Infective Endocarditis ; what’s all the fuss over one word?

1. Infective Endocarditis; what’s all the fuss over one word? ConalGormley “Antibiotic prohylaxis against infective endocarditis is not recommended routinely for patients undergoing dental procedures”

2. Aetiology Definition: 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

3. Pathogenesis Bacteria 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.

4. 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. 

5. Conflicting Advice In 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

6. High risk patients What 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

7. IE Signs and Symptoms These are very subtle and should IE be suspected should be referred to GP or their cardiologist urgently. • Malaise • Fever • Unexplained sudden weight loss • Red spotty rash (petechiae) • Worsening murmur • Muscle joint pain • Night sweats • Shortness of breath • Osler’s nodes • Nail splintering

8. IE Signs and Symptoms This 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.

9. Invasive procedure Is all Dentistry invasive? Defined as any procedure that perforates the oral mucosa or manipulates any of the gingival or periapical tissues. ESC Low Risk • LA to non-infected tissues • Caries removal • Suture removal • Dental radiography • Orthodontics • Prosthodontics • Trauma to lips/ skin ESC High Risk • Root CanalTreatment • Extractions • Scaling • Infiltration to infected tissues

10. SDCEP Guidelines Invasive 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 area • Placement of dental implants including temporary anchorage devices, mini-implants • Uncovering implant sub-structures Non-invasive dental procedures • Infiltration or block local anaesthetic injections in non-infected soft tissues • BPE 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.

11. 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. 

12. Prescribing Regimen Amoxicillin, 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.

13. Prescribing Regimen Clindamycin 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.

14. Prescribing Regimen Mark 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.

15. Montgomery Vs Lanarkshire Ultimately 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.

16. Routine Advice • Appendix 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.

17. Routine Advice • Risks 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.

18. 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!

19. References 1.) 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

20. Questions? Thank you for listening.