Transcript DH 303 Concepts II Bacterial Endocarditis

Everything You Want To Know About
Premedication and the New American
Heart Association Guidelines
WDHA Presentation/ January 10th 2008
Kelly Anderson RDH, MHS
Topics to be discussed……
History of the premedication guidelines
 Definition, incidence, and characteristics of
bacterial endocarditis
 Controversy surrounding the old guidelines/
benefits of the new guidelines
 Differences between the old and the new
guidelines
 Premedication for other dental/dental
hygiene patients

History of AHA Guidelines
American Heart Association has made
recommendations for more than 50 years
 Updated in 1960, 1965, 1972 (ADA
endorsed), 1977, 1984, 1990
 Most recent was 1997- grouped patients
into high, moderate and low risk groups

Rationale for Revisions

Quality of evidence for IE prophylaxis was
based on a few cases- not enough
evidence!
Infective Endocarditis/ Endarteritis

A microbial infection most often in proximity
to congenital or acquired heart defect
◦ endocarditis- infection of the heart valves or
endocardium
◦ endarteritis- infection of major vessels leading
into and out of the heart
Incidence

In general population not known
◦ Less than 1% of the population (estimated)
◦ 4,000 to 15,000 cases of IE occurring in the
U.S. per year
Other Considerations: Incidence

Does not appear to be decreasing with use of
prophylactic antibiotics

60 to 80% of the cases present in patients with
some type of predisposing heart or arteriole
disease

Fewer than 1 in 5 cases are associated with medical
or dental procedures

Important!!!
Undiagnosed or untreated IE
◦ mortality rate of 100%
Etiology

Bacteria
80% of the
Streptococcus- Sub acute
cases
Staphylococcus Aureus- acute
Order of events:
1. Bacteremia introduced in blood
stream
2. Infects damaged endocardium near
high flow area such as the heart or
prosthetic joints
CARDIAC LESION
Symptoms and Signs/ Occurrence: IE

Signs &Symptoms
– Weakness
– Unexplained
fever
– Weight loss
– Fatigue
– Chest pain
– Cardiac murmur

Sub acute: Strep
– Progresses over a
period of weeks to
months

Acute
– Develops over a
period of days to 1
week
– Complications
develop quickly and
can lead to death is 6
weeks
Pathophysiology/Complication

Treated IE patients
◦ hospital stay ranges from 4-6 wks
◦ increases the risk for reinfection,
congestive heart failure, renal disease,
scarred valve
◦ mortality rate for treated patients is 1070%
◦ mortality rate for untreated patients is
100%
Signs and Symptoms of Dental Induced
IE
Appear within 2 wk of medical of dental
procedure and may lead to death within 6
weeks
 Sub-acute IE is caused most often by AlphaHemolytic Streptococci (the most common
found in dental induced bacteremias)
 At risk….without exposure to medical or
dental procedures*
◦ elderly
◦ patients with valvular prosthesis
◦ IV drug users
*Other bacteria may be the causative agent
in these high risk patients

Potential Problems with Dental
Care-Frequency of Bacteremia

Procedures and Risks for bacteremia:
perio surgery
36-88%
perio scaling
8-80%
prophy (polishing)
0-40%
toothbrushing
0-40%
chewing
7-50%
Antibiotic Prophylaxis may prevent
endocarditis by:
Killing or damaging the bacteria
 Decreasing bacterial adherence to
irregular heart surfaces
 This is controversial! There are no
controlled studies on the efficacy of
antibiotic prophylaxis

Controversy Over Antibiotic Prophylaxis for
Dental Procedures
◦ Rareness of disease following medical/dental
procedures
◦ If dental treatment causes 1% of IE in the U.S,
the overall risk is 1 case of IE per 14 million
dental procedures
◦ Evidence linking IE and dental procedures is
not conclusive
◦ Incidence of anaphylactic type of reaction to
antibiotic is 400-800 deaths per year in the
U.S. after the use of penicillin
◦ Bacterial resistance becoming a problem
Risks Outweigh the Benefits for
Premedication for Low-Moderate Risk
Patients
 Antibiotics not needed for individuals
with low or moderate risk for BE
 Absolutely necessary for high risk
patients
WHY NEW GUIDELINES?




IE is much more likely to result from frequent
exposure to random bacteremias associated with
daily activities
Prophylaxis may prevent an exceedingly small
number of cases of IE, if any
The risk of antibiotic-associated adverse events
exceed the benefit, if any, from prophylactic
antibiotic therapy
Maintenance of optimal health and hygiene may
reduce the incidence of bacteremia and is more
important than prophylactic antibiotics for a dental
procedure to reduce the risk of IE
NEW GUIDELINES:AHA Considers High
Risk
Individuals-Premedication Indicated
Prosthetic cardiac valve: mechanical or
tissue
 Previous history of infective endocarditis
 Congenital Heart Disease which is
unrepaired
 Congenital heart defects repaired during
the first six months after surgery
 Cardiac Transplant with cardiac
complications

CONSIDERED MODERATE RISK
INDIVIDUALS- Premedication NOT
Indicated Now





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Mitral Valve Prolapse with or without
regurgitation
Pathological/Organic heart murmur
Previous rheumatic fever with or without
valvular dysfunction
Previous Kawaskasi disease with or without
valvular dysfunction
Systemic Lupus Erythematosis (1/4 of these
patients have cardiac involvement)
Rheumatoid Arthritis with cardiac involvement
Other acquired valvular dysfunction
CONSIDERED MODERATE RISK
INDIVIDUALS- Premedication NOT Indicated
Now (cont.)
Previous coronary bypass graft surgery
 Coronary artery stents
 Heart transplants patient without
complications
 Cardiac pacemakers
 Implanted defibrillators

Antibiotic Prophylaxis Regimen

Following current loading guidelines:
► 30-60 minutes before procedure
► Next 1 to 2 hours is the best coverage
of antibiotics
► Ideally give subsequent loads of
antibiotics 9 to 14 days after initial
treatment to allow the oral flora to
return to normal

The dose can be given 2 hours after the
procedure if it was accidentally not given
Patients already receiving Antibiotics

Select an antibiotic from a different class
rather than increase dosage of current
antibiotic to minimize resistance
Example: If patient is already taking
amoxicillin, use clindamycin.
AMERICAN HEART ASSOCIATION
RECCOMENDATION- new guidelines
Adults
Amoxicillin 2 grams orally (500 X 4
tablets), 30-60 minutes before
appointment
 Children
Amoxicillin 50mg/kg. orally, 30-60 minutes
before appointment

Situation
Antibiotic Agent
Regimen *
Standard Prophylaxis
Amoxicillin
Adults: 2.0 g.
Children : 50 mg / kg
Orally 30-60 minutes before procedure
Unable to take oral
medication
Ampicillin
Adults: 2.0 g IM or IV
Children: 50 mg / kg IM or IV
within 30-60 minutes before procedure
Allergic to Penicillin
Clindamycin
Adults: 600 mg
Children: 20 mg / kg
Orally 30-60 minutes before procedure
** Cephalexin or cefadroxil
Adults: 2.0 g
Children: 50 mg / kg
Orally 30-60 minutes before procedure
Azithromycin or
clarithromycin
Adults: 500 mg
Children: 15 mg / kg
orally 30-60 minutes before procedure
Clindamycin
Adults: 600 mg
Children: 20 mg / kg IV 30-60 minutes
before procedure
Cefazolin
Adults: 1.0 g
Children: 25 mg / kg IM or IV
within 30-60 minutes before procedure
Allergic to Penicillin and
unable to take Oral
Medications
* Total children’s dose should not exceed adult dose
** Cephalosporin's should not be used in individuals with immediate-type hypersensitivity reaction to penicillins
PROCEDURES TO GIVE
ANTIBIOTIC PROPHYLAXIS
Probing
 Recall maintenance
 Cleaning of the teeth
 Subgingival fiber placement
 Extraction
 Scaling and Root Planing

PROCEDURES NOT NEEDING
ANTIBIOTIC PROPHYLAXIS
Restorative dentistry with or without
cord
 Local anesthetic (non-PDL)
 Root canal therapy (not beyond apex)
 Impressions
 Suture removal
 Placement of the rubber dam

MYTHS/MISBELIEFS
Most physicians and dentists are aware
and comply with the AHA guidelines
 Most cases of IE or oral origin are
produced by dental procedures
 AHA regimens give total protection
against developing endocarditis after
dental procedures
 Antibiotics should be given for any
procedure that causes bleeding
 If a patient is already on antibiotic therapy
for another infection, the patient is
covered

Additional Conditions Requiring
Premedication
End Stage Renal Disease/Renal dialysis
patients
 Prosthetic joint repair
 Cerebrospinal fluid shunts
 Chemotherapy patients
 HIV patients
 Sickle Cell patients
 Hemophiliacs

ESRD
Hemodialysis: Premedication
needed to prevent Endarteritis
Central Catheter -placed for urgent
dialysis (temporary)
or no other options
(permanent). Most
prone for infection
•Access through
vascular means
Fistula -- native
artery and vein joined
to create high flow
system. Best long
term outcome, but
take awhile to mature
AV Graft -- artificial
(Gortex) placed in a
“U” or “straight”
formation between
artery and vein. Easy
to place, can be used
early, but many
ESRD: No premedication needed
Peritoneal Dialysis --CCPD & CAPD
• 10% of dialysis patients
• Done at home
• CCPD -- cycler, at night
• CAPD -- 4-5 bags/day
• Installation of hypertonic solution
(glucose) intraabdominal to draw off
toxins & fluid
• Reduced risk of infection unless
direct contamination (peritonitis)
• No heparin
Dental/Dental Hygiene
Modifications for ESRD Patients
Consultation with nephrologists advisable
for premedication considerations
 Blood pressure taken on the arm without
the shunt/fistula
 Scheduling dental hygiene care the day
after dialysis- heparin concerns
 Determining risk for increased bleeding;
may need INR time, platelet count

Prosthetic Joint: ADVISORY
STATEMENT
Made by the ADA and American Academy
of Orthopedic Surgeons in 1997:
1.Scientific evidence does not support the
need for antibiotic prophylaxis for dental
procedures
2.It is also not indicated for pins, screws,
plates or total hip replacement
3.It is only indicated for high risk patients
PROSTHETIC JOINT HIGH RISK
PATIENTS
►Immunocompromised or suppressed patients:
rheumatoid arthritis, systemic lupus, drug or
radiation induced immunosuppression
► Insulin-dependent diabetes (Type 1 diabetes)
► First 2 years after joint replacement
► Previous prosthetic joint infection
► Malnourishment
► Hemophilia
NEUROLOGICAL DISORDERS/
CEREBROSPINAL FLUID SHUNTS
Hydrocephalus is a condition in which fluid
accumulates in the brain
 Necessitates a shunt to drain fluid
 75,000 placed each year in the U.S.
 Only the ventriculoatrial shunt is at risk from
infection from invasive dental procedures so
premedication is indicated with current AHA
regimen
 Consultation with medical doctor needed
before dental hygiene treatment

With the
Ventriculoperitneal
shunt in place,
cerebrospinal fluid flows
into the ventricular
(collection) catheter and
down the exit catheter,
which shunts the fluid
into the peritoneal cavity.
page url:http://www.cinn.org/crarticles/CR-nph.html
A small catheter is passed into a
ventricle of the brain. A pump is
attached to the catheter to keep the
fluid away from the brain. Another
catheter is attached to the pump and
tunneled under the skin, behind the
ear, down the neck and chest and into
the peritoneal cavity (abdominal
cavity). The CSF is absorbed in the
peritoneal cavity.
Prevention of Complications
During Chemotherapy
Consult with oncologist for any procedure
If dental procedure is indicated, schedule
appointment either a day or several days before
chemo treatment when levels of WBC are high
 If invasive procedures:


◦ Antibiotic prophylaxis-for central venous
catheters or ports- AHA guidelines/consult
oncologist
◦ Postpone treatment if WBC/neutrophil count
less than 1,000 cells/mm3
◦ Platelet replacement if platelet count is below
50,000/mm3 -for urgent care
Indwelling catheters
http://orbit.unh.edu/cancer/PO
RTA1.jpg
Treatment Plan Modification for
Cancer Patients
Establish a schedule for dental hygiene and
dental treatment to begin at least 14 days
before cancer treatment begins
 Only emergency dental care during
chemotherapy based on prognosis of underlying
disease
 With special considerations, patients who are in
remission can receive most indicated dental
treatment

Questions to ask the oncologist during
chemotherapy
What is the patient’s complete blood count
including neutrophil and platelet counts?
 Are adequate clotting factors present to
prevent bleeding?
 Does the patient have a central venous
catheter? Pre-medication indicated?
 What is the scheduled sequence of cancer
treatments?

HIV Patient Considerations
Premedication
Premedication
indicated when:
► Neutrophils drop
below 500 cells/mm³
► Not based on CD4
count anymore- CD4
is an indicator for
oral lesions

Viral load is
considered as well as
neutrophil level
 High viral load
indicates the patient’s
drug therapy is not
effective and level of
transmission

Erythematous Candidiasis
TREATMENT: Antifungals
Local/Topical
Applications
► Clotrimazole
(Mycelex)
► Nysatin
Copyright © 1996-2000 David Reznik, D.D.S. All Rights Reserved.
Hairy Leukoplakia/ Epstein-Barr
Virus

Treatment:
► For cosmetic
purpose only
► Acyclovir
Copyright © 1997 Cesar A. Migliorati, DDS MS
Oral Medicine Specialist, All Rights Reserved.
Kaposi’s Sarcoma
Treatment:
►Radiation
►Chemotherapy
►Cure rates vary
from 30-50%
Human Papillomavirus Lesions/ HPV

Treatment:
► Surgical or
Laser excision
► Recurrence is
common
DermAtlas, Johns Hopkins University
Sickle Cell Patients

Prophylactic antibiotics to prevent any
infection from dental procedures because
they are highly susceptible to infection
Treatment Plan Modifications for
Sickle Cell Patients
Consult physician for premedication guidelines
 Routine dental care during non-crisis period
 Short, non-stressful appointments
 Prophylactic antibiotics to prevent any infection from
dental procedures because they are highly susceptible
to infection
 Avoid low concentration of oxygen with Nitrous Oxideuse 50% oxygen
 Avoid infection
◦ If it occurs, treat in aggressive manner
◦ Pain control with acetaminophen is small doses

Hemophiliacs/ Infusion


The factor replacement is
called infusion performed by:
◦ patient
◦ or care giver
◦ Patients who infuse at
home do it on an average
of every 2-4 months
Young patients with an early
history of bleeding:
◦ have an “intra-venous porta-cath”
◦ surgically placed for ease
of the infusion process
Dental Management of Serious Bleeding Disorder

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Consult, consult, consult physician before dental
treatment.
Establish PT,PTT or INR time before invasive procedures.
Patients at risk can experience spontaneous bleeding with
minor trauma to oral tissues
Be careful when inserting x-rays
No block anesthesia given unless replacement factors have
been given
Conservative periodontal procedures can be done
without replacement therapy
Aspirin and NSAIDs should not be used for pain relief
Patients with serious bleeding problems need hospitalized
for dental treatment
Pre-medication usually indicated for hemophilia
Replacement factor DDAVP/EACA can be given when
anticipating bleeding prior to appointment
Sources
Little JW, Falace D, Miller C, Rhodus N.
Dental Management of the Medically
Compromised Patient, Sixth edition:
Mosby 2002.
 Prevention of Infective Endocarditis;
2007 American Heart Association;
http://circ.ahajournals.org/cgi/content/full/
116/15/1736
