ESC Congress - News - 2007 - ENDOCARDITIS

ESC Congress - 2007

Date : 3 September 2007

Reported by : Boudoulas, Harisios (Greece)

Challenges in endocarditis Symposium

Infective endocarditis is a serious and often fatal disease with multiple cardiac and extracardiac manifestations. As a general rule, endocarditis affects patients with underlying valvular heart disease (especially prosthetic valves) and congenital heart disease. Patients with intracardiac catheters, e.g. pacemakers, defibrillators, are also prone to endocarditis. The disease is common in IV drug abusers and patients with compromised immune systems. Criteria and guidelines have been established for the diagnosis and management of endocarditis; these guidelines however cannot replace clinilca judgement, clinical experience and common sense. Endocarditis should be suspected in any patient with unusual symptoms, fever, “Not feeling well”, especially if a heart murmur is present.

Patients with endocarditis or suspected endocarditis should be managed in a large medical center where a cardiologist, a cardiac surgeon, and an infectious disease physician should be involved in the patient’s care. Blood cultures should be obtained in all patients, and therapy with antibiotics should be based on the isolated microorganism and sensitivity tests. It should be emphasised that up to 30% of blood cultures could be negative if they are obtained after the initiation of antibiotic therapy.

A transoesophageal echocardiogram (TEE) should be performed in all patients with endocarditis. Size and precise location of vegetations, aortic root abscess (10-30% of patients) can be only defined with TEE. Surgery, if it is indicated (heart failure, embolic events, large size vegetations) should be performed without delay.

Extracardiac manifestations of endocarditis, such as skin lesions, neurologic phenomena, renal and other organ involvement are not uncommon. Clinical manifestations of endocarditis in developing countries may be quite different. As a general rule, the diagnosis is delayed (more than a month) and the presence of other infectious diseases, e.g. malaria, may alter the clinical picture and the course of the disease.

Patients with valvular heart disease, congenital heart disease and intracardiac catheters should maintain the best oral hygiene to prevent endocarditis.

Conclusions:

Endocarditis is a serious and often fatal disease with multiple cardiac and extracardiac manifestations. The management of endocarditis should be based primarily on good clinical judgement and common sense. Patients with endocarditis should be managed in a large medical center. A cardiologist, cardiac surgeon and infectious diseases specialist should be involved in the patient’s care. Blood cultures should be obtained in all patients with suspected endocarditis prior to therapy with antibiotics. Optimal oral hygiene can help prevent the development of infective endocarditis

Prevention of infective endocarditis: new US Guidelines

Prevention of infective endocarditis: new US Guidelines bring major changes for at-risk patients

Infective endocarditis (IE) is a life-threatening disease associated with a high mortality rate. To avoid its severe complications, several recommendations have been published during the past 20 years about the best use of antimicrobial prophylaxis to prevent IE in patients who undergo a dental, gastrointestinal (GI) or genitourinary (GU) tract procedures. However, efficacy of such prophylaxis has been questioned and several authorities have suggested that guidelines need to be revised and simplified.

The new American guidelines for prevention of infective endocarditis

The main changes in the updated American recommendations are as follows:

1. IE prophylaxis for dental procedures should be recommended only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from IE.

2. For patients with these underlying cardiac conditions, prophylaxis is recommended for all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa.

3. Prophylaxis is not recommended based solely on an increased lifetime risk of acquiring IE.

4. Administration of antibiotics solely to prevent endocarditis is not recommended for patients who undergo a genitourinary or gastrointestinal tract procedure.

A considerable change for patients with cardiac disease


These represent a considerable change and limitation in the current use of endocarditis prophylaxis for Americans with cardiac disease; for instance:

• patients at risk: only those with the highest risk of adverse outcome in case of IE are considered for prophylaxis, including prosthetic cardiac valves, previous endocarditis, unrepaired congenital heart disease, and cardiac transplants who develop cardiac valvulopathy.
Most patients with valvular heart disease are no longer considered candidates for antibiotic prophylaxis;

• the dental procedures for which IE prophylaxis is recommended: all procedures involving manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa are considered at risk and need prophylaxis when performed in at-risk patients;

• the GU or GI tract procedures: antibiotic prophylaxis is no longer recommended in these procedures

Limits to applying American guidelines in Europe

Before applying the American guidelines in Europe, we need to consider their limitations.

First, the new guidelines are not based on randomised studies.

Second, such radical modifications may be difficult to accept and understand by both patients and practitioners, and much effort will be required to explain them carefully, particularly so that patients understand the shift from focus on dental procedures towards a greater access to dental care and oral health for those with cardiac disease associated with the worst outcome after IE.

Third, these guidelines probably will be followed by a reduction in the number of antibiotic prescriptions for preventing IE in the USA. It will be important to monitor the consequences on the epidemiologic profile of IE in the USA.

Finally, prospective placebo-controlled double-blinded studied of antibiotic prophylaxis of IE in patients at risk of IE remain necessary, as well as additional prospective case-control studies.The ESC is developing a new version of the 2004 IE guidelines. These will focus on prevention, diagnosis and treatment of IE and are expected by 2009.

Revised AHA Guidelines for Prevention of Endocarditis

Revised AHA Guidelines for Prevention of Endocarditis

Allan S. Brett, MD

Journal Watch. 2007;6(6) ©2007 Massachusetts Medical Society
Posted 07/25/2007

Major changes include a narrowed list of cardiac conditions that warrant prophylaxis, and the elimination of gastrointestinal and genitourinary indications for prophylaxis.

Summary

The complex 1997 American Heart Association (AHA) recommendations for preventing infective endocarditis have guided practice during the past decade. However, experts have long acknowledged that the evidence to support the effectiveness of endocarditis prophylaxis is not compelling. For example, cumulative exposure to bacteremia from daily oral activities (e.g., chewing, brushing, flossing) is thousands of times greater than exposure from a few dental visits yearly. Thus, prophylaxis for dental procedures is likely to prevent only a tiny proportion of cases of endocarditis, at best.

In view of the limited evidence, the AHA has published a new guideline with the following key elements:

1. Prophylaxis is now recommended only for patients with these four conditions:

prosthetic cardiac valve
previous infective endocarditis
certain types of congenital heart disease (see guideline for details)
cardiac transplantation with valvulopathy

2. For patients with the conditions listed above, prophylaxis should be given only before:
dental procedures that involve manipulation of gingival tissue or the periapical region of teeth, or perforation of oral mucosa (see guideline for dental procedures that do not require prophylaxis)

incision or biopsy of respiratory tract mucosa
procedures on infected skin or musculoskeletal structures

3. Prophylaxis is no longer recommended for gastrointestinal or genitourinary procedures. However, if urine is colonized by enterococcus, eradication before invasive urinary procedures is reasonable.

4. A single 2-g dose of amoxicillin, given 30 to 60 minutes before the procedure, remains the regimen of choice (see guideline for alternatives in cases of penicillin allergy or inability to take oral medication).

Comment

This new guideline will substantially reduce the number of people who receive endocarditis prophylaxis. Conspicuous changes from the previous guideline include the elimination of acquired valvular dysfunction (including mitral valve prolapse) from the list of cardiac conditions warranting prophylaxis, and the elimination of gastrointestinal and genitourinary indications for prophylaxis. In my view, primary care clinicians should read the full guideline so that they can knowledgeably advise patients and dentists who might resist these changes.

Antibiotic prophylaxis seldom needed for dental procedures, say updated recommendations

Apr 19, 2007

Dallas, TX - Prophylactic antibiotic therapy for dental procedures is unlikely to prevent many cases of infective endocarditis and should be restricted to patients who would be at highest risk from the infection, such as those with prosthetic valves or certain congenital heart defects, according to updated guidelines issued this week by the American Heart Association (AHA) and published online April 19, 2007 in Circulation [1].

"We've concluded that if giving prophylactic antibiotics prior to a dental procedure works at all—and there's no evidence that it does work—we should reserve that preventive treatment only for those people who would have the worst outcomes if they get infective endocarditis," according to the chair of the new guidelines' writing group, Dr Walter R Wilson (Mayo Clinic, Rochester, MN), as quoted in a statement issued by the AHA. "This changes the whole philosophy of how we have constructed these recommendations for the past 50 years."

Based on an analysis of available literature, the document concludes that "random bacteremia" resulting from routine daily activities, such as chewing food or tooth brushing, is far more likely to cause infective endocarditis than bacteremia secondary to dental procedures.

"There should be a shift in emphasis away from a focus on a dental procedure and antibiotic prophylaxis toward a greater emphasis on improved access to dental care and oral health in patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis and those conditions that predispose to the acquisition of infective endocarditis," according to the updated guidelines.

Prophylactic antibiotics, they state, should not be given based on a lifetime risk of infective endocarditis but are recommended for high-risk patients undergoing "procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa." Such "high-risk" patients, according to the report, include recipients of cardiac transplants who develop cardiac valvulopathy and patients with:

• Prior infective endocarditis.

• Prosthetic cardiac valves.

• Unrepaired cyanotic congenital heart defects, including palliative shunts and conduits.

• Congenital heart defects completely repaired with prosthetic material or a device, whether placed by surgery or by catheter intervention, during the first six months after the procedure.

• Repaired congenital defects with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device.

Patient groups that may have received routine antibiotic prophylaxis in the past but are now inappropriate for it include those with mitral and aortic valve disease, rheumatic heart disease, or structural disorders like ventricular or atrial septal defects or hypertrophic cardiomyopathy, according to the AHA statement.

The revised guidelines were developed with the participation of and have been endorsed by the American Dental Association, the Infectious Diseases Society of America, and the American Academy of Pediatrics.

Disclosures of potential conflicts of interest for the writing group and the document's reviewers are included in the report

Source

Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis guidelines from the American Heart Association. A guideline from the 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. Circulation 2007. DOI:10.1161/CIRCULATIONAHA.106.183095. Available at: http://www.theheart.org/viewDocument.do?document=http%3A%2F%2Fcirc.ahajournals.org.

Related links

Make sure to floss! Intensive treatment of periodontal disease improves endothelial function [HeartWire > Other News; Feb 28, 2007]
The changing face of infective endocarditis [HeartWire > Other News; Jul 02, 2002]