SBE prophylaxis-From Pairodocs-Laura

[PairoDocs]

There have been some changes in the guidelines. Here are the new ones:

Table 1. Cardiac Conditions for Which Prophylaxis with Dental Procedures is Recommended

Cardiac valvulopathy in a cardiac transplant recipient

Congenital heart disease*

Congenital heart defect completely repaired within the previous six months with prosthetic material or device, whether placed by surgery or by catheter†

Repaired congenital heart disease with residual defects at the site or adjacent to the site of a prosthetic patch or device (which inhibit endothelialization)

Unrepaired cyanotic congenital heart disease, including palliative shunts and conduits

Previous infective endocarditis

Prosthetic cardiac valve

*-Except for the conditions listed, antibiotic prophylaxis is no longer recommended for patients with any other form of congenital heart disease.

†-Prophylaxis is recommended because endothelialization of prosthetic material occurs within six months after the procedure.

Adapted with permission from Wilson W, Taubert KA, Gewitz M, et al.; for the American Heart Association Rheumatic Fever, Endocarditis and Kawasaki Disease Committee; Council on Cardiovascular Disease in the Young; Council on Clinical Cardiology; the Council on Cardiovascular Surgery and Anesthesia; and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Prevention of infective endocarditis [published correction appears in Circulation. 2007;116(15):e376-377]. Circulation. 2007;116(15):1745.


Table 2. Antibiotic Regimens for Patients at High Risk of Infective Endocarditis Undergoing Dental Procedures

Route of administration
Agent
Dosage

Adults
Children

IM or IV
Ampicillin

or cefazolin (Ancef, brand not available in the United States) or ceftriaxone (Rocephin)
2 g IM or IV
50 mg per kg IM or IV

1 g IM or IV
50 mg per kg IM or IV

IV or IM (in patients allergic to penicillin or ampicillin)
Cefazolin or ceftriaxone*

or clindamycin (Cleocin)
1 g IM or IV
50 mg per kg IM or IV

600 mg IM or IV
20 mg per kg IM or IV

Oral
Amoxicillin
2 g
50 mg per kg

Oral (in patients allergic to penicillin or ampicillin)
Cephalexin (Keflex)*†

or clindamycin

or azithromycin (Zithromax) or clarithromycin (Biaxin)
2 g
50 mg per kg

600 mg
20 mg per kg

500 mg
15 mg per kg

IM = intramuscularly; IV = intravenously.

*-Cephalosporins should not be used in patients with a history of anaphylaxis, angioedema, or urticaria after taking penicillin or ampicillin.

†-Or other first- or second-generation oral cephalosporin in equivalent adult or pediatric dosage.

Adapted with permission from Wilson W, Taubert KA, Gewitz M, et al.; for the American Heart Association Rheumatic Fever, Endocarditis and Kawasaki Disease Committee; Council on Cardiovascular Disease in the Young; Council on Clinical Cardiology; the Council on Cardiovascular Surgery and Anesthesia; and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Prevention of infective endocarditis [published correction appears in Circulation. 2007;116(15):e376-377]. Circulation. 2007;116(15):1747.

Table 3. Summary of Major Changes in the Updated AHA Guidelines for Prevention of Infective Endocarditis
Antibiotic prophylaxis is no longer recommended for patients with any form of congenital heart disease except those listed in Table 1

Antibiotic prophylaxis is not recommended based solely on an increased lifetime risk of infective endocarditis

Antibiotic prophylaxis is recommended only for patients with conditions listed in Table 1 who are undergoing dental procedures that involve manipulation of gingival tissues or periapical region of teeth, or perforation of the oral mucosa

Antibiotic prophylaxis is recommended only for patients with conditions listed in Table 1 who are undergoing procedures on the respiratory tract or infected skin, skin structures, or musculoskeletal tissue

Antibiotic prophylaxis solely to prevent infective endocarditis is not recommended for patients undergoing gastrointestinal or genitourinary tract procedures

Prophylaxis for infective endocarditis is not recommended in patients undergoing ear or body piercing, tattooing, vaginal delivery, or hysterectomy

Recommendations for prophylaxis of infective endocarditis should be limited to patients with conditions listed in Table 1

AHA = American Heart Association.

Adapted with permission from Wilson W, Taubert KA, Gewitz M, et al.; for the American Heart Association Rheumatic Fever, Endocarditis and Kawasaki Disease Committee; Council on Cardiovascular Disease in the Young; Council on Clinical Cardiology; the Council on Cardiovascular Surgery and Anesthesia; and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Prevention of infective endocarditis [published correction appears in Circulation. 2007;116(15):e376-377]. Circulation. 2007;116(15):1748.


Sorry if these tables didn't print out exactly. Most of the people in this forum with valve disease need prophylaxis for dental procedures, but not for many other procedures. These are the new AHA guidelines which were reprinted in the February 2008 issue of American Family Physician. There was also mention in the article about waiting 10 days after finishing a course of antibiotics to allow normal flora to re-establish itself. If one is taking antibiotics long-term (this was not defined), prophylaxis with an antibiotic in a different class is recommended, except for cephalosporins. AND, there was no mention of a need to separate dental procedures by 14 days as there was previously. If the pre-procedure dose gets missed, you can take it up to 2 hours after the procedure.

The reason for all this? Chris had to have some dental work done today. Of course, we forgot to ask the dentist to call in for his antibiotics, so I had to do it. He was badly in need of a cleaning, too, because the prolonged intubation he had caused some receding of his gums despite the most excellent care he got to prevent this. He did not and does not have any gingivitis, however. He also broke a couple of teeth recently, and so has to go back for more work, which, supposedly will not involve gingival manipulation.

The AHA still does not know if SBE prophylaxis does any real good! They have found that routine daily activites such as flossing, tooth brushing, chewing, and even using a toothpick are more risky than most dental procedures since they regularly increase the microflora, and now place their emphasis on good dental hygeine, oral care regimens, access to dental care, and avoidance of things that can cause problems with gums and teeth, such as smoking.

Poor dentition and gingival disease may be the single greatest enemy we have in the health care field! It causes preterm labor, low birth weight babies, heart disease, respiratory disease, and sepsis! Who knew? (except for maybe my mom, because she made us bike the 3 miles to the dentist when we had no health insurance because it was "important"). I am very grateful to the dentist who cared for us as children, because he only charged $10 for a visit and cleaning. He explained that we never pulled up in Mercedes as some of his patients did and stated that we couldn't pay our bills. He understood that it was important for our overall health to get good dental care, so he gave us a break.

Sorry this post was so long. I'll let Chris tell you about his visit, which ended up being 3 hours long!

Better Day in Idaho,
-Laura

 

[Lynlw]

I'm a little confused are these the changes that were made last year and reprinted in 2/08 or are there changes since last years new guidelines?

 

[PairoDocs]

Last year's changes reprinted for us dummies; also, backed up by more research.

Pleasant in Idaho,
-Laura

 

[Lynlw]

Ok thanks, I learned something tho, I don't remember seeing they don't recomend antibiotics for tattoos and ear piercing before, that is interesting

 

[KristyW]

Ok thanks, I learned something tho, I don't remember seeing they don't recomend antibiotics for tattoos and ear piercing before, that is interesting

Lyn,

I'm not sure that it was ever in the protocol for tattoos and piercings, but there are those who will "extrapolate" and say that any "incusion" under the skin would require antibiotics. I think (and I may be wrong) that this statement was included to clear up any possible misunderstandings.

Remember that if the valve is not one you were born with...it's artificial and the protocols apply.

 

[Lynlw]

Lyn,

I'm not sure that it was ever in the protocol for tattoos and piercings, but there are those who will "extrapolate" and say that any "incusion" under the skin would require antibiotics. I think (and I may be wrong) that this statement was included to clear up any possible misunderstandings.

Remember that if the valve is not one you were born with...it's artificial and the protocols apply.

Justin meets the criteria for several ways, I think he will/would be one of the ones listed til the very end. which in a way makes it easier then others that have to figure it out, convince their dentist ect

 

[hall]

Good information, thank you for the post.

Deb

 

[KristyW]

If the pre-procedure dose gets missed, you can take it up to 2 hours after the procedure.

Laura

Hey Laura,

Is this statement in the article? As the front desk person in a small dentists office, there are times when our patients forget their premeds and we reschedule. If I can find this reference that it's ok to take when they get here or when they get home...that would be great!.

 

[PairoDocs]

Is this statement in the article? As the front desk person in a small dentists office, there are times when our patients forget their premeds and we reschedule. If I can find this reference that it's ok to take when they get here or when they get home...that would be great!.

Yes, it was in in the article. If the procedure took longer than 2 hours, however, I'm not sure. I have tried to email this article to another person, but not successfully. If you have access to a medical library, they may be able to get you a copy.

Hazy but pleasant in Idaho,
-Laura

 

[tobagotwo]

This is a good reposting of what Nancy had brought up in May of 2007. Due to the number of recent inquiries, it was time for it again. http://www.valvereplacement.com/forums/showthread.php?p=242882&highlight=dental#post242882

The reasons for the guidelines change were posted in Table 2 of the doctors' report:

TABLE 2. Primary Reasons for Revision of the IE Prophylaxis 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, GI tract, or GU tract procedure.

Prophylaxis may prevent an exceedingly small number of cases of IE, if any, in individuals who undergo a dental, GI tract, or GU tract procedure.

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 to reduce the risk of IE.

Thirty two doctors from some of America's most famous facilities and universities (including the Mayo Clinic and Boston's Brigham and Womens), researching 153 major studies, spanning thousands of patients and over fifty years of medical records agree on this point.

In the results of the study, they aren't saying dental work may not on rare occasions cause bacterial endocarditis. They say that they found no evidence that prophylactic antibiotics prevent it from happening.

I have reposted the part of the old guidelines that was descriptive of procedures several times since the change, because the new statement seems vague to most people.

Antibiotic prophylaxis is recommended only for patients with... [a replaced valve (RDH)] ...who are undergoing dental procedures that involve manipulation of gingival tissues or periapical region of teeth, or perforation of the oral mucosa

The basic interpretation is that if the gum is not expected to be broken, and there is no work being done below the gum line, there is no reason for predosing with antibiotics. That would include most fillings, caps, and similar above-gum repair activities. The off chance that your dentist might miss with an implement and poke your gum is not given as reason for antibiotic prophylaxis (you stand the same possibility with your own toothbrush at home).

By the same token, dental cleanings, gum work, root canal, and extractions would be considered intrusive to the gums, or a reasonable cause for bleeding, so the antibiotics would still be taken for those procedures.

Best wishes,

 

[pamela]

I don't know if this link will work but I'll quote the paragraph of interest wrt the two hour limit as well http://circ.ahajournals.org/cgi/content/full/116/15/1736#TBL3183095

General Principles
An antibiotic for prophylaxis should be administered in a single dose before the procedure. If the dosage of antibiotic is inadvertently not administered before the procedure, the dosage may be administered up to 2 hours after the procedure. However, administration of the dosage after the procedure should be considered only when the patient did not receive the pre-procedure dose. Some patients who are scheduled for an invasive procedure may have a coincidental endocarditis. The presence of fever or other manifestations of systemic infection should alert the provider to the possibility of IE. In these circumstances, it is important to obtain blood cultures and other relevant tests before administration of antibiotics intended to prevent IE. Failure to do so may result in delay in diagnosis or treatment of a concomitant case of IE.

 

[Susan BAV]

I found this bit interesting:

"Prophylaxis for infective endocarditis is not recommended in patients undergoing ear or body piercing, tattooing, vaginal delivery, or hysterectomy..."

I had IV antibiotics following a hysterectomy. I had always read [somewhere, but where?] that it was important to do so. Is that part of the guideline's new/changed information?

 

[PairoDocs]

I found this bit interesting:

"Prophylaxis for infective endocarditis is not recommended in patients undergoing ear or body piercing, tattooing, vaginal delivery, or hysterectomy..."

I had IV antibiotics following a hysterectomy. I had always read [somewhere, but where?] that it was important to do so. Is that part of the guideline's new/changed information?

Most surgeons give a dose of IV antibiotics following certain surgeries or during the surgery, and that includes hysterectomy of any type. The reason? It's obviously more difficult to completely clean the vagina, both because of anatomy and because of its location. It is not usually for SBE prophylaxis, since everyone gets the dose, not only cardiac patients. The same goes for C-sections, since there is frequent exposure to vaginal flora. Once again, I don't know all the statistics regarding success in preventing infection. Yes, it is also part of the changed information, though.

Hot and stifling in Idaho,
-Laura