Antibiotic Prophylaxis Against Infective Endocarditis PDF

An#bio#c Prophylaxis against Infec#ve Endocardi#s Tutor Debbie Hemington Module BMS  GDC Learning Outcomes 1.1.3 Explain general and systemic disease and their relevance to oral health 1.1.8 Describe the properties of relevant medicines and therapeutic agents and discuss their application to pat...

An#bio#c Prophylaxis against Infec#ve Endocardi#s Tutor Debbie Hemington Module BMS  GDC Learning Outcomes 1.1.3 Explain general and systemic disease and their relevance to oral health 1.1.8 Describe the properties of relevant medicines and therapeutic agents and discuss their application to patient management 1.2.2 Recognise the importance of and record a comprehensive and contemporaneous patient history 1.5.2 Obtain valid consent from the patient before starting treatment, explaining all the relevant options and possible costs 1.7.2 Explain the impact of medical and psychological conditions in the patien 1.8.4 Take responsibility for ensuring compliance with current best practice guideline 1.10.3 Underpin all patient care with a preventive approach that contributes to the patient’s long-term oral health and general health Aim This is the headline Describe the risks of infec/ve endocardi/s (IE) and be able to apply the current an/bio/c prophylaxis (AP) guidance to prevent IE in dental pa/ents. Learning outcomes Describe infec/ve endocardi/s (IE) Specify the pa/ent who are most at risk Outline the dental procedures that out a pa/ent at risk of a bacteraemia Outline the current an/bio/c prophylaxis (AP) guidance to prevent IE What is Infec#ve Endocardi#s ? Image credit clicks.co.za Infec#ve endocar##s Is a life threatening bacterial infec/on of the heart ADects the heart valves in par/cular Rare – 1:10,000 people/year Predisposing cardiac condi/ons increase risk 50% of new cases have no known pre-exis/ng cardiac disease Fatality 30% of cases 50% require cardiac surgery Incidence is rising in the UK Vegetation of bacteria grow on heart valves Cause inflammation Image credit clicks.co.za Image credit cthsurgery.com  Bacteria or fungi enter bloodstream and attach to the heart What causes it ? Grow on the heart valves and cause inflammation Oral streptococci implicated in some cases Only 25% of IE pa/ents had Image credit thesdc.co.uk undergone an invasive dental procedure prior to diagnosis Cumula/ve low grade bacteraemia triggered by toothbrushing, Vossing, chewing are of more signiWcance- preven/on is vital. Image credit I E early symptoms IE is hard to diagnose Early symptoms are oXen vague: Feeling unwell High temp – 38C or above Sweats or chills, esp at night Breathlessness, especially during physical ac/vity Weight loss Tiredness/fa/gue Muscle, joint or back pain- unrelated to physical ac/vity IE late complica#ons Heart problems, eg: valve damage and heart failure Stroke Seizure Paralysis Abscesses in heart, brain, lungs & other organs Pulmonary embolism Kidney damage Kidney damage Enlarged spleen Death An#bio#c Prophylaxis Image credit: survival-32.azurewebsites.net What is an#bio#c prophylaxis? Giving pa/ents high dose an/bio/cs 1 hour prior to delivering invasive dental treatment that might cause a bacteraemia Prevents bacteria infec/ng the damaged endocardium Usually Amoxycillin or Clindamycin 2013 – Cochrane review – insuccient evidence of eDec/veness of AP in preven/ng IE Risk of adverse reac/ons Cautious with patients who have gastrointestinal tract disease Current guidance 2 key guidance documents: Na/onal Ins/tute for Health and Care Excellence (NICE) (2016) Prophylaxis against infec3ve endocardi3s: an3microbial prophylaxis against infec3ve endocardi3s in adults and children undergoing interven3onal procedures. Available at: hfps://www.nice.org.uk/guidance/cg64 Scohsh Dental Clinical EDec/veness Programme (2018) An3bio3c Prophylaxis Against Infec3ve Endocardi3s. Available at: hfps://www.sdcep.org.uk/wp-content/uploads/2018/08/SDCEP-An/bio/c -Prophylaxis-Implementa/on-Advice.pdf AP advice from Na#onal Ins#tute for Health and Care Excellence (NICE) Prior to 2008, AP rou/nely prescribed for all pa/ents at risk of IE 2008-2016 AP not recommended for any pa/ent at risk of IE 2016+ ‘an3bio3c prophylaxis is not recommended rou$nely for people undergoing dental procedures’ SD CEP An/bio/c prophylaxis | Scohsh D ental Clinical EDec/ven (sdcep.org.uk) Image credit: SDCEP Who is at risk of IE ? Do they all need an/bio/c prophylaxis? Only the pa/ents with the condi/ons in bold need AP And only for speciWc invasive dental procedures Who is most at risk of IE ? Do they need AP for every dental procedure? Only for INVASIVE dental procedures When is AP not given? Joint replacements Pacemaker Coronary artery stents Coronary artery bypass graXs Renal dialysis Intravenous access devices Immunocompromised pa/ents Solid organ transplants Care with post H&N radiotherapy pa/ents who may need it with extrac/ons to prevent MRONJ Image credit: drchristophersherman.com  Witness taking antibiotic and record time An#bio#c prophylaxis regimes Standard an/bio/c regime:  An/bio/c regime if allergic to amoxicillin: Pa#ents most at risk of IE Important that pa/ents are not discouraged from having dental treatment Liaise with referring GDP and cardiologist about AP and IE preven/on Informed consent (Montgomery) – ‘material risks’, Wnd out what speciWc pa/ent wants to know Discuss beneWts (preven/on of IE) and risks (hypersensi/vity, anaphylaxis and an/bio/c-related coli/s) Give informa/on leaVet Document all discussions Think about how to maximise the amount of treatment in each visit, bearing in mind pt’s medical history Preven/on +++ Prescribing an#bio#cs Prescrip/on wrifen by referring GDP If a pa/ent has had a course of an/bio/cs in preceding 6 weeks, select an/bio/c from a diDerent an/bio/c class BUT if pa/ents require sequen/al invasive treatments over a short /me period, the same an/bio/c can be prescribed for each treatment episode If neither Amoxicillin or Clindamycin are suitable, seek advice from specialist Where should AP be taken? At Eastman, take ABC in hospital and wait 1 hour In general dental prac/ce: First time, pt should take AP in the dental practice and wait 1 hour Subsequent times, pt can take AP at home 1 hour prior to appointment What about pa#ents who are at increased risk of IE but not in the highest risk group Discuss risk of IE Discuss potential benefits and risks of AP Explain that AP is no longer routinely recommended Emphasise good oral health and prevention Discuss symptoms of endocarditis Give information leaflet Ensure any dental infections are treated promptly to reduce the risk of IE developing Flowchart to download An/bio/c prophylaxis | Scohsh D ental Clinical EDec/ven (sdcep.org.uk) Give wriNen informa#on to pa#ents at increased risk of IE hfps://www.sdcep.org.uk/wp-co ntent/uploads/2018/08/SDCEP-A n/bio/c-Prophylaxis-Pa/ent-Infor ma/on.pdf Summary Described infec/ve endocardi/s (IE) SpeciWed the pa/ents who are most at risk of this disease Outlined the dental procedures that put a pa/ent at risk of a bacteraemia Outline the current an/bio/c prophylaxis (AP) guidance to prevent IE Further reading Glenny AM, Oliver R, Roberts GJ, Hooper L, Worthington HV. An/bio/cs for the prophylaxis of bacterial endocardi/s in den/stry. Cochrane Database of Systema/c Reviews 2013, Issue 10. Available at: hfps://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD00381 3.pub4/full [Accessed 03 August 2021]. Dental Protec/on. An/bio/c prophylaxis against infec/ve endocardi/s. Available from hfps://www.dentalprotec/on.org/uk/ar/cles/an/bio/c-prophylaxis [Accessed 03 August 2021]. References www.sdcep.org.uk