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The prevention of infective endocarditisAn examination of the current use of The Prevention of Infective Endocarditis Guidelines released by the American Heart Association in 2007

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Earn 1 continuing education credit

This continuing education course was prepared by faculty at the Columbia University College of Dental Medicine and the College of Physicians and Surgeons. It is sponsored by Aetna Dental® plans.

Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company and its affiliates (Aetna).

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Background and summary

In 2010 the Columbia University College of Dental Medicine surveyed a group of 107 dentists and 50 cardiologists in the U.S. They were asked about their use of the Prevention of Infective Endocarditis (IE) Guidelines, released by the American Heart Association (AHA) in 2007. The surveys assessed their adoption of the guidelines. They also looked for areas of uncertainty or a lack of clarity on what the guidelines were recommending.

The responses show most practitioners follow the 2007 recommendations. But some are not. Four major areas clinicians need to know about:

1. Where recommended, an antibiotic regimen in patients should begin 30 to 60 minutes prior to the procedure.

2. An antibiotic regimen is not required for all adult patients with valvular heart disease.

3. Antibiotic prophylaxis is not indicated for procedures that are not subgingival in nature, such as the placement of orthodontic brackets.

4. Patients with a history of congenital heart disease that has been adequately repaired with no residual effects do not require antibiotic prophylaxis.

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Box 1 has a summary of the overall survey results.The 2007 IE guidelines substantially change the ones released in 1997. Knowledge of previous guidelines and current clinical practice may hinder adoption. This document gives an overview of the 2007 AHA guidelines. It emphasizes those areas that, based on clinician surveys, have a higher degree of noncompliance.

Summary of survey findings

Key areas in which practitioners are following the 2007 AHA IE Guidelines

• The majority of clinicians (more than 80 percent) knew that amoxicillin was the appropriate antibiotic therapy for adult patients with a prosthetic heart valve and no further complications prior to a tooth extraction.

• The majority of clinicians (more than 80 percent of dentists and cardiologists) knew that patients with a history of previous infective endocarditis and no other significant medical history require antibiotic prophylaxis during a routine cleaning including subgingival scaling, but do not require antibiotic prophylaxis for dental radiographs and impressions.

• For adult patients with a prosthetic heart valve and an allergy to penicillin, most clinicians (96.3 percent of dentists and 98 percent of cardiologists) were aware that both clindamycin and azithromycin were appropriate antibiotic regimens before a procedure.

Key areas in which practitioners are following the 2007 AHA IE Guidelines

• For adult patients with a prosthetic heart valve and no other complications, 21.5 percent of dentists and 40 percent of cardiologists knew to begin the antibiotic regimen 30 to 60 minutes prior to the procedure. Most dentists (63.6 percent) and cardiologists (42 percent) would administer the dose one hour before the procedure, but no earlier, an instruction from an older guideline.

• Only 38 percent of dentists and 54 percent of cardiologists recognized that adult patients with valvular heart disease and no other known complications no longer required antibiotic prophylaxis prior to a tooth extraction.

• Only 67 percent of dentists and 38 percent of cardiologists knew that patients with history of previous infective endocarditis and no other significant medical history do not require antibiotic prophylaxis during the placement of orthodontic brackets (no subgingival manipulation).

• Approximately 61 percent of dentists and 76 percent of cardiologists knew that patients with a history of congenital cardiac malformation (no other complications), for example, an atrial septal defect, that was adequately repaired five years prior, did not require an antibiotic regimen for a dental extraction.

Box 1

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The Prevention of Infective Endocarditis Guidelines published by the AHA, 1955-2007

In April 2007, the AHA updated its guidelines for the prevention of infective endocarditis (IE). The revised guidelines were published in Circulation: Journal of the American Heart Association. They were based on scientific evidence that suggests preventive antibiotics prior to dental visits are not necessary for most people. They also say the unnecessary use of these antibiotics might result in allergic reactions and eventual antibiotic resistance. The 2007 guidelines, therefore, were designed to substantially reduce the number of patients who received IE prophylaxis. It is a major change from the guidelines previously released by the AHA.

The AHA has made recommendations for the prevention of IE for over 50 years. The first set of guidelines was released in 1955. Since then, there have been 10 revisions to the guidelines, including the 2007 update. In 1960, the AHA guidelines noted that because of the prolonged use of preventive antibiotics for IE there was a possibility that penicillin-resistant oral microflora might emerge.1

In 1977, for the first time, patients and procedures were categorized into high and low risk groups. This resulted in complicated tables and numerous footnotes that ultimately made the guidelines difficult for clinicians and patients to interpret, understand and remember.2 In 1984, an attempt to simplify the prophylactic regimens was made.3 In 1990, an updated and more complete list of cardiac conditions and dental or surgical procedures for which prophylaxis was and was not recommended was provided.4 In 1997, cardiac conditions were classified as high, moderate and low-risk. A recommendation was made that the low-risk group should not receive prophylaxis.5 Most notably, the 1997 recommendations accepted that most cases of IE were not caused by an invasive procedure. Those cases were more likely to be the result of bacteremias from everyday activities.

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The guidelines are modified from year to year, but the intent hasn’t changed. They aim to promote good clinical practices and avoid a life-threatening infection. Table 1 has a summary of the documents published from 1955 through 2007.

Table 1

Summary of American Heart Association recommended antibiotic regimens for dental & respiratory tract procedures from 1955 to 2007

Year Primary treatment regimens for dental procedures

1955 On the day of surgery: Aqueous penicillin 600,000 units IM and procaine penicillin in oil containing 2% aluminum monosterate 600,000 U IM administered 30 minutes before the surgical procedure.

1957 For two days before surgery: Penicillin 200,000 to 250,000 U by mouth four times daily. On the day of surgery: penicillin 200,000 to 250,000 U by mouth four times daily and aqueous penicillin 600,000 U with procaine penicillin 600,000 U IM 30 to 60 minutes before the procedure. For two days after the surgery: 200,000 to 250,000 U by mouth four times daily.

1960 Step 1: Prophylaxis two days before surgery with procaine penicillin 600,000 U IM each day.

Step 2: On day of surgery: Procaine penicillin 600,000 U IM supplemented by crystalline penicillin 600,000 U IM one hour before the procedure.

Step 3: For two days after the surgery: Procaine penicillin 600,000 U IM each day.

1965 On the day of surgery: Procaine penicillin 600,000 U, supplemented by crystalline penicillin 600,000 U IM one to two hours before the procedure.

For two days after the procedure: procaine penicillin 600,000 IM each day.

1972 Procaine penicillin G 600,000 U mixed with crystalline penicillin G 200,000 U IM one hour before the procedure. Repeat once daily for two days after the procedure.

1977 Aqueous crystalline penicillin G 1,000,000 U IM mixed with procaine penicillin G 600,000 U IM. Administer 30 to 60 minutes before procedure. Then give penicillin V 500 milligrams orally every two hours for eight doses.

1984 Penicillin V 2 grams orally one hour before the procedure; then 1g six hours after the initial dose.

1990 Amoxicillin 3 grams orally one hour before the procedure; then 1.5g six hours after the initial dose.

1997 Amoxicillin 2 grams orally one hour before the procedure.

2007 Amoxicillin 2 grams orally 30 to60 minutes before the procedure. (For children: Amoxicillin

50 milligrams per kilogram)

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The AHA guidelines released prior to 2007 were based on five widely accepted beliefs about IE:

1. Certain underlying cardiac conditions are predisposed to IE.

2. Bacteremia with organisms known to cause IE occurs commonly in association with invasive dental, gastrointestinal (GI) or genitourinary (GU) tract procedures.

3. IE is an uncommon, but life-threatening disease. Prevention is preferable to treatment of an established infection.

4. Antimicrobial prophylaxis is effective for the prevention of experimental IE in animals.

5. Antimicrobial prophylaxis can be effective in humans to prevent IE subsequent to invasive dental, GI or GU tract procedures.

In 2007, the committee* that had been appointed by the AHA to look at and revise the 1997 guidelines reported that its review of the literature indicated that the first four beliefs were still valid. But the fifth lacked validity. No published data convincingly supported the idea that prophylactic antibiotics were effective in the prevention of IE associated with bacteremia from invasive dental, GI or GU tract procedures This finding, therefore, resulted in a revision of the 1997 guidelines and the release of new ones in 2007.

*Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, Bolger A, Cabell CH, Takahashi M, Baltimore RS, Newburger JW, Strom BL, Tani LY, Gerber M, Bonow RO, Pallasch T, Shulman ST, Rowley AH, Burns JC, Ferrieri P, Gardner T, Goff D, Durack DT, American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease, American Heart Association Council on Cardiovascular Disease in the Young, American Heart Association Council on Clinical Cardiology, American Heart Association Council on Cardiovascular Surgery and Anesthesia, Quality of Care and Outcomes Research Interdisciplinary Working Group.

Rationale for revising the 1997 guidelines

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• Bactereia resulting from daily activities is much more likely to cause IE than bacteremia associated with a dental procedure.

• An extremely small number of cases of IE are prevented by antibiotic prophylaxis even if prophylaxis is 100 percent effective.

• Antibiotic prophylaxis is not recommended based solely on an increased lifetime risk of acquisition of IE.

• Recommendations for IE prophylaxis are for those conditions listed in Table 2. They are limited to dental procedures that involve manipulation of gingival tissues, periapical region of teeth and/or perforation of oral mucosa (Table 3).

• Antibiotic prophylaxis is no longer recommended for any other form of congenital heart disease (CHD). (Exceptions: see Table 2.)

• Antibiotic prophylaxis solely to prevent IE is not recommended for GU or GI tract procedures.

Summary of major changes in the AHA 2007 document for dental procedures6

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What the 2007 changes mean for clinicians

Cardiac conditions for which prophylaxis with dental procedures is reasonable

There is no published data supporting the idea that the administration of prophylactic antibiotics prevents IE associated with bacteremia from an invasive procedure. But the 2007 guidelines recommend that patients who have the highest risk of adverse outcome from IE, and who would derive the greatest benefit from the prevention of IE, should get prophylactic antibiotics before an invasive procedure. Therefore, in patients with underlying cardiac conditions associated with the highest risk of adverse outcome from IE (Table 2), IE prophylaxis for dental procedures is reasonable even though its effectiveness is unknown.

Dental procedures and antibiotic prophylaxis

Antibiotic prophylaxis is reasonable for patients with the conditions listed in Table 2 who undergo any dental procedure that involves the gingival tissues or periapical region of a tooth and/or for those procedures that perforate the oral mucosa. Although IE prophylaxis is reasonable for these patients, its effectiveness is unknown. Routine impressions that do not involve gingival retraction or manipulation of the subgingival region do not require antibiotic prophylaxis. Only orthodontic treatment that involves the placement of bands below the gingival margin, resulting in gingival retraction or manipulation, requires antibiotic prophylaxis. Regular orthodontic care such as the placement of brackets and wires does not require antibiotic prophylaxis.

Cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis for which prophylaxis with dental procedures is reasonable

• Previous case of infective endocarditis

• Prosthetic cardiac valve or prosthetic material used for cardiac valve repair

• Certain forms of Congenital Heart Disease (CHD)

• Unrepaired cyanotic CHD, including palliative shunts and conduits

• Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the surgical procedure

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

• Cardiac transplantation recipients who develop cardiac valvulopathy

Table 2

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Dental procedures for which endocarditis prophylaxis is reasonable

ExamplesAll dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa

• Biopsies

• Suture removal

• Placement of orthodontic bands

Dental procedures for which endocarditis prophylaxis is not reasonable

• Injecting routine anesthetic through non-infected tissue

• Taking dental radiographs

• Placing removable prosthodontic or orthodontic appliances

• Placing orthodontic brackets

• Adjusting orthodontic appliances

The following events are not actual dental procedures. Therefore, prophylaxis is NOT recommended.

• The loss of deciduous teeth

• Trauma to the lips and oral mucosa

Table 3

Table 4

Direct prophylactic antimicrobial therapy against viridans group streptococci for high-risk patients who will be having the procedures listed in Table 3.

Tables 3, 4 and 5 summarize the dental procedures for which IE prophylaxis is and is not reasonable.

Table 5

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Antibiotic regimens — general principles

Administer an antibiotic for prophylaxis in a single dose 30 to 60 minutes before the procedure. If inadvertently not administered before, it is acceptable to do so up to two hours after. But consider administering it after only if 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.6

Amoxicillin is the preferred choice for oral therapy. It is well absorbed in the gastrointestinal tract and provides high and

sustained serum concentrations. For individuals who are allergic to penicillin or amoxicillin, use cephalexin or another first or second-generation oral cephalosporin, clindamycin, azithromycin or clarithromycin.

Because of possible cross-reactions, a cephalosporin should not be administered to patients with a history of anaphylaxis, angioedema or urticaria after treatment with any form of penicillin, including ampicillin or amoxicillin. Patients who are unable to tolerate an oral antibiotic may be treated with ampicillin, ceftriaxone, or cefazolin administered intramuscularly or intravenously. For ampicillin-allergic patients who are unable to tolerate an oral agent, therapy is recommended with parenteral cefazolin, ceftriaxone, or clindamycin.6

Table 6

Dental procedure – regimens

Situation Agent Regimen: Single dose 30-60 minutes before procedure

Adults Children

Oral Amoxicillin 2 grams 50 milligrams per kilogram

Unable to take oral medication

Ampicillin or Cefazolin or ceftriaxone

2 g IM* or IV† 1 g IM or IV

50 mg/kg IM or IV

50 mg/kg IM or IV

Allergic to penicillins or ampicillin oral

Cephalexin‡ ф or Clindamycin or Azithromycin or clarithromycin

2 g

600 mg

500 mg

50 mg/kg

20 mg/kg

15 mg/kg

Allergic to penicillins or ampicillin and unable to take oral medication

Cefazolin or ceftriaxone ф or Clindamycin

1 g IM or IV 600 mg IM or IV

50 mg/kg IM or IV

20 mg/kg IM or IV

* IM: Intramuscular

† IV: Intravenous

‡ Or other first- or second-generation oral cephalosporin in equivalent or pediatric dosage

ф Cephalosporins should not be used in a person with a history of anaphylaxis, angioedema or uticaria with penicillins or ampicillin.

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Practitioner and patient shared concern about the 2007 changes

Until the release of the 2007 guidelines, it was accepted that patients with vulvular murmurs should take an antibiotic prophylaxis prior to a dental or other invasive procedure to help prevent IE. Patients who had underlying cardiac risk factors had been educated about their increased risk of developing IE and, as a result, expected to have antibiotic prophylaxis prior to any invasive treatment. Such patients were concerned. So were practitioners, especially dentists, who were accustomed to prescribing antibiotic prophylaxis to their at-risk patients. To address these concerns, the committee developed talking points to help them explain the 2007 changes (Box 2) to their patients.

Pathogenesis of infective endocarditis

Turbulent blood flow from congenital or acquired heart disease can result in nonbacterial thrombotic endocarditis on the surface of a cardiac valve or where endothelial damage is present. Bacteria in the bloodstream can colonize the valve or areas of endothelial damage resulting in a bacteremia. Transient bacteremias caused by viridans group streptococci occur commonly in association with dental procedures. It also occurs routinely with everyday oral hygiene procedures and daily activities such as chewing. Microorganisms that mature in valvular vegetations are metabolically inactive rather than in an active growth and are less responsive to the bactericidal effects of antibiotics.

Rationale for or against prophylaxis of infective endocarditis

In the past, the AHA recommended antimicrobial prophylaxis to prevent IE for patients who have cardiac conditions and those scheduled for bacteremia-producing dental procedures. The AHA recommendation was based on the following principles:

• Bacteremia causes endocarditis.

• Bacteremia caused by viridans group streptococci is associated with a dental procedure.

• Certain dental procedures can cause IE.

• Viridans group streptococci are susceptible to the prophylaxis antibiotics.

• The risk of significant adverse reactions to an antibiotic is low.

• The rates of morbidity and mortality from IE are high.

Most of these principles remain valid. But there is little scientific proof that dental procedures may cause IE in patients with underlying cardiac risk factors. Likewise, evidence that antibiotic prophylaxis is effective in preventing IE is lacking. In fact, bacteremia-producing dental procedures cause only a small number of IE cases each year, according to published studies. Consequently, only an extremely small number of cases of IE might be prevented assuming that antibiotic prophylaxis were 100 percent effective.

In addition, the majority of cases of IE caused by oral microflora are most likely the result of random bacteremias from routine daily activities, such as chewing food, brushing and flossing. With this in mind, the recommendation was to place more emphasis on improving access to dental care and oral health for patients with underlying cardiac conditions and those at greater risk of an adverse outcome from IE. Providing antibiotic prophylaxis in the long term might do more harm than good.

• Infective endocarditis (IE) is much more likely to result from frequent exposure to random bacteremias associated with daily activities than from bacteremia caused by a dental, gastrointestinal (GI) tract or gastrourinary (GU) tract procedure.

• Prophylaxis may prevent an exceedingly small number of cases of IE, if any, in people 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. It is more important that prophylactic antibiotics for a dental procedure to reduce the risk of IE.

Box 2

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Specific situations and circumstances

Patients using antibiotics

The 2007 guidelines recommend the following for patients already using antibiotics:

• In patients who are already receiving long-term antibiotic therapy with a drug that is also used for IE prophylaxis for a dental procedure: Select an antibiotic from a different class rather than increase the dosage of the current one. For example, antibiotic regimens used to prevent the recurrence of acute rheumatic fever are given in dosages lower than those to prevent IE.6

• Individuals who take an oral penicillin for secondary prevention of rheumatic fever or for other purposes: These patients are likely to have viridans group streptococci in their oral cavity that are resistant to penicillin or amoxicillin. In such cases, use either clindamycin, azithromycin, or clarithromycin for IE prophylaxis for a dental procedure, but only for the patients shown in table 2. Because of possible cross-resistance of viridans group streptococci with cephalosporins, avoid this class of antibiotics. If possible, it is best to delay a dental procedure until at least 10 days after completion of the antibiotic therapy. This may allow time for the usual oral flora to be re-established.6

• Patients receiving parenteral antibiotic therapy for IE may require dental procedures, particularly if cardiac valve replacement surgery is anticipated. In these cases, the IE therapy should continue and the dosage given 30 to 60 minutes before the dental procedure. High doses are required. The concentration will help overcome any low-level resistance developed among mouth flora (unlike the concentration that would occur after oral administration).6

Patients using anticoagulants

The 2007 guidelines recommend the following for patients using anticoagulants:

• Avoid intramuscular injections for IE prophylaxis patients who are receiving anticoagulant therapy. In these cases, give oral regimens whenever possible. Use intravenously administered antibiotics for patients who are unable to tolerate or absorb oral medications.6

Dental considerations for patients who undergo cardiac surgery

The 2007 guidelines recommend the following for patients who undergo cardiac surgery:

• A careful preoperative dental evaluation is prudent. This will help ensure that required dental treatment is done whenever possible before cardiac valve surgery or replacement or repair of CHD. Such measures may decrease the rate of late prosthetic valve endocarditis caused by viridans group streptococci.6

Other considerations

There is no evidence associating coronary artery bypass graft surgery with a long-term risk for infection. Those who have undergone this procedure should not be on antibiotic prophylaxis for dental work. Likewise, patients with coronary artery stents should not be on antibiotic prophylaxis.6

There is not enough data to support specific recommendations for patients who have undergone a heart transplant. Such patients are at risk of acquired valvular dysfunction, especially during episodes of rejection. Endocarditis in a heart transplant patient is associated with a high risk of adverse outcome.

The use of IE prophylaxis for dental procedures in cardiac transplant recipients who develop cardiac valvulopathy is reasonable. But the usefulness is not well established.6

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Continuing education questions:

The prevention of infective endocarditis

InstructionsFill in the appropriate boxes on your answer sheet and return it by either fax or mail to Aetna for 1 CE credits.

• You must complete questions 1 through 10 to receive credit.

• No fees are charged for participating in this continuing education activity.

1. When a patient who requires antibiotic prophylaxis presents for a dental visit, for which of the following procedures is antibiotic prophylaxis indicated? A. Biopsies B. Suture removal C. Placement of orthodontic bands D. All of the above

2. Dental procedures for which endocarditis prophylaxis is NOT reasonable include which of the following: A. Routine anesthetic injections through non-infected tissue B. Taking dental radiographs C. Extraction of a tooth D. A and B E. All of the above

3. Which antibiotic is recommended for oral administration in the prophylactic regimen for patients who are not allergic to penicillins? A. Penicillin V B. Erythromycin C. Amoxicillin D. Azithromycin

4. Patients who are already receiving antibiotics that are recommended for IE prophylaxis for a dental procedure, for example, to prevent the recurrence of acute rheumatic fever should be managed by: A. Increasing the dosage of the current medication B. Selecting an antibiotic from a different class C. All of the above

5. Patients who are unable to take oral medication, but are not allergic to antibiotics, can receive which of the following IM or IV medications? A. Ampicillin B. Clindamycin C. Vancomycin

6. When should an antibiotic prophylactic regimen begin? A. 30-60 minutes before the procedure B. 1 hour before the procedure, but no earlier C. 2 hours before the procedure D. 1 day before the procedure

7. For a patient with a prosthetic heart valve, what dosage size would you recommend for use after an extraction? A. Post-procedure dose is not required B. 250 mg oral amoxicillin C. 500 mg oral amoxicillin D. 1 gram oral amoxicillin

8. If a dental extraction is required for a patient with a history of congenital cardiac malformation, for example, an atrial septal defect that was adequately repaired five years ago, is antibiotic prophylaxis recommended? A. Yes B. No

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9. A patient at high risk for infective endocarditis presents with shedding deciduous teeth. An antibiotic prophylactic regimen should be prescribed for this patient. A. True B. False

10. The current American Heart Association guidelines (2007) recommend antibiotic prophylaxis only for patients with the highest risk of adverse outcomes from infective endocarditis. Patients who are considered to be at high risk for endocarditis include those who have: A. Previous case of infective endocarditis B. Prosthetic cardiac valve or prosthetic material used for cardiac valve repair C. Valvular heart disease

The responses to questions 11 – 20 are optional and will only be reported in the aggregate. Results will not be reviewed at the individual level.

11. Are patient education materials on tobacco use prevention and cessation available in your reception room? A. Yes B. No

12. During the past three months, for patients with heart conditions, did you use or recommend an antibiotic prophylactic regimen? A. Yes B. No

13. Have you ever advised an at-risk patient that antibiotics may be necessary with dental treatment? A. Yes B. No

14. After reading this clinical update on infective endocarditis, I can now identify which patients require antibiotic prophylaxis? A. Strongly Agree B. Agree C. Neither agree nor disagree D. Disagree E. Strongly disagree

15. After reading this clinical update on infective endocarditis, I can now identify which dental procedures require antibiotic prophylaxis? A. Strongly Agree B. Agree C. Neither agree nor disagree D. Disagree E. Strongly disagree

16. After reading this clinical update on infective endocarditis, I can now identify the correct dosage and medication to use for patients who can tolerate oral antibiotics. A. Strongly Agree B. Agree C. Neither agree nor disagree D. Disagree E. Strongly disagree

17. Please indicate your impression of the American Heart Association Infective Endocarditis guidelines. A. Very helpful B. Helpful C. Somewhat helpful D. Not helpful

Continuing education questions:

The prevention of infective endocarditis (continued)

Correct answers for 1-10: (1.D, 2.D, 3.C, 4.B, 5.A, 6.A, 7.A, 8.B, 9.B, 10.C)

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18. Dental patients who cannot take oral medications for infective endocarditis should have their care managed in a hospital setting (clinic). A. Strongly Agree B. Agree C. Neither agree nor disagree D. Disagree E. Strongly disagree

19. The 2007 American Heart Association (AHA) guidelines recommend a more conservative approach to the use of antibiotic prophylaxis. Therefore, some of your current patients no longer need antibiotics prior to dental procedures. In your practice, have you stopped recommending antibiotic prophylaxis to patients who are no longer considered to be at high risk for infective endocarditis? A. Yes, I have changed my recommendations for all my patients. B. No, I have been following the pre 2007 AHA guidelines. C. I have changed my recommendations for some of my patients, but not all.

20. Overall, this clinical update enhanced my ability to understand use of antibiotics for patients at high risk for infective endocarditis. A. Strongly Agree B. Agree C. Neither agree nor disagree D. Disagree E. Strongly disagree

21. Please rate the relevance of this clinical update to your clinical practice. 1 2 3 4 5 Irrelevant Relevant

22. Please provide comments about the course, and/or suggestions for future courses.

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Notes

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Notes

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Notes

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tear along dotted linetear along dotted line

Summary of American Heart Association recommended antibiotic regimens for dental & respiratory tract procedures from 1955 to 2007

Year Primary treatment regimens for dental procedures

1955 On the day of surgery: Aqueous penicillin 600,000 units IM and procaine penicillin in oil containing 2% aluminum monosterate 600,000 U IM administered 30 minutes before the surgical procedure.

1957 For two days before surgery: Penicillin 200,000 to 250,000 U by mouth four times daily. On the day of surgery: penicillin 200,000 to 250,000 U by mouth four times daily and aqueous penicillin 600,000 U with procaine penicillin 600,000 U IM 30 to 60 minutes before the procedure. For two days after the surgery: 200,000 to 250,000 U by mouth four times daily.

1960 Step 1: Prophylaxis two days before surgery with procaine penicillin 600,000 U IM each day.

Step 2: On day of surgery: Procaine penicillin 600,000 U IM supplemented by crystalline penicillin 600,000 U IM one hour before the procedure.

Step 3: For two days after the surgery: Procaine penicillin 600,000 U IM each day.

1965 On the day of surgery: Procaine penicillin 600,000 U, supplemented by crystalline penicillin 600,000 U IM one to two hours before the procedure.

For two days after the procedure: procaine penicillin 600,000 IM each day.

1972 Procaine penicillin G 600,000 U mixed with crystalline penicillin G 200,000 U IM one hour before the procedure. Repeat once daily for two days after the procedure.

1977 Aqueous crystalline penicillin G 1,000,000 U IM mixed with procaine penicillin G 600,000 U IM. Administer 30 to 60 minutes before procedure. Then give penicillin V 500 milligrams orally every two hours for eight doses.

1984 Penicillin V 2 grams orally one hour before the procedure; then 1g six hours after the initial dose.

1990 Amoxicillin 3 grams orally one hour before the procedure; then 1.5g six hours after the initial dose.

1997 Amoxicillin 2 grams orally one hour before the procedure.

2007 Amoxicillin 2 grams orally 30 to60 minutes before the procedure. (For children: Amoxicillin

50 milligrams per kilogram)

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eCardiac conditions associated with the highest risk of adverse outcome from infective endocarditis for which prophylaxis with dental procedures is reasonable

• Previous case of infective endocarditis

• Prosthetic cardiac valve or prosthetic material used for cardiac valve repair

• Certain forms of Congenital Heart Disease (CHD)

• Unrepaired cyanotic CHD, including palliative shunts and conduits

• Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the surgical procedure

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

• Cardiac transplantation recipients who develop cardiac valvulopathy

Dental procedures for which endocarditis prophylaxis is reasonable

ExamplesAll dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa

• Biopsies

• Suture removal

• Placement of orthodontic bands

Dental procedures for which endocarditis prophylaxis is not reasonable

• Injecting routine anesthetic through non-infected tissue

• Taking dental radiographs

• Placing removable prosthodontic or orthodontic appliances

• Placing orthodontic brackets

• Adjusting orthodontic appliances

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tear along dotted line

Dental procedure - regimens

Situation Agent Regimen: Single dose 30-60 minutes before procedure

Adults Children

Oral Amoxicillin 2 grams 50 milligrams per kilogram

Unable to take oral medication

Ampicillin or Cefazolin or ceftriaxone

2 g IM* or IV† 1 g IM or IV

50 mg/kg IM or IV

50 mg/kg IM or IV

Allergic to penicillins or ampicillin oral

Cephalexin‡ ф or Clindamycin or Azithromycin or clarithromycin

2 g

600 mg

500 mg

50 mg/kg

20 mg/kg

15 mg/kg

Allergic to penicillins or ampicillin and unable to take oral medication

Cefazolin or ceftriaxone ф or Clindamycin

1 g IM or IV 600 mg IM or IV

50 mg/kg IM or IV

20 mg/kg IM or IV

* IM: Intramuscular

† IV: Intravenous

‡ Or other first- or second-generation oral cephalosporin in equivalent or pediatric dosage

ф Cephalosporins should not be used in a person with a history of anaphylaxis, angioedema or uticaria with penicillins or ampicillin.

The following events are not actual dental procedures. Therefore, prophylaxis is NOT recommended.

• The loss of deciduous teeth

• Trauma to the lips and oral mucosa

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1. Committee on Prevention of Rheumatic Fever and Bacterial Endocarditis, American Heart Association. Prevention of rheumatic fever and bacterial endocarditis through control of streptococcal infections. Circulation 1960;21:151-5.

2. Kaplan EL, Anthony BF, Bisno A, et al. (Committee on Prevention of Rheumatic Fever and Bacterial Endocarditis, American Heart Association). Prevention of bacterial endocarditis. Circulation 1977;56(1):139A-143A.

3. Shulman ST, Amren DP, Bisno AL, et al. (Committee on Prevention of Rheumatic Fever and Bacterial Endocarditis, American Heart Association). Prevention of bacterial endocarditis: a statement for health professionals by the Committee on Rheumatic Fever and Infective Endocarditis of the Council on Cardiovascular Disease in the Young. Circulation 1984;70(6):1123A-1127A.

4. Dajani AS, Bisno AL, Chung KJ, et al. Prevention of bacterial endocarditis: recommendations by the American Heart Association. JAMA 1990; 264(22):2919-22.

5. Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis: recommendations by the American Heart Association. JAMA 1997;277(22):1794-801.

6. The Heart Association: Prevention of infective endocarditis: guidelines from the American Heart Association. Available http://circ.ahajournals.org/content/116/15/1736.full.pdf Accessed August 18, 2015.

This examination of the current use of the prevention of Infective Endocarditis Guideline released by the American Heart Association in 2007 was prepared by David A. Albert, DDS, MPH; Angela Ward, RDH, MA, Ed.D; Sharifa Z. Williams, MPH, CPH of the Columbia College of Dental Medicine; and Giora Weisz, MD; Robert B. MacArthur, Pharm.D of the Columbia University Medical Center. This project was funded by the Aetna Foundation.

References

Copyright to the original guidelines is owned by the American Heart Association, Inc. (AHA). Reproduction of the AHA guidelines without permission is prohibited. Single reprint is available by calling 1-800-242-8721 (US only), or writing the American Heart Association, Public Information, 7272 Greenville Ave., Dallas, TX 75231-4596.

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All patient care and related decisions are your responsibility in consultation with your patient. This information does not dictate or control your clinical judgment regarding the appropriate treatment of any individual patient. Please be aware that not all dental plans cover all of the treatments or tests described in this document. This publication is not intended to provide dental/medical advice nor any endorsement by Aetna of any specific product, vendor, drug or pharmaceutical. Continuing education credit is available from Aetna Dental upon completion of the examination questions. This course is available to offices participating in an Aetna Dental® network online at www.aetnadental.com. Offices without Internet access can obtain a copy of the CE course by calling the Aetna National Dentist Line at 1-800-451-7715. This course is accepted by the Academy of General Dentistry for membership maintenance credits.

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