SUBACUTE BACTERIAL ENDOCARDITIS and ANTIMICROBIAL PROPHYLAXIS

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SUBACUTE BACTERIAL ENDOCARDITIS and ANTIMICROBIAL PROPHYLAXIS

  1. 1. SUBACUTE BACTERIAL ENDOCARDITIS and ANTIMICROBIAL PROPHYLAXIS <ul><li>LCDR Marc E. Arena </li></ul><ul><li>Comprehensive Dentistry </li></ul><ul><li>NPDS Bethesda, MD </li></ul>
  2. 2. The Root of All Evil
  3. 3. Infective Endocarditis <ul><li>Subacute Bacterial Endocarditis </li></ul><ul><li>microbial infection of heart valves or endocardium </li></ul><ul><li>infective endarteritis </li></ul>
  4. 4. Infective Endocarditis <ul><li>Subacute Bacterial Endocarditis </li></ul><ul><li>10-60 cases per million people per year </li></ul><ul><li>80% of cases from patients with predisposing conditions </li></ul>
  5. 5. Infective Endocarditis <ul><li>Causes </li></ul><ul><li>Rapid onset- </li></ul><ul><li>Staphylococcus Aureus </li></ul><ul><li>Insidious onset- </li></ul><ul><li>Streptococcus Viridans </li></ul>
  6. 6. Infective Endocarditis <ul><li>SYMPTOMS </li></ul><ul><li>Weakness </li></ul><ul><li>Fatigue </li></ul><ul><li>Weight loss </li></ul><ul><li>Fever </li></ul><ul><li>Chills </li></ul><ul><li>Night sweats </li></ul><ul><li>Anorexia </li></ul><ul><li>Arthralgia </li></ul>
  7. 7. Infective Endocarditis <ul><li>SIGNS </li></ul><ul><li>Petechial Hemorrhages </li></ul><ul><li>Linear Hemorrhages </li></ul><ul><li>Osler Nodes </li></ul><ul><li>Janeway Lesions </li></ul><ul><li>Retinal Hemorrhages </li></ul><ul><li>Heart Murmur </li></ul>
  8. 8. Infective Endocarditis <ul><li>Outcome </li></ul><ul><li>Fatal 10-70% of cases </li></ul>
  9. 9. Infective Endocarditis <ul><li>Complications </li></ul><ul><li>Reinfection </li></ul><ul><li>Congestive heart failure </li></ul><ul><li>Renal Disease </li></ul><ul><li>Cerebral Vascular Accident </li></ul>
  10. 10. Conspiracy Theories
  11. 11. Endocarditis and Dentistry <ul><li>Dental procedures produce a transient bacteremia: </li></ul><ul><li>Streptococcus Viridans </li></ul><ul><li>S. Mutans </li></ul><ul><li>S. Mitis </li></ul>
  12. 12. Endocarditis and Dentistry <ul><li>Risk of bacteremia from daily activities, </li></ul><ul><li>homecare & eating </li></ul><ul><li>1000 times greater than risk from dental treatment </li></ul><ul><li>Streptococcus Viridans </li></ul><ul><li>S. Mutans </li></ul><ul><li>S. Mitis </li></ul>
  13. 13. Endocarditis and Dentistry <ul><li>Documentation </li></ul><ul><li>Anecdotal evidence </li></ul><ul><li>In vitro studies </li></ul><ul><li>Double blind placebo study not likely </li></ul>
  14. 14. Ideal Antimicrobial Prophylaxis <ul><li>Benefits outweigh risks </li></ul><ul><li>Antibiotics in blood prior to bacterial dissemination </li></ul><ul><li>Loading dose </li></ul><ul><li>Antibiotics specifically effective </li></ul><ul><li>Antibiotics time specific </li></ul><ul><li>Cheap and easy to use </li></ul>
  15. 15. Antimicrobial Recommendations <ul><li>ADA/AHA (August 1997) </li></ul><ul><li>ADA/AAOS (July 1997) </li></ul>
  16. 16. Indications for Prophylaxis <ul><li>Cardiac Conditions </li></ul><ul><li>(table 1) </li></ul><ul><li>HIGH RISK </li></ul><ul><li>Prosthetic heart valves </li></ul><ul><li>Previous endocarditis </li></ul><ul><li>Congenital heart disease </li></ul><ul><li>Pulmonary shunts </li></ul>
  17. 17. Indications for Prophylaxis <ul><li>Cardiac Conditions </li></ul><ul><li>(table 1) </li></ul><ul><li>MODERATE RISK </li></ul><ul><li>Congenital cardiac malformations </li></ul><ul><li>Acquired valvar dysfunction </li></ul><ul><li>Hypertrophic cardiomyopathy </li></ul><ul><li>MVP with regurgitation </li></ul>
  18. 18. Indications for Prophylaxis <ul><li>OTHER CONDITIONS </li></ul><ul><li>Rheumatic heart disease </li></ul><ul><li>Systemic lupus erythematosus </li></ul><ul><li>Marfan’s Syndrome </li></ul><ul><li>Prior history of drugs to treat obesity </li></ul><ul><ul><li>Fenfluramine </li></ul></ul><ul><ul><li>Phentermine </li></ul></ul><ul><ul><li>Dex-fenfluramine </li></ul></ul>
  19. 19. Antimicrobial Prophylaxis Not Recommended <ul><li>Cardiac Conditions </li></ul><ul><li>Isolated secundum atrial septal defect </li></ul><ul><li>Repaired atrial septal defect, ventricular septal defect or patent ductus arteriousus </li></ul><ul><li>Previous CABG </li></ul><ul><li>MVP without valvar regurgitation </li></ul>
  20. 20. Antimicrobial Prophylaxis Not Recommended <ul><li>Cardiac Conditions </li></ul><ul><li>Physiologic, functional or innocent heart murmurs </li></ul><ul><li>Previous Kawasaki disease without valvar dysfunction </li></ul><ul><li>Previous Rheumatic fever without valvar dysfunction </li></ul><ul><li>Cardiac pacemakers and implanted defibrillators </li></ul>
  21. 21. Antimicrobial Prophylaxis Not Recommended <ul><li>Other than Cardiac Conditions </li></ul><ul><li>Neutropenic patient </li></ul><ul><li>Diabetic patient </li></ul><ul><li>Asplenic patient </li></ul><ul><li>End stage renal disease </li></ul><ul><li>Transplant patient </li></ul><ul><li>HIV patient </li></ul>
  22. 22. Antimicrobial Prophylaxis Not Recommended <ul><li>Other than Cardiac Conditions </li></ul><ul><li>Total joint replacement (after two years) </li></ul><ul><li>Other implanted devices </li></ul><ul><ul><li>Cerebrospinal fluid shunts </li></ul></ul><ul><ul><li>Intravascular access device </li></ul></ul><ul><ul><li>Penile implant </li></ul></ul><ul><ul><li>Breast implants </li></ul></ul><ul><ul><li>Intraocular implants </li></ul></ul>
  23. 23. Dental Procedures Associated with Bacteremias <ul><li>Periodontal Procedures </li></ul><ul><ul><li>surgery </li></ul></ul><ul><ul><li>scaling and root planing </li></ul></ul><ul><ul><li>probing and recall maintenance </li></ul></ul><ul><ul><li>subgingival placement of antibiotic fibers or strips </li></ul></ul><ul><ul><li>Prophylactic cleaning where bleeding is anticipated </li></ul></ul>
  24. 24. Dental Procedures Associated with Bacteremias <ul><li>Extractions </li></ul><ul><li>Implant placement </li></ul><ul><li>Reimplantation of avulsed teeth </li></ul><ul><li>Endodontics beyond the apex </li></ul><ul><li>Placement of orthodontic bands </li></ul><ul><li>Intraligamentary injections </li></ul>
  25. 25. Dental Procedures NOT Associated with Bacteremias <ul><li>Restorative dentistry </li></ul><ul><li>Local anesthetic injections </li></ul><ul><li>Intracanal endodontics and post placement </li></ul><ul><li>Rubber dams </li></ul><ul><li>Suture removal </li></ul>
  26. 26. Dental Procedures NOT Associated with Bacteremias <ul><li>Removal of prosthodontic or orthodontic appliances </li></ul><ul><li>Oral impressions </li></ul><ul><li>Fluoride treatments </li></ul><ul><li>Radiographs </li></ul><ul><li>Orthodontic appliance adjustment </li></ul><ul><li>Shedding of primary teeth </li></ul>
  27. 27. Antimicrobial Prophylaxis Regimens ADA/AHA <ul><li>Standard general prophylaxis: </li></ul><ul><li>Amoxicillin </li></ul><ul><li>Adults: 2.0 grams; Children: 50mg/kg orally 1 hour before procedure </li></ul>
  28. 28. Antimicrobial Prophylaxis Regimens ADA/AHA <ul><li>Unable to take oral medications: </li></ul><ul><li>Ampicillin </li></ul><ul><li>Adults: 2.0 grams IM or IV; Children: 50mg/kg IM or IV within 30 min before procedure </li></ul>
  29. 29. Antimicrobial Prophylaxis Regimens ADA/AHA <ul><li>Allergic to penicillin: </li></ul><ul><li>Clindamycin </li></ul><ul><li>Adults: 600mg; Children: 20mg/kg orally 1 hour before procedure </li></ul>
  30. 30. Antimicrobial Prophylaxis Regimens ADA/AHA <ul><li>Allergic to penicillin: </li></ul><ul><li>Cephalexin or cefadroxil </li></ul><ul><li>*not recommended for use in patients with immediate-type hypersensitivity to PCN </li></ul><ul><li>Adults: 2.0 grams; Children: 50mg/kg orally 1 hour before procedure </li></ul>
  31. 31. Antimicrobial Prophylaxis Regimens ADA/AHA <ul><li>Allergic to penicillin: </li></ul><ul><li>Azithromycin or clarithromycin </li></ul><ul><li>Adults: 500mg; Children: 15mg/kg orally 1 hour before procedure </li></ul>
  32. 32. Antimicrobial Prophylaxis Regimens ADA/AHA <ul><li>Allergic to penicillin and unable to take oral medications: </li></ul><ul><li>Clindamycin </li></ul><ul><li>Adults: 600mg; Children: 20mg/kg IV within 30 min before the procedure </li></ul>
  33. 33. Antimicrobial Prophylaxis Regimens ADA/AHA <ul><li>Allergic to penicillin and unable to take oral medications: </li></ul><ul><li>Cefazolin </li></ul><ul><li>* not recommended in patients with severe PCN allergy </li></ul><ul><li>Adults: 1.0gram; Children: 25mg/kg IV or IM within 30 min before the procedure </li></ul>
  34. 34. Antimicrobial Prophylaxis Regimens ADA/AAOS <ul><li>Not allergic to penicillin and able to take oral medications: </li></ul><ul><li>Cephalexin, cephradine or amoxicillin </li></ul><ul><li>Adults: 2.0grams orally 1 hour before the procedure </li></ul>
  35. 35. Antimicrobial Prophylaxis Regimens ADA/AAOS <ul><li>Not allergic to penicillin and unable to take oral medications: </li></ul><ul><li>Cefazolin </li></ul><ul><li>Ampicillin </li></ul><ul><li>Adults: 1.0gram IV or IM 1 hour before the procedure </li></ul><ul><li>Adults: 2.0grams IV or IM 1 hour before the procedure </li></ul>
  36. 36. Antimicrobial Prophylaxis Regimens ADA/AAOS <ul><li>Allergic to penicillin and able to take oral medications: </li></ul><ul><li>Clindamycin </li></ul><ul><li>Adults: 600mg orally 1 hour before the procedure </li></ul>
  37. 37. Antimicrobial Prophylaxis Regimens ADA/AAOS <ul><li>Allergic to penicillin and unable to take oral medications: </li></ul><ul><li>Clindamycin </li></ul><ul><li>Adults: 600mg IV 1 hour before the procedure </li></ul>
  38. 38. Recommendations <ul><li>Screen all patients </li></ul><ul><li>Excellent homecare </li></ul><ul><li>Homecare mastered before routine treatment </li></ul>
  39. 39. Recommendations <ul><li>Expeditious treatment </li></ul><ul><li>7-14 days between appointments </li></ul>
  40. 40. Recommendations <ul><li>Patients already taking antibiotics need a different antibiotic </li></ul><ul><li>Prerinse (not gingival irrigation) </li></ul><ul><li>Edentulous patients </li></ul>
  41. 41. Recommendations <ul><li>If unexpected bleeding occurs institute antibiotic prophylaxis within 2 hours! </li></ul>
  42. 42. HAVE YOU SEEN THIS MAN?

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