Conal Gormley “Antibiotic - PowerPoint Presentation

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Conal Gormley“Antibiotic prohylaxis against infective endocarditis is not recommended routinely for patients undergoing dental procedures”

Infective

Endocarditis

; what’s all the fuss over one word?

AetiologyDefinition: Infective (bacterial) endocarditis (IE) is an infection of either the heart’s inner lining (endocardium) or the heart valves. 

High morbidity and mortality rates

Approx 2150 cases per annum in the UK

15-20% die when get admitted to hospital;

Further 10-15% die in the year following admission.

Rare 1:10,000 per annum

PathogenesisBacteria and/ or fungal organisms are implicated with specific known link to oral

viridans

streptococci.

These bacteria can be traced to the

Mouth and Upper Respiratory System,

Skin

GI and Urinary Tracts

35-45% streptococci

viridans

, 35-45% staphylococci

Antibiotic have been given as prophylaxis for these high risk patients since around 1923.

Conflicting Advice NICE guidelines (CG 64) published in 2008. Reviewed evidence or lack of it. No randomised controlled trials, no systematic reviews (and not likely to have any in the future). 

They concluded to stop giving Antibiotic Prophylaxis for "at-risk" patients as no evidence that it is improving outcomes.

This was contradictory to both the European Society of Cardiology and the American Heart Association (again based on weak evidence) who argued that we should continue with Antibiotic Prophylaxis as risk of adverse drug reaction is outweighed by risks related to IE. 

Conflicting AdviceIn the years since 2008

there has been an increased incidence of IE within the UK

outwith

measurements that include the rest of the world. 

88% fall in prophylactic prescribing

This prompted review of the guidance again to which NICE concluded;

“Antibiotic prophylaxis against infective endocarditis is not recommended

routinely

for patients undergoing dental procedures” NICE 2016

High risk patientsWhat to look for in a patient’s Medical History;

Previous history of IE

Prosthetic heart valves

Valve repairs using prosthetic material

Cyanotic congenital heart disease

Congenital heart disease repaired with prosthetic material (up to 6 months post-op, or lifelong if residual shunt or regurgitation

IE Signs and SymptomsThese are very subtle and should IE be suspected should be referred to GP or their cardiologist urgently.

Muscle

joint pain

Night sweats

Shortness of breath

Osler’s

nodes

Nail

splintering

Malaise

Fever

Unexplained

sudden weight loss

Red spotty rash

(petechiae)

Worsening

murmur

IE Signs and SymptomsThis can happen in 2 ways;

1. Acute

– happens of a course of a few days following an invasive procedure e.g. dental treatment or getting a body piercing, tattoo etc. 

2. Subacute

– over a period of weeks or even months  following an invasive procedure.

Invasive procedureIs all Dentistry invasive?

Defined as any procedure that perforates the oral mucosa or manipulates any of the gingival or

periapical

tissues.

ESC High Risk

Root

Canal

Treatmen

t

Extractions

Scaling

Infiltration to infected tissues

ESC Low Risk

LA to non-infected tissues

Caries removal

Suture

removal

Dental

radiography

Orthodontics

Prosthodontics

T

rauma

to lips/ skin

SDCEP GuidelinesInvasive dental procedures

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 (PMC/SSCs)

Full periodontal examinations (including pocket charting in diseased tissues)

Root surface instrumentation/sub-gingival scaling

Incision and drainage of abscess

Dental extractions

Surgery involving elevation of a

muco-periosteal

flap or

muco-gingival areaPlacement of dental implants including temporary anchorage devices, mini-implantsUncovering implant sub-structures

Non-invasive dental proceduresInfiltration or block local anaesthetic injections in non-infected soft tissuesBPE screening

Supra-gingival scale and polish

Supra-gingival restorations

Supra-gingival orthodontic bands and separators

Removal of sutures

Radiographs

Placement or adjustment of orthodontic or removable

prosthodontic

appliances

N.B. In addition, antibiotic prophylaxis is not recommended following exfoliation of primary teeth or trauma to the lips or oral mucosa.

What do we prescribe?High Risk patients undergoing invasive dental procedure (Non-Routine Management)

Amoxicillin is much safer compared to Clindamycin with far fewer adverse drug reactions

Anaphylaxis, Antibiotic associated colitis, hypersensitivity reaction, increase risk of primary and secondary C. Diff

Important to check Medical history for Allergy to Penicillin and those who are elderly and have a history of GI tract issues.

However Antibiotic prophylaxis risk still outweighs the benefit considering morbidity and  how poor Quality of Life is post- IE. 

Prescribing RegimenAmoxicillin, 3 g Oral Powder Sachet*

Give: 3 g (1 sachet) 60 minutes before procedure

(3 g prophylactic dose) 

Dose for children:

Amoxicillin Oral Suspension*, 250 mg/5 ml or 3 g Oral Powder Sachet*

6 months – 17 years: 50 mg/kg;

maximum dose 3 g

(prophylactic dose)

NB: Amoxicillin, like other

penicillins

, can result in hypersensitivity reactions, including rashes and anaphylaxis, and can cause antibiotic-associated colitis, which may be fatal. Do not give amoxicillin to patients with a history of anaphylaxis,

urticaria

or rash immediately after penicillin administration as these individuals are at risk of immediate hypersensitivity.

Amoxicillin potentially alters the anticoagulant effect of

warfarin and therefore the INR of a patient taking warfarin should be monitored.Refer to Appendix 1 of the BNF and BNFC for details of drug interactions.ESC say only 2g but 2g not readily available in UK so 3g suitable alternative

.

Prescribing RegimenClindamycin

Capsules, 300 mg

Give: 600 mg (2 capsules) 60 minutes before procedure

(600 mg prophylactic dose) 

Dose for children*:

6 months – 17 years: 20 mg/kg;

maximum dose 600 mg

(prophylactic dose)

NB: Advise patient that capsules should be swallowed with a glass of water.

Do not prescribe

clindamycin

to patients with diarrhoeal states.

Be aware that

clindamycin

can cause the side-effect of antibiotic-associated colitis, which may be fatal.Refer to Appendix 1 of the BNF and BNFC for details of drug interactions.*As clindamycin is not available as an oral suspension, it may not be possible to give the appropriate dose for some child weight ranges. Azithromycin oral suspension is a suitable alternative in this situation.

Prescribing RegimenMark on prescription that drugs are for prophylaxis

For patients who require sequential invasive treatments over a short time period, the same antibiotic can be prescribed for the purposes of prophylaxis for each treatment episode.

Ensure drug is taken 30-60mins prior to invasive treatment. If a patient has decided to take Antibiotic off location important for them to contact practice prior to this to ensure planned treatment is going ahead.

Montgomery Vs LanarkshireUltimately it is all about

Consent

Provide your patient with material risks and benefits;

Explain guidance, if they decide to go with this then document and record, if decide to go against again document and record but it is the patients decision.

Explain risk of Antibiotic prophylaxis Vs without, risk of IE depending on their risk category or without.

To have or not to have.... That is the question.

Routine AdviceAppendix 3 +4 of SDCEP very good and provides practice leaflets.

Ensure that the patient and/or their carer or guardian are aware of their risk of infective

endocarditis

and provide advice about prevention, including:

Importance of maintaining good oral health;

Flossing, tooth brushing, eating have just as much exposure at low level as invasive treatment.

Know Symptoms that may indicate infective

endocarditis

and when to seek expert advice.

Routine AdviceRisks

of undergoing invasive procedures, including non-medical procedures such as body piercing or tattooing.

If, following this discussion, the patient requests antibiotic prophylaxis, consider seeking advice from their cardiologist.

Ensure that any episodes of dental infection in patients at increased risk of infective

endocarditis

are investigated and treated promptly to reduce the risk of

endocarditis

developing.

Early Detection

If unsure about anything with relation to IE or about this speak to the patient’s Cardiologist

Early detection is vital to improving mortality and ultimately our patients quality of life!

References1.) BDJ Article ;Guidelines on prophylaxis to prevent infective

endocarditis

M. H.

Thornhill

,*1 M. Dayer,2 P. B. Lockhart,3 M. McGurk,4 D. Shanson,5 B. Prendergast6 and J. B. Chambers7

2.) ESC Guidelines;

https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Infective-Endocarditis-Guidelines-on-Prevention-Diagnosis-and-Treatment-of

3.) SDCEP

Antibiotic Prophylaxis Against Infective

Endocarditis

Implementation Advice;

http://www.sdcep.org.uk/wp-content/uploads/2018/08/SDCEP-Antibiotic-Prophylaxis-Implementation-Advice.pdf

Questions?

Thank you for listening.