extractionprosthetic heart valves.

Why?To whom?When?What?

WHY

INFECTIVE ENDOCARDITIS

1. Number of bacteria entering the blood

2. Ability of bacteria to adhere to endocardium

3. Host factors increasing susceptibility (Neutropenia, Immunodeficiency, Malignancy, DM, alcohol or IV drug abuse)

4. Surgical trauma and DENTAL EXTRACTIONS

5. Congenital heart defects (Bicuspid aortic valve, VSD, PDA)

6. Rheumatic and other valvular disease

7. Prosthetic heart valves

8. Other cardiac diseases

BACTEREMIA

infective endocarditis

dental or other iatrogenic manipulation

Bacteremia 0-25% 25-50% 50-80%

Dental procedures Scaling and root planing

Periodontal prophylaxis

Extraction of tooth

Periodontal surgery

Multiple tooth extractions

Oral hygiene

procedures

Tooth brushing Use of interdental

sticks

Flossing

Water irrigation

Chewing

Sign & symptoms are highly variable

3 or 4 weeks after dental operation, there is insidious onset of low fever and a mild malaise

Pallor or light pigmentation of the skin, joint pains and Hepatosplenomegaly are typical

Progressive heart damage

Infection or embolic disease of many organs, especially the kidneys

SPLINTER HEMORRHAGE

JANEWAY LESIONS

ROTH’S SPOT

OSLER’S NODE

SUBCONJUCTIVAL HEMORRHAGE

1.To confirm the diagnosis 1)Blood Cultures

REJECTED

chance of dental extractions causing IEin a patient with valvular disease

1 in 3000

• Death from anaphylaxis to antibiotics are possibly 5 to 6 times more likely than death from IE

no evidence for the need for procedures that do not induce bleeding

Identification of patients at risk

Planned preventive dental care

Deciding which treatments require antimicrobial cover

Appropriate antibiotics at appropriate time

TO WHOM IS ANTIBIOTIC

PROPHYLAXIS GIVEN?

Risk of infective endocarditis after dental treatment

Dental radiography

Endodontics not beyond apex

Exfoliation of primary teeth

Impression making

Non surgical procedure that don’t induce bleeding

Abscess incision and drainage

Suture removal

Orthodontic band removal

Biopsy ?????

Recommending authority

Regimen

UK: British society for Antimicrobial Chemotherapy (1992)

A. Amoxicillin:3g 1h before treatmentB. Clindamycin:600mg 1h before treatment

EUROPEAN CONSENSUS (1995)

A. Amoxicillin:3g 1h before treatmentB. Clindamycin:300-600mg 1h before treatment

American Heart Association (1997)

A. Amoxicillin:2g 1h before treatmentB. Clindamycin:300-600mg 1h before treatment

Situation Agent Regimen—Single Dose 30-60 minutes before procedureAdult Children

Oral Amoxicillin 2 g 50 mg/kg

Unable totake oralmedication

Ampicillin or 2 g IM or IV* 50 mg/kg IMor IVCefazolin or

Ceftriaxone1 g IM or IV

50 mg/kg IMor IV

Allergic toPenicillin orAmpicillin—Oral regimen

Cephalexin or 2g 50mg/kg

Clindamycin or 600mg 20mg/kg

Azithromycin orClarithromycin

500mg 15mg/kg

Allergic toPenicillin orAmpicillin andunable to takeoral medication

Cefazolin orCeftriaxone

1 g IM or IV 50 mg/kg IMor IV

ORClindamycin

600 mg IMor IV

20 mg/kg IMor IV

*Adapted from Prevention of Infective Endocarditis: Guidelines From the American Heart Association,

by the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease. Circulation, 2007

CLINICAL SITUATION DRUG REGIMEN

Patient not allergic topenicillin ORpt. who have not received more than a single dose of penicillin in the previous month.

Amoxicillin AdultsOral amoxicillin 3g administered 1h before the procedureChildren <5yrs:oral amoxicillin 250mg 1hr before procedure.

5-10 yrs:Oral amoxicillin 500mg administered 1h before the procedure

>10yrs:use adult dose

CLINICAL SITUATION DRUG REGIMEN

Patient allergic topenicillin ORpt. who have had received more than a single dose of penicillin in the previous month.

Clindamycin AdultsOral clindamycin 600mg administered 1h before the procedureChildren <5yrs:oral clindamycin 150mg 1hr before procedure.

5-10 yrs:Oralclindamycin 300mg administered 1h before the procedure

>10yrs:use adult dose

CLINICAL SITUATION DRUG REGIMEN

The oral suspension of clindamycin is no longer available in UK.If children are unwilling or unable to swallow tablets or capsules, or pt are suffering with dysphagia,then azithromycin is suitable option.

Azithromycin (as a suspension)

Adults500mg administered 1h before the procedureChildren <5yrs:oral azithromycin 200mg 1hr before procedure.

5-10 yrs:Oralazithromycin 300mg administered 1h before the procedure

>10yrs:use adult dose

CLINICAL SITUATION DRUG REGIMEN

Patient not allergic topenicillin ORpt. who have not received more than a single dose of penicillin in the previous month.

AmoxicillinOrAmpicillin

Adultsi.v.amoxicillin 2 g administered upon attainment of GA and immediately before procedure

Children <5yrs:i.v.amoxicillin 250mg administered upon attainment of GA and immediately before procedure.

5-10 yrs:i.v.amoxicillin 500mg administered upon attainment of GA and immediately before procedure

>10yrs:use adult dose

CLINICAL SITUATION

DRUG REGIMEN

Patient allergic topenicillinOR

Patient who have had received more than a single dose of penicillin in the previous month.

Clindamycin Adultsi.v.clindamycin 300mg infused over at least 10 minutes upon attainment of GA and commenced before the start of dental surgery. This is followed by oral or i.v clindamycin 150mg 6 hrs later.Children <5yrs:i.v. clindamycin 75 mg infused over at least 10 minutes upon attainment of GA and commenced before the start of dental surgery.

5-10 yrs:i.v. clindamycin 150 mg infused over at least 10 minutes upon attainment of GA and commenced before the start of dental surgery.

>10yrs:use adult dose

CLINICAL SITUATION DRUG REGIMEN

For those at highest risk; prosthetic heart valveORprevious IE

AmoxicillinGentamycin

Adultsi.v. amoxicillin 2 g within the 30 mins before the procedure plus i.v.gentamicin 1.5 mg/kg within the same time periodFollowed postoperatively by oral amoxicillin 1g or i.v.amoxicillin 1g at 6 hrs post procedure

Children <5YRS as for<10YRS. I.V. Amoxicillin 1 g within the 30 mins before the procedure plus i.v. gentamycin 1.5mg/kg within the same time period. Followed post operatively by oral amoxicillin at 6 hrs post-procedure

CLINICAL SITUATION DRUG REGIMEN

For those at highest risk; prosthetic heart valve or previous IE

For patients allergic to penicillin

VancomycinGentamycin

Adultsi.v. Vancomycin 1 g infused over the 2 hrs before the procedure plus i.v.gentamicin 1.5 mg/kg within the same time period

Children <5YRS as for<10YRS.i.v. Vancomycin 20mg/kg infused over the 2 hr before the procedure plus i.v. gentamycin 1.5mg/kg within the same time period.Followed post operatively by oral amoxicillin at 6 hrs post-procedure

10% Povidone-Iodine or 0.5% Chlorhexidine gelChlorhexidine 0.2% mouthwash

• Good dental health

report any unexplained illness.

warning card

• If multiple visits are unavoidable at least 9-14 days

antibiotics must be given before extractions ,scaling and surgery involving the periodontal tissues with a recognized predisposing cardiac disorder.

Multiple visits for treatment using local anesthesia

a period of 1 month should elapse

amoxicillin one visit clindamycin clarithromycin next visit

congenital heart defect, immune deficienciesgross plaque accumulation periodontal

diseasedon’t appear to be particularly susceptible to IE.

keep periodontal infection at its lowest possible level

EXTRACTIONS, SCALING AND SURGERY INVOLVING THE PERIODONTAL TISSUES

bleeds

prophylaxis

Q. Which of the following patients would NOT need endocarditis prophylaxis?

A. Patient with previous IE

B. Patient with prosthetic cardiac valves

C. Pulmonary stenosis

D. Surgically conducted systemic –pulmonary shunts.

Q. What is the prevalence of bacteremia after a single tooth extraction?

A. 10-15%

B. 25-50%

C. 50-80%

D. 80-100%

Q. In which of the following dental procedure endocarditis prophylaxis is not recommended?

A. Sub gingival procedures

B. Sialography

C. Endodontic beyond the root apex

D. Abscess incision and drainage

A. Pyrexia

B. Embolic phenomenon

C. New valvular regurgitations

D. Intravenous drug misuse

Q. DRUG REGIMEN OF:

Amoxicillin:2g 1h before treatment

Clindamycin:300-600mg 1h before treatment

WAS GIVEN BY?

A. UK: British Society for Antimicrobial Chemotherapy (1992)

B. EUROPEAN CONSENSUS (1995)

C. American Heart Association (1997)

D. None of the above.