ada guidelines.pdf
TRANSCRIPT
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Guidelines for
Antibiotic Prophylaxis
Rachel Miller, M.D.Clinical Professor
Dept. of Internal Medicine
April 27, 2012
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Areas of Focus
Antibiotic prophylaxis forinfective endocarditis
Antibiotic prophylaxis forindividuals withprosthetic joints
Antibiotic use for open
wounds
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Objectives
Review and apply the new AHA practice guidelines forthe prevention of infective endocarditis.
Discuss the current recommendations for the preventionof prosthetic joint infections.
Identify the risk factors for infection after traumatic skinlacerations and the scenarios where antibioticprophylaxis is indicated.
Evaluate the risk of administering prophylactic antibioticsvs. the scientific evidence for benefit into clinicaldecision-making.
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Guidelines for the Prevention ofInfective Endocarditis
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Theoretical Basis for
Endocarditis ProphylaxisPathogenesis of endocarditis:
Formation of non-infected thrombus on an abnormalendothelial surface
Secondary infection of this thrombus occurs during
transient bacteremia with bacterial adherence Proliferation of bacteria within thrombus with vegetation
formation
Prevention/prompt tx of transient bacteremiainterrupts this sequence
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The History of Antibiotic Prophylaxis
to Prevent Endocarditis
1930: Antibiotic prophylaxis for IE becomes standardpractice
1955: 1stAHA document on IE prophylaxis
19901984
1977 Several iterations of AHA guidelines documents19721965
1957
2007: Newest revision by AHA in conjunction with ADA,IDSA, AAP
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Time for a Change.
Rationale for change:
Only an extremely small # of cases may be prevented byantibiotic prophylaxis, even if it was 100% protective
IE is more likely to result from frequent exposure to randombacteremias associated with daily activities.
Antibiotic-associated adverse effects exceed the benefits ofprophylaxis
PRACTICE GUIDELINE: FOCUSED UPDATE
ACC/AHA 2008 Guideline Update on Valvular Heart Disease:
Focused Update on Infective Endocarditis
A Report of the American College of Cardiology/American Heart Association
Task Force on Practice Guidelines
Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular
Angiography and Interventions, and Society of Thoracic Surgeons
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Does antibiotic prophylaxis really
prevent endocarditis?
It does in animal models of valvular heartdisease with induced bacteremia.
It can reduce bacteremia associated with dentalprocedures.
No study in humans has definitively
demonstrated IE prevention after invasiveprocedures.
Prophylaxis failures occur.
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Bacteremia is a Common
Occurrence in Daily LifeIncidence of bacteremia after various procedures
Dental extraction 18-85% Chewing 32-88%
Tooth brushing 20-40%
(higher if sonicating) EGD 8-12%
Colonoscopy 0-10%
Urethral dilatation 18-33% Urethral catheterization 8%
Nasotracheal suctioning 16%
Estimated 5370 min (~90 hrs) of bacteremia/mo in dentulouspersons who chew and practice standard oral hygiene
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Estimated Endocarditis Risk
Associated with Dental Procedures
Underlying Heart Dx
# Dental Procedures/
1 Case of Endocarditis
None 14 million
Congenital Heart Dx 475,000
Rheumatic Heart Dx 142,000
Prosthetic Heart Valve 114,000
Previous Endocarditis 95,000
AHA Guidelines, Circulation, May 2007
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the focus on the frequency of bacteremia
associated with a specific dental procedure and theAHA guidelines for prevention of IE have resulted inan overemphasis on antibiotic prophylaxis and an
under-emphasis on maintenance of good oralhygiene and access to routine dental care, whichare likely more important in reducing the lifetime riskof IE than the administration of antibiotic prophylaxisfor a dental procedure.
AHA Guidelines, Circulation, May 2007
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The Major Changes in the
Updated AHA Guidelines
Prophylaxis is aimed at those at highest risk foran adverse outcome of IE, rather than solelybased on an increased lifetime risk of IE.
Significant simplification of conditions andprocedures that warrant prophylaxis.
Overall, more evidence based, rather than
opinion based.
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Conditions of Highest Risk
Included
Prosthetic heart valves
Prior endocarditis
Cyanotic heart disease Unrepaired
Repaired congenital heartdx with prosthetic materialor device x6 mo
Repaired with residual
defects Heart transplant with
valvulopathy
Not included
Bicuspid aortic valve
Acquired aortic or mitralvalve disease MVP with regurgitation
Prior valve repair Hypertrophic
cardiomyopathy with
latent or restingobstruction
AHA Guidelines, Circulation, May 2007
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Procedures Warranting Antibiotic
Prophylaxis to Prevent IEDental Procedures:
All dental procedures that
involve manipulation ofgingival tissue, periapicalregion of the teeth, orperforation of the oral
mucosa.
Dental extractions
Periodontal procedures Endodontic instrumentation
Prophylactic cleaning
Initial placement of orthodontic
bands (not brackets)
Respiratory procedures: Procedures involving
incision/ biopsy of themucosa
Removal of tonsils/adenoids
TBBX but NOTbronchoscopy only
GU procedures:
ONLY during activeenterococcal infection
GI procedures:
NO LONGER INCLUDED
AHA Guidelines, Circulation, May 2007
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IE Prophylaxis Regimens
for Dental ProceduresSituation Agent Adults* Children*
Oral Amoxicillin 2 g 50 mg/kg
Unable to takeoral meds
Ampicillin
Cefazolin orCeftriaxone
2 gm IM/IV
1 gm IM/IV
50 mg/kg IM/IVfor all
PCN Allergy-
oral
Cephalexin
Clindamycin
Azithromycin
2 gm
600 mg
500 mg
50 mg/kg
20 mg/kg
15 mg/kgPCN Allergy-unable to takeoral meds
Cefazolin orCeftriaxone
Clindamycin
1 gm IM/IV
600 mg IM/IV
50 mg/kg IM/IV
20 mg/kg IM/IV
* Single dose given 30-60 min before procedure
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Endocarditis and Pharyngitis
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Should patients with valvular heart disease and
pharyngitis be treated more readily with antibiotics?Proposed rationale #1:
Streptococci are a common cause of IE, thusantibiotic therapy will prevent bacteremia andsubsequent IE.
The Facts: Streptococci account for 60-80% of IE cases
Group A Streptococci (GAS) IE is extremely rare
Ratio of IE to non-IE bacteremia cases for GAS is 1:32
Conclusion: Persons with pharyngitis and valvular heart dxdo not require Abx tx on the basis of preventing GAS IE.
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Should patients with valvular heart disease andpharyngitis be treated more readily with antibiotics?
Proposed rationale #2:
Streptococcal pharyngitis can predispose to rheumatic
fever and subsequent rheumatic heart disease, which maymake underlying valvular disease worse.
The facts:
GAS pharyngitis is a known trigger of rheumatic fever (RF) Recurrent GAS pharyngitis can lead to recurrent episodes of RF
and eventual valvular heart disease (
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Infective Endocarditis Prophylaxis
Summary of Major Points Only an extremely small # of IE cases will likely
be prevented by antibiotic prophylaxis forprocedures (dental).
The latest AHA guidelines have significantlytrimmed the indications for antibiotic prophylaxis.
The treatment approach to GAS pharyngitisshould not be altered on the basis on underlyingvalvular heart disease.
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Antibiotic Prophylaxis for Patients
with Total Joint Replacements
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The Clinical Landscape
More than 750,000 total joint arthroplasties doneannually in the US
As the US population ages, demand is expected to riseby 200-600% over the next 25 yrs
Prosthetic joint infections (PJIs) cause significant
morbidity and mortality
Attributable cost of a single PJI episode is 3-4x the cost
of the primary arthroplasty (usually >$50,000)
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The Gray Zone of Antibiotic
Prophylaxis to Prevent PJIs
Purposefully omittedfrom AHA IE preventionguidelines
The analogy of PJIswith IE is invalid
No convincing evidencethat prophylaxis duringdental procedures
prevents PJIs
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Advisory Statement of the
ADA and AAOS Oral bacteremias induced by daily events are
more common than dental-treatment induced
Critical period for PJI is up to 2 yrs after surgery
No prophylaxis is needed for patients with pins,screws and plates
Good dental health PRIOR to joint replacementhighly encouraged
JADA 134:895, 2003
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Summarized Recommendations from
the ADA/ AAOS Advisory Statement
Antibiotic prophylaxis is not routinely indicated for most
dental patients with TJRs. However, it is advisable toconsider pre-medication in a small number of patientswho may be at potential increased risk.*
JADA 134:895, 2003
High risk ~
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.but the debate continued.
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2009 Information Statement from
AAOS safety committee
http://www.aaos.org/about/papers/advistmt/1033.asp
Prior 2 yr designation now removed
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Dental Procedures & PJIs
Counterpoint #1 Study Design:
Single center, prospective case-control study of 339 inpatients
w/wo hip or knee PJI from 2001-2006 at the Mayo Clinic Findings:
No
risk of PJIs in pts undergoing high or low risk dental
procedures without antibiotic prophylaxis
Antibiotic prophylaxis did not
the risk of PJIs
No difference with subset analysis of PJIs of potential dental/oralorigin
Trend toward
PJIs in pts with >1 dental hygiene visit
Conclusions: Data refute the AAOS recommendation of universal antibiotic
prophylaxis for dental procedures in pts with arthroplasties
Berbari EF, Clin Inf Dis 50:8, 2010
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Dental Procedures & PJIs
Counterpoint #2 Study Design:
Data from Medicare Current Beneficiary Survey (1997-2006)
1000 participants with JR, identified those with PJI (42 pts) andcompared them with matched controls
Findings:
No association between dental procedures and PJIs in eithertime-to-event analysis nor the case-control analysis
Trend toward more dental procedures in preceding 90 days incontrol pts than those with PJIs
Conclusions: Dental procedures not associated with a higher risk of PJIs
The 2009 AAOS Information Statement should be reconsidered
Skaar DD, JADA 142:1343, 2011
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The Final Recommendations
Remain Gray.
Not intended as standard of care or substitute for clinicaljudgment.
Practitioners must exercise their own clinical judgmentin determining whether or not antibiotic prophylaxis isappropriate.
JADA 134:895, 2003
http://www.aaos.org/about/papers/advistmt/1033.asp
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Antibiotic Prophylaxis for
Traumatic Lacerations & Open Wounds
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Background
Lacerations and open wounds are the 3rd mostcommonly encountered problems in the ED
Account for 8% of the 95 million ED visits in US/ year
Variable risk of infection depending on type of injury
Incised, puncture, bites, abrasions
Common Goals of Treatment: Avoiding infection Optimal functional and cosmetic result
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General Principles of Initial
Traumatic Wound Management Wound cleansing
Use tap water or normal salineFor contaminated wounds, use pressure irrigation
Keep the wound moist
Topical antimicrobial agents
Cover with an occlusive dressing
Ascertain tetanus immunization status
Dire DJ,Acad Emer Med 2:4, 1995Singer AJ, NEJM 359:10, 2008
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Risk Factors for Infection in Patients
with Traumatic Lacerations Study Design:
Cross-sectional, prospective
Data sheets collected at time of repair & suture removal
Study Population: Univ Med Center at Stony Brook, 1992-1996
All pts with traumatic lacerations eligible, without standardizingwound tx
Results: 5521 pts enrolled, 194 infections (3.5%) over 4 yrs Mean time of presentation: 2.1 (+/- 3.6 hrs after injury) Foreign body/bite wounds accounted for
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Risk Factors for Infection in Patientswith Traumatic Lacerations
Hollander JE,Acad Emer Med 8:716, 2001
Characteristic Relative Risk of Infection
Risk of Infection
Age* OR 1.01 per yr of lifeDiabetes* 3.9
Longer, wider, deeper, jagged* 1.6-1.8
Foreign body identified* 2.9Visible contamination 1.8
Risk of Infection
Head/scalp wounds* 0.3Blunt mechanism of injury 0.5
* Remained significant by multivariate modelingAdjustment for systemic antibiotic prophylaxis did not alter results
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High-Risk Wounds where Antibiotic
Prophylaxis Recommended Significant immunocompromise
DM, PVD, AIDS, lymphedema, steroid use
Open fractures or wounds into joints
Wounds involving tendons or cartilage
Gross contamination & cannot be adequatelycleaned
Puncture or crush injuries
Bite wounds Oral wounds
>18 hr delay in presentation
Moran GJ, Infect Dis Clin No Amer22:117, 2008
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Antibiotic Recs for High-Risk Wounds
Clinical Scenario Recommended Antibiotic
Most settings 1st generation cephalosporin
Intra-oral wounds Penicillin
Bite woundsGrossly contaminated or devitalized
Amoxicillin-clavulanate
Moran GJ, Infect Dis Clin No Amer22:117, 2008
Additional Points:
Parenteral antibiotics not shown to more effective than oral antibiotics It is not necessary to include activity against CA-MRSA For most cutaneous wounds, 24 hrs of antibiotics after wound closure
is sufficient
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Plantar Puncture Wounds
Superficial infection rate is 2-10% Staph, Strep
Pseudomonas (tennis shoes)
risk for deep, forefoot
wounds, delayed presentation
No randomized trials haveevaluated the benefits of
prophylactic Abx Prospective, observational
study suggests cleansing alonelikely adequate with close f/u
Singer AJ, NEJM 359:1037, 2008
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Mammalian Bite Wounds
Risk of Infection Dog: 3-18%, usu. lacerations
Human: up to 50%, MC joints
Cat: 28-80%, puncture
Bacteriology Primarily mixed anaerobes and
aerobes
Cats: Pasteurella multocida
Dogs: P. multocida,Capnocytophaga canimorsus
Humans: HBV, HIV
Singer AJ, NEJM 359:1037, 2008
Moran GJ, Infect Dis Clin No Amer22:117, 2008
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Mammalian Bite Wounds
Rec prophylactic antibiotics
Amoxicillin-clavulanate Cipro + clindamycin (adults)
Cipro + TMP-SMX (peds)
Duration: 3-5 days
Systematic data reviewconcludes benefit of
antibiotic prophylaxis onlyfor hand bites andcat/human bites
Singer AJ, NEJM 359:1037, 2008
Moran GJ, Infect Dis Clin No Amer22:117, 2008
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One More Point.
The Negative Aspects of Antibiotic Prophylaxis
Non-fatal adverse reactionsRash, GI sxms, C. difficile colitis
Stevens-Johnson syndrome, TENS
Fatal anaphylactic reactionsEst. 15-25 rxns/ 1million treated with PCN
Drug interactions
Adding to the resistance burden The hassle factor
A large # of pts need to be treated to prevent a single case of infection.The risk of antibiotic associated adverse events exceeds the benefit, if any.
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Take Home Points
The data on which antibiotic prophylaxis
recommendations are based is limited andinconclusive.
Less is (likely) more
Antibiotic prophylaxis guidelines are onlyguidelines. They are no substitute for clinical
judgment.