Antibiotic Prophylaxis for Infective Endocarditis
Exam Pass Notes
Key Takeaways
- Antibiotic prophylaxis (ABP) is not routinely recommended for preventing infective endocarditis (IE) in dental patients.
- High-risk patients may require ABP, determined through consultation with a cardiologist.
- Maintaining good oral hygiene is crucial to reduce IE risk from everyday bacteraemia.
- NICE CG64 and SDCEP guidance emphasize collaborative decision-making and documentation.
- Antibiotic resistance and adverse reactions remain significant concerns in ABP use.
Overview
- Infective endocarditis is a rare but serious infection with high mortality and morbidity rates.
- Routine activities like tooth brushing contribute more to IE risk than dental procedures.
- NICE CG64 (2008, updated 2015 and 2016) advises against routine ABP, citing weak evidence of efficacy.
- SDCEP provides detailed implementation advice for high-risk cases.
Criteria for High-Risk Patients
- Prosthetic valves or material used in valve repair.
- History of infective endocarditis.
- Certain congenital heart defects, such as cyanotic conditions or those with residual defects after repair.
- Acquired valvular heart disease or hypertrophic cardiomyopathy.
Challenges in ABP Guidance
- Ambiguities in identifying high-risk patients and selecting appropriate regimens.
- Variability in implementation across practices.
- Balancing individual patient risks with broader public health concerns.
Key Discussion Points With Patients
- IE Risk: Rare but severe, with less than 1 case per 10,000 annually in the general population.
- Bacteraemia Sources: Includes dental procedures, brushing, flossing, and chewing.
- ABP Risks: Includes nausea, allergic reactions, anaphylaxis, and antibiotic resistance.
- Prevention: Emphasize oral hygiene, regular check-ups, and reduced sugar intake.
Antibiotic Regimens
- Amoxicillin (Preferred): 3 g orally 60 minutes before procedure for adults; 50 mg/kg for children (max 3 g).
- Clindamycin (Penicillin-Allergic): 600 mg orally for adults; 20 mg/kg for children (max 600 mg).
- Alternatives: Azithromycin or intravenous options for specific cases.
Prevention Strategies
- Maintain excellent oral hygiene to minimize bacteraemia from routine activities.
- Promptly treat dental infections to reduce IE risk.
- Document patient discussions and decisions thoroughly in clinical records.
Legal and Ethical Considerations
- Consent must align with the principles of Montgomery v Lanarkshire Health Board.
- Inform patients about material risks, benefits, and alternatives.
- Ensure documentation reflects shared decision-making.
Clinical Application
- For most patients, routine ABP is unnecessary—focus on education and prevention.
- Consult cardiology specialists for high-risk patients requiring ABP.
- Encourage patients to recognize IE symptoms (e.g., fever, fatigue, unexplained weight loss) and seek prompt medical care.