The establishment and maintainence of optimal oral health and oral hygiene procedures is the most effective way to decrease the risk of endocarditis and other infections in at risk patients.

References

Dental Management of the Medically Compromised Patient.  Little, Falace, Miller and Rhodus. 8th Edition

J Andrade, E. Stadnick, A Mohamed. Infective endocarditis practice: An update for clinical practice. BCMJ 2008 50:8, 451-455.

 

Wilson W, et al. Journal of the American Dental Association.  (January 2008) 139:3S-24S.

 

Conditions for Which Antibiotic Prophylaxis is NOT Recommended

Antibiotic prophylaxis has been advocated for the patients with the following conditions when they undergo dental treatment.  However, no evidence of need or efficacy to prevent infections has been documented.

 

The following conditions/devices have NOT been found to be susceptible to distant site infection from bacteremia secondary to invasive dental treatment.  Antibiotic prophylaxis is NOT recommended

  • Chronic indwelling catheters of any kind

  • Renal dialysis arteriovenous shunt

  • Cerebrospinal fluid shunts

  • Vascular grafts

  • Orthopedic screws, plates or pins

  • Prosthetic joints

  • Implanted pacemaker or defibrillator

  • Coronary artery stents

  • Breast implants

  • Penile implants

  • Valvular dysfunction due to:

    • Previous use of fenfluramine and/or dexfenfluramine

    • IV drug use

    • Kawasaki disease

    • Hypertrophic cardiomyopathy

    • Systemic lupus erythematosus

 

The following conditions have NOT been found to cause increased susceptibility to dental/orofacial infection. Antibiotic prophylaxis is NOT recommended 

  • Immunosuppressive drugs (e.g., steroid therapy, chemotherapy, DMARDs)

  • Autoimmune disease (e.g., systemic lupus erythematosus, rheumatoid arthritis)

  • Insulin-dependent diabetes

  • HIV infection/AIDS

  • Splenectomy

  • Severe neutropenia

  • Sickle cell anemia

  • Head and neck radiotherapy

  • Solid organ transplants

  • Stem cell and bone marrow transplants

Assumptions behind the practice of antibiotic prophylaxis

  • Dental manipulation of oral tissues causes an abrupt increase of oral bacteria in the blood, lasting minutes to hours.

    • Dental procedures CAN cause bacteremias.  However, so can normal daily activities such as eating and oral hygiene procedures which could cause multiple bacteremias each day.  

  • This increase in bacterial loading can cause devastating infections systemically or to specific structures or devices.

    • No studies prove that the magnitude of bacteremia caused by dental procedures is higher than for daily activities. 

  • A large dose of antibiotics shortly before the dental procedure will counter the effects of this increase, and decrease the numbers of infections cause by this "transient bacteremia".

    • While studies have shown that amoxicillin reduces the bacteremia associated with dental procedures, there have been no studies that show the efficacy of antibiotic prophylaxis to prevent infective endocarditis or other distant infections in dental patients.

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