Antibiotic Prophylaxis Against Infective Endocarditis - Dental Guidance PDF

Antibiotic Prophylaxis against Infective Endocarditis 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...

Antibiotic Prophylaxis against Infective Endocarditis 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 infective endocarditis (IE) and be able to apply the current antibiotic prophylaxis (AP) guidance to prevent IE in dental patients. Learning outcomes Describe infective endocarditis (IE) Specify the patient who are most at risk Outline the dental procedures that out a patient at risk of a bacteraemia Outline the current antibiotic prophylaxis (AP) guidance to prevent IE What is Infective Endocarditis ? Image credit clicks.co.za Infective endocartitis Is a life threatening bacterial infection of the heart Affects the heart valves in particular Rare – 1:10,000 people/year Predisposing cardiac conditions increase risk 50% of new cases have no known pre-existing cardiac disease Fatality 30% of cases 50% require cardiac surgery Incidence is rising in the UK Image credit clicks.co.za Image credit cthsurgery.com What causes it ? Oral streptococci implicated in some cases Only 25% of IE patients had Image credit thesdc.co.uk undergone an invasive dental procedure prior to diagnosis Cumulative low grade bacteraemia triggered by toothbrushing, flossing, chewing are of more significance- prevention is vital. Image credit I E early symptoms IE is hard to diagnose Early symptoms are often vague: Feeling unwell High temp – 38C or above Sweats or chills, esp at night Breathlessness, especially during physical activity Weight loss Tiredness/fatigue Muscle, joint or back pain- unrelated to physical activity IE late complications 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 Antibiotic Prophylaxis Image credit: survival-32.azurewebsites.net What is antibiotic prophylaxis? Giving patients high dose antibiotics 1 hour prior to delivering invasive dental treatment that might cause a bacteraemia Prevents bacteria infecting the damaged endocardium Usually Amoxycillin or Clindamycin 2013 – Cochrane review – insufficient evidence of effectiveness of AP in preventing IE Risk of adverse reactions Current guidance 2 key guidance documents: National Institute for Health and Care Excellence (NICE) (2016) Prophylaxis against infective endocarditis: antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures. Available at: https://www.nice.org.uk/guidance/cg64 Scottish Dental Clinical Effectiveness Programme (2018) Antibiotic Prophylaxis Against Infective Endocarditis. Available at: https://www.sdcep.org.uk/wp-content/uploads/2018/08/SDCEP-Antibiotic -Prophylaxis-Implementation-Advice.pdf AP advice from National Institute for Health and Care Excellence (NICE) Prior to 2008, AP routinely prescribed for all patients at risk of IE 2008-2016 AP not recommended for any patient at risk of IE 2016+ ‘antibiotic prophylaxis is not recommended routinely for people undergoing dental procedures’ SD CEP Antibiotic prophylaxis | Scottish D ental Clinical Effectiven (sdcep.org.uk) Image credit: SDCEP Who is at risk of IE ? Do they all need antibiotic prophylaxis? Only the patients with the conditions in bold need AP And only for specific 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 grafts Renal dialysis Intravenous access devices Immunocompromised patients Solid organ transplants Care with post H&N radiotherapy patients who may need it with extractions to prevent MRONJ Image credit: drchristophersherman.com Antibiotic prophylaxis regimes Standard antibiotic regime:  Antibiotic regime if allergic to amoxicillin: Patients most at risk of IE Important that patients are not discouraged from having dental treatment Liaise with referring GDP and cardiologist about AP and IE prevention Informed consent (Montgomery) – ‘material risks’, find out what specific patient wants to know Discuss benefits (prevention of IE) and risks (hypersensitivity, anaphylaxis and antibiotic-related colitis) Give information leaflet Document all discussions Think about how to maximise the amount of treatment in each visit, bearing in mind pt’s medical history Prevention +++ Prescribing antibiotics Prescription written by referring GDP If a patient has had a course of antibiotics in preceding 6 weeks, select antibiotic from a different antibiotic class BUT if patients require sequential invasive treatments over a short time period, the same antibiotic 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 practice: 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 patients 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 Antibiotic prophylaxis | Scottish D ental Clinical Effectiven (sdcep.org.uk) Give written information to patients at increased risk of IE https://www.sdcep.org.uk/wp-co ntent/uploads/2018/08/SDCEP-A ntibiotic-Prophylaxis-Patient-Infor mation.pdf Summary Described infective endocarditis (IE) Specified the patients who are most at risk of this disease Outlined the dental procedures that put a patient at risk of a bacteraemia Outline the current antibiotic prophylaxis (AP) guidance to prevent IE Further reading Glenny AM, Oliver R, Roberts GJ, Hooper L, Worthington HV. Antibiotics for the prophylaxis of bacterial endocarditis in dentistry. Cochrane Database of Systematic Reviews 2013, Issue 10. Available at: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD00381 3.pub4/full [Accessed 03 August 2021]. Dental Protection. Antibiotic prophylaxis against infective endocarditis. Available from https://www.dentalprotection.org/uk/articles/antibiotic-prophylaxis [Accessed 03 August 2021]. References www.sdcep.org.uk