New Guidelines for Infective Endocarditis
The emphasis on bacteraemia from everyday procedures such as toothbrushing is an important factor in the new guidelines from the American Heart Association (AHA), published in April 2007(13). The consensus view of the AHA is that individuals are more at risk from the persistent bacteraemia that occurs as a result of persistently poor oral hygiene than a single infrequent dental operative procedure. Antibiotic prophylaxis is recommended for high risk cardiac conditions only which are:
1- Prosthetic Valves
2- Previous IE
3- Unrepaired Cyanotic Congenital Heart Disease, including palliative shunts and conduits
These guidelines are very similar to those published by the BSAC(3). This is not surprising as the BSAC guidelines were based on the draft AHA guidelines proposed at the International Symposium on Modern Concepts in Endocarditis and Cardiovascular Infections, 2005. All procedures, except for a simple examination with a mirror should have antibiotic prophylaxis in the high risk (AHA) or ‘at risk’ (BSAC). This means that only a small group of patients will need prophlyaxis for a wider range of treatment procedures. In the United Kingdom, only the Paediatric BNF has published the new dental recommendations. The National Institute for Clinical Excellence will decide in the near future which guidelines the BNF should accept. However, it is difficult to envisage NICE not accepting the BSAC recommendations in view of the recent AHA publication.
During the last 10 years or so, it has become increasingly obvious that a ‘single event bacteraemia’ has a low probability of seeding a vegetation on a damaged heart valve. It is far more likely that one of the many small bacteraemia episodes occurring during ‘everyday’ activities will seed a vegetation thus leading to IE. It is not possible to identify precisely the causative bacteraemia.
The new guidelines from both the BSAC(3) and the AHA(13) provide dentists and doctors with a simple scheme which will be easy to implement. In addition, there will be the enormous benefit of reducing antibiotic prescription thus minimising the risk of proliferation of antibiotic resistant microorganisms in the population. Both the BASC and the AHA have been sensitive to the development of antibiotic resistance in children within the community(14).
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