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How Have Endocarditis Prophylaxis Guidelines Changed?

After more than 50 years of recommending antibiotic prophylaxis coverage for all invasive dental procedures and other types of oral surgery for virtually all children with congenital heart disease, the American Heart Association (AHA) has radically reduced the indications for prophylaxis as of April 2007. Although the length of time to give antibiotics around dental surgery or oral surgery had dropped several times since the initial recommendations from 1955 up to the most recent revision in 1997, the 2007 document represents a major departure from all previous AHA recommendations.

This decision was reached by an expert panel of pediatric cardiologists, pediatric infectious disease specialists, and adult cardiologists. The decision to dramatically revise the endocarditis prophylaxis guidelines was made by this large group of consultants to the AHA after an exhaustive review of the medical literature. A strict evidence-based analysis was utilized and the committee found no evidence for a Class I recommendation for prophylaxis (Class I being defined as a recommendation for which there is evidence and/or general agreement that a given procedure or treatment is beneficial, useful, and effective). Similarly the committee could not find any Level of Evidence A (defined as evidence derived from multiple randomized clinical trials or meta-analyses) in favor of the widespread use of antibiotics to prevent infectious endocarditis (IE). The primary reasons for revision of the IE prophylaxis guidelines are as follows:

  1. IE is much more likely to result from frequent exposure to random bacteremias associated with daily activities than from bacteremia caused by a dental, GI tract, or GU tract procedure.
  2. Prophylaxis may prevent an exceedingly small number of cases of IE, if any, in individuals who undergo a dental, GI tract, or GU tract procedure.
  3. The risk of antibiotic-associated events exceeds the benefit, if any, from prophylactic antibiotic therapy.
  4. Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of IE.

The committee did do an analysis of cardiac conditions with the highest risk of adverse outcome from endocarditis and for these uncommon conditions the committee continues to recommend prophylaxis. The cardiac conditions which were judged to meet the standard of highest risk are:

  1. Patients with a prosthetic cardiac valve
  2. Patients with a history of previous episodes of endocarditis
  3. Patients with unrepaired cyanotic congenital heart disease
  4. Patients who are post-operative or post-interventional catheterization with prosthetic material in place for six months while endothelialization occurs (i.e. ASD devices, PDA coils, etc.)
  5. Repaired congenital heart disease where there is a residual defect at the site of or adjacent to prosthetic material (i.e. a post-op VSD with a patch leak)
  6. Post-cardiac transplant patients with cardiac valvulopathy

Patients in these six groups will continue to receive antibiotic prophylaxis as before, i.e. for all dental procedures that involve manipulation of gingival tissue or the periapical region of the teeth or perforation of the oral mucosa. The taking of dental radiographs, the placement or removal of orthodontic appliances, the placement of orthodontic brackets, the shedding of deciduous teeth, and bleeding from trauma to the lips or oral mucosa not requiring stitches do not require antibiotic prophylaxis. Gastrointestinal, genitourinary procedures and manipulations, vaginal delivery, hysterectomy and tattooing do not require antibiotic prophylaxis. While the committee recommends against body piercing in these remaining high risk groups, the use of antibiotic prophylaxis remains controversial.

As a result of these recommendations the majority of our patients and specifically those with unrepaired VSD’s or atrial septal defects, pulmonic stenosis, aortic stenosis, and coarctation of the aorta as well as patients with transposition and tetralogy of Fallot as well as the other cyanotic conditions who have had successful surgery no longer need antibiotic prophylaxis for dental surgery or other oral surgery. Over the first few months of these new recommendations I have found the parents of our patients to be very receptive to the new recommendations. Only time, of course, will tell whether this major revision to AHA policy proves to be completely correct for children with congenital heart disease.

The full report (.pdf) can be found in The Journal of the American Dental Association (JADA 138:739-760, 2007).

Michael S. Schaffer, M.D. Professor of Pediatrics, Medical Director of Outpatient Services, Pediatric Cardiology, Children's Hospital Colorado/University of Colorado School of Medicine