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Antibiotic prophylaxis for Infective Endocarditis: Deepak Chand, BPKIHS, Nepal
- 8. 1. Number of bacteria entering the blood 2. Ability of bacteria to adhere to endocardium 3. Host factors increasing susceptibility (Neutropenia, Immunodeficiency, Malignancy, DM, alcohol or IV drug abuse) 4. Surgical trauma and DENTAL EXTRACTIONS 5. Congenital heart defects (Bicuspid aortic valve,VSD, PDA) 6. Rheumatic and other valvular disease 7. Prosthetic heart valves 8. Other cardiac diseases
- 15. dental or other iatrogenic manipulation
- 17. Bacteremia 0-25% 25-50% 50-80% Dental procedures Scaling and root planing Periodontal prophylaxis Extraction of tooth Periodontal surgery Multiple tooth extractions Oral hygiene procedures Tooth brushing Use of interdental sticks Flossing Water irrigation Chewing
- 19. Sign & symptoms are highly variable 3 or 4 weeks after dental operation, there is insidious onset of low fever and a mild malaise Pallor or light pigmentation of the skin, joint pains and Hepatosplenomegaly are typical Progressive heart damage Infection or embolic disease of many organs, especially the kidneys
- 21. SPLINTER HEMORRHAGE JANEWAY LESIONS ROTH’S SPOT OSLER’S NODE SUBCONJUCTIVAL HEMORRHAGE
- 22. 1.To confirm the diagnosis 1)Blood Cultures
- 25. REJECTED
- 27. chance of dental extractions causing IE in a patient with valvular disease 1 in 3000
- 28. • Death from anaphylaxis to antibiotics are possibly 5 to 6 times more likely than death from IE
- 30. no evidence for the need for procedures that do not induce bleeding
- 31. Identification of patients at risk Planned preventive dental care Deciding which treatments require antimicrobial cover Appropriate antibiotics at appropriate time
- 34. Risk of infective endocarditis after dental treatment
- 39. Dental radiography Endodontics not beyond apex Exfoliation of primary teeth Impression making Non surgical procedure that don’t induce bleeding Abscess incision and drainage Suture removal Orthodontic band removal Biopsy ?????
- 41. Recommending authority Regimen UK: British society for Antimicrobial Chemotherapy (1992) A. Amoxicillin:3g 1h before treatment B. Clindamycin:600mg 1h before treatment EUROPEANCONSENSUS (1995) A. Amoxicillin:3g 1h before treatment B. Clindamycin:300-600mg 1h before treatment American Heart Association (1997) A. Amoxicillin:2g 1h before treatment B. Clindamycin:300-600mg 1h before treatment
- 42. Situation Agent Regimen—Single Dose 30-60 minutes before procedure Adult Children Oral Amoxicillin 2 g 50 mg/kg Unable to take oral medication Ampicillin or 2 g IM or IV* 50 mg/kg IM or IVCefazolin or Ceftriaxone 1 g IM or IV 50 mg/kg IM or IV Allergic to Penicillin or Ampicillin— Oral regimen Cephalexin or 2g 50mg/kg Clindamycin or 600mg 20mg/kg Azithromycin or Clarithromycin 500mg 15mg/kg Allergic to Penicillin or Ampicillin and unable to take oral medication Cefazolin or Ceftriaxone 1 g IM or IV 50 mg/kg IM or IV OR Clindamycin 600 mg IM or IV 20 mg/kg IM or IV *Adapted from Prevention of Infective Endocarditis:Guidelines From the American Heart Association, by theCommittee on Rheumatic Fever, Endocarditis, and Kawasaki Disease. Circulation, 2007
- 43. CLINICAL SITUATION DRUG REGIMEN Patient not allergic to penicillinOR pt. who have not received more than a single dose of penicillin in the previous month. Amoxicillin Adults Oral amoxicillin 3g administered 1h before the procedure Children <5yrs:oral amoxicillin 250mg 1hr before procedure. 5-10 yrs:Oral amoxicillin 500mg administered 1h before the procedure >10yrs:use adult dose
- 44. CLINICAL SITUATION DRUG REGIMEN Patient allergic to penicillinOR pt. who have had received more than a single dose of penicillin in the previous month. Clindamycin Adults Oral clindamycin 600mg administered 1h before the procedure Children <5yrs:oral clindamycin 150mg 1hr before procedure. 5-10 yrs:Oral clindamycin 300mg administered 1h before the procedure >10yrs:use adult dose
- 45. CLINICAL SITUATION DRUG REGIMEN The oral suspension of clindamycin is no longer available in UK. If children are unwilling or unable to swallow tablets or capsules, or pt are suffering with dysphagia,then azithromycin is suitable option. Azithromycin (as a suspension) Adults 500mg administered 1h before the procedure Children <5yrs:oral azithromycin 200mg 1hr before procedure. 5-10 yrs:Oral azithromycin 300mg administered 1h before the procedure >10yrs:use adult dose
- 46. CLINICAL SITUATION DRUG REGIMEN Patient not allergic to penicillinOR pt. who have not received more than a single dose of penicillin in the previous month. Amoxicillin Or Ampicillin Adults i.v.amoxicillin 2 g administered upon attainment of GA and immediately before procedure Children <5yrs:i.v.amoxicillin 250mg administered upon attainment of GA and immediately before procedure. 5-10 yrs:i.v.amoxicillin 500mg administered upon attainment of GA and immediately before procedure >10yrs:use adult dose
- 47. CLINICAL SITUATION DRUG REGIMEN Patient allergic to penicillin OR Patient who have had received more than a single dose of penicillin in the previous month. Clindamycin Adults i.v.clindamycin 300mg infused over at least 10 minutes upon attainment of GA and commenced before the start of dental surgery.This is followed by oral or i.v clindamycin 150mg 6 hrs later. Children <5yrs:i.v. clindamycin 75 mg infused over at least 10 minutes upon attainment of GA and commenced before the start of dental surgery. 5-10 yrs:i.v. clindamycin 150 mg infused over at least 10 minutes upon attainment of GA and commenced before the start of dental surgery. >10yrs:use adult dose
- 48. CLINICAL SITUATION DRUG REGIMEN For those at highest risk; prosthetic heart valve OR previous IE Amoxicillin Gentamycin Adults i.v. amoxicillin 2 g within the 30 mins before the procedure plus i.v.gentamicin 1.5 mg/kg within the same time period Followed postoperatively by oral amoxicillin 1g or i.v.amoxicillin 1g at 6 hrs post procedure Children <5YRS as for<10YRS. I.V. Amoxicillin 1 g within the 30 mins before the procedure plus i.v. gentamycin 1.5mg/kg within the same time period. Followed post operatively by oral amoxicillin at 6 hrs post-procedure
- 49. CLINICAL SITUATION DRUG REGIMEN For those at highest risk; prosthetic heart valve or previous IE For patients allergic to penicillin Vancomycin Gentamycin Adults i.v.Vancomycin 1 g infused over the 2 hrs before the procedure plus i.v.gentamicin 1.5 mg/kg within the same time period Children <5YRS as for<10YRS. i.v.Vancomycin 20mg/kg infused over the 2 hr before the procedure plus i.v. gentamycin 1.5mg/kg within the same time period. Followed post operatively by oral amoxicillin at 6 hrs post-procedure
- 50. 10% Povidone-Iodine or 0.5% Chlorhexidine gel Chlorhexidine 0.2% mouthwash • Good dental health
- 52. warning card • If multiple visits are unavoidable at least 9-14 days
- 53. antibiotics must be given before extractions ,scaling and surgery involving the periodontal tissues with a recognized predisposing cardiac disorder.
- 54. Multiple visits for treatment using local anesthesia a period of 1 month should elapse amoxicillin one visit clindamycin clarithromycin next visit
- 57. congenital heart defect, immune deficiencies gross plaque accumulation periodontal disease don’t appear to be particularly susceptible to IE.
- 58. keep periodontal infection at its lowest possible level
- 60. EXTRACTIONS, SCALING AND SURGERY INVOLVINGTHE PERIODONTALTISSUES
- 63. Q. Which of the following patients would NOT need endocarditis prophylaxis? A. Patient with previous IE B. Patient with prosthetic cardiac valves C. Pulmonary stenosis D. Surgically conducted systemic –pulmonary shunts.
- 64. Q. What is the prevalence of bacteremia after a single tooth extraction? A. 10-15% B. 25-50% C. 50-80% D. 80-100%
- 65. Q. In which of the following dental procedure endocarditis prophylaxis is not recommended? A. Sub gingival procedures B. Sialography C. Endodontic beyond the root apex D. Abscess incision and drainage
- 66. A. Pyrexia B. Embolic phenomenon C. New valvular regurgitations D. Intravenous drug misuse
- 67. Q. DRUG REGIMEN OF: Amoxicillin:2g 1h before treatment Clindamycin:300-600mg 1h before treatment WAS GIVEN BY? A. UK: British Society for Antimicrobial Chemotherapy (1992) B. EUROPEAN CONSENSUS (1995) C. American Heart Association (1997) D. None of the above.
Editor's Notes
- Experience in the pre-penicillin era showed that, even patients with established rheumatic heart disease, IE only rarely followed dental extractions. It is clear now that a few healthy patient probably less than 5 %acquire IE as a result of dental treatment, as shown by large surveys and increasing varieties of non dental causes of bacteremia.