Patient Presentation
A 9-year-old female came to clinic for her health maintenance examination. She was doing well.
She had a history of atrial septal defect that she had repaired by a prosthetic device placed by an interventional cardiology procedure 2 years ago.
She had taken prophylactic antibiotics in the past for dental procedures, but her mother heard on the news that there were new guidelines and wanted to know if her daughter needed to continue to take the antibiotics.
The past medical history was otherwise normal.
The pertinent physical exam showed a thin female with growth percentiles in the 10-25%. Her cardiac examination showed a regular rate and rhythm without murmurs. Her upper extremity pulses were equal to her lower extremity pulses.
The diagnosis of a healthy female with stable, repaired, atrial septal defect was made. The physician was not aware of the new recommendations. He went to the American Dental Association’s website which gave him an overview of the recommendations and then he also accessed the new guidelines from the American Heart Association.
Since she was more than 2 years out from her procedure, she was not deemed to be at highest risk and therefore prophylactic antibiotics were not recommended for dental procedures or other procedures.
Discussion
The American Heart Association updated their prophylactic antibiotics guidelines for infective endocarditis (IE) prevention in May 2007. The guidelines are aimed at patients with the greatest risks, and eliminate patients with fewer risks who previously had prophylactic antibiotics recommended.
The Committee recommended changes after a literature evaluation. The changes were recommended based upon the risk/benefit balance of potential adverse side effects to the antibiotics verses risk of developing IE.
The main reasons for the new recommendations are that : 1. IE is more likely to be caused by activities of daily living (such as toothbrushing) than by various medical procedures (e.g. dental, gastrointestinal or genitourinary), 2. prophylaxis if given may prevent a very small number of IE cases and the risks of prophylactic antibiotic therapy outweigh the benefits,
and, 3. “maintenance of oral health and hygiene may decrease the incidence of bacteremia and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of IE.”
Infective endocarditis is a serious, potentially life-threatening but uncommon condition.
It is thought to be caused by a series of events where there is endothelial damage on the cardiac valve or elsewhere, production of nonbacterial thrombosis at the site of the endothelial damage, bacteria from a bacteremia in the bloodstream that then adheres to the thrombosis and finally proliferation of the bacteria within the thrombosis forming a vegetation.
Learning Point
The cardiac conditions associated with the highest risk of adverse outcome from IE for which antibiotic prophylaxis for dental procedures is recommended are:
- Previous IE
- Prosthetic cardiac valve
- Congenital heart disease (CHD)
- Unrepaired cyanotic CHD including palliative shunts and conduits
- Completely repaired CHD defect with prosthetic material or device, whether placed by catheter intervention or surgery, during the first 6 months after the procedure. (Endothelialization of the prosthetic material occurs during the first 6 months after the procedure so that prophylaxis is needed during this time period only.)
- Repaired CHD that has residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization)
- Cardiac transplantation recipients who develop cardiac valvulopathy
Note: except for the CHD conditions noted above, antibiotic prophylaxis is NOT RECOMMENDED for any other CHD conditions.
Dental procedures for which antibiotic prophylaxis is recommended are:
- All dental procedures that involve manipulation of the gingival tissue or the periapical region of the teeth or perforation of the oral mucosa in patients with underlying cardiac conditions associated with the highest risk of adverse outcome from IE listed above.
Dental procedures for which antibiotic prophylaxis is not recommended are:
- Anesthesia (routine) through non-infected tissue
- Dental radiographs, taking of
- Appliances, placement of removable prosthodontic or orthodontic
- Appliances, adjustment of orthodontic
- Brackets, placement of orthodontic
- Deciduous teeth shedding
- Bleeding from trauma to the lips or oral mucosa
Recommendations for respiratory tract, skin, musculoskeletal procedures
- Prophylactic antibiotics are recommended only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from IE listed above.
Recommendations for gastrointestinal or genitourinary procedures
- Prophylactic antibiotics solely to prevent IE is not recommended during gastrointestinal or genitourinary procedures.
- For patient with patients with underlying cardiac conditions associated with the highest risk of adverse outcome from IE previously listed above who are being treated with antibiotics for other reasons, may have antibiotics that prevent IE considered in the overall antibiotic treatment plan.
Questions for Further Discussion
1. What U.S. government agency produces the National Guideline Clearinghouse website that lists current guidelines from multiple institutions and organizations?
2. What are the five T’s of congenital heart disease?
3. What medications are recommended for treatment of IE?
Related Cases
- Disease
- Symptom/Presentation
- Specialty
- Age
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Information prescriptions for patients can be found at MedlinePlus for these topics: Endocarditis
and Congenital Heart Defects.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
American Dental Association. Infective Endocarditis. Available from the Internet at http://www.ada.org/prof/resources/topics/infective_endocarditis.asp (rev. 4/19/07, cited 5/2/07).
American Heart Association Rheumatic Fever,
Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular
Disease in the Young, and the Council on Clinical Cardiology, Council on
Cardiovascular Surgery and Anesthesia, and the Quality of Care and
Outcomes Research Interdisciplinary Working Group. Prevention of Infective Endocarditis
Guidelines. Circulation. 2007;115: Available from the Internet at http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.106.183095 (cited 5/3/07).
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
6. Information technology to support patient care decisions and patient education is used.
8. Health care services aimed at preventing health problems or maintaining health are provided.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.
15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.
16. Learning of students and other health care professionals is facilitated.
17. A therapeutic and ethically sound relationship with patients is created and sustained.
25. Quality patient care and assisting patients in dealing with system complexities is advocated.
Author
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa
Date
June 18, 2007
Pediatric Education 