Antibiotic Prophylaxis Against Infective Endocarditis

Question 1

Who are included in the special consideration sub-group for those at increased risk of infective endocarditis?

Answer 1

• prosthetic valve
• previous episode of infective endocarditis
• congenital heart disease

Question 2

What is the management for patients in the special consideration sub-group for increased risk of infective endocarditis (IE)?

Answer 2

Ensure patient is aware of their risk of IE and provide advice about prevention:
* potential benefits and risks of antibiotic prophylaxis, and an explanation of why antibiotic prophylaxis is nno longer routinely recommended
* importance of maintaining good oral health
* symptoms that may indicate infective endocarditis and when to seek expert advice
* risks of undergoing invasive procedures, including non-medical procedures ie body piercing or tattooing

Contact patient’s cardiology consultant, cardiac surgeon or local cardiology centre to determine if prophylaxis should be considered for invasive procedures.

If the cardiologist advises that prophylaxis should be considered, discuss the potential benefits and risks of prophhylaxis for invasive dental procedures with the patient to allow them to make an informed decision

Give advice on possible adverse events ie. hypersensitivity, anaphylaxis and antibiotic-related colitis

Question 3

What patients are at increased risk of infective endocarditis?

Answer 3

• acquired valvular heart disease with stenosis or regurgitation
• hypertrohpic cardiomyopathy
• previous endocardicitis
• structural congenital heart disease, including surgically corrected or palliated structural conditions, but excluding isolated atrial septal defect, fully repaired ventricular septal defect or fully repaird patent ductus arteriosus, and closure devices that are judged to be endothelialised;
• valve replacement

Question 4

What is Infective Endocarditis?

Answer 4

A rare (less than 1 case per 10,000 individuals per year) but life-threatening infection of the endocardium, particularly affectinng the heart valves.

Question 5

List examples of invasive dental procedures.

Answer 5

• placement of matrix bands
• placement of sub-gingival rubber dam clamps
• sub-gingival restorations including fixed prosthodontics
• endodontic treatment before apical stop has been established
• preformed metal crowns
• full periodontal examinations
• root surface instrumentation/sub-gingival PMPR
• incision and drainage of abscess
• dental extractions
• surgery involving elevations of a mucosal periosteal flap or muco-gingival area
• placement of dental implants including TADs, mini-implants
• uncovering implant sub-structures

AB prophylaxis, if given, should only be for invasive dental procedures.

Question 6

What can you prescribe for antibiotic prophylaxis?

Answer 6

Amoxicillin, 3g Oral Powder Sachet
3g (1 sachet) 60 minutes before procedure

Penicillin allergy:

Clindamycin Capsules, 300mg
600mg (2 capsules) 60 minutes before procedure swallowed with water

C/I: diarrhoea

Question 7

Describe the points to cover during AB prophylaxis discussion with patient.

Answer 7

• due to heart condition/previous episode of IE, there is a very small risk of developing IE following an invasive dental procedure
• IE is an infection of the lining of the heart, often involving the heart valves, caused mainly by bacteria which enter the blood from outside the body
• IE is a very rare but serious condition. risk is less than 1 case per 10,000 people per year.
• having an invasive dental procedure, ie. extraction, may increase the chances of bacteria entering the bloodstream
• everyday activities, ie. toothbrushing, flossing and chewing, can also cause transiennt bacteraemias and stress the importance of good oral hygiene to reduce the risk from oral bacteria
• potential benefits and risks of AB prophylaxis, and why AB prophylaxis is no longer routinely recommended (dental procedures no longer thought to be the main cause of IE; unclear whether AB prophylaxis prevents IE; AB can cause side effects ie. nausea, diarrhoea, allergy, anaphylaxis and antibiotic-related colitis)
• importance of maintaining good oral health (regular dental checks, excellent oral hhygiene, reduce frequency of sugary snacks and drinks to prevent tooth decay)
• risks of undergoing invasive procedures including non-medical procedures ie. body piercing or tattooing
• contact GP if they notic any of the following symptoms/flu-like illness: fever, sweats or chills especially at night, breathlessness especially during physical activity, weight loss, fatigue, muscle, joint or back pain unrelated to recent physical activity
• record all discussions with the patient in their clinical notes