Update on IE prophylaxis- we are moving on!

2007 the AHA issued guidance for IE prophylaxis that greatly simplified the recommendations and proposed substantive changes—changes that would affect hundreds of thousands of patients. Since then, we, and most likely all of you, have been barraged by our surgical and dental colleagues and patients with inquiries—"Are you sure this is the right thing to do? Would you mind putting the recommendation in writing before I proceed?"


Evidence is now moving from "procedure-related bacteremia" toward "cumulative bacteremia" as the more likely cause of most cases of IE. For instance, daily activities such as tooth brushing are estimated to produce bacteremia 6 million times higher than a single tooth extraction. Thus, continued episodic bacteremia due to poor dentition may pose a much greater risk for the development of IE than a single dental procedure.

A final impetus for change was that the guidelines themselves had become more complicated with each revision, with ambiguous recommendations for which specific patient and which particular procedure required the prophylaxis.
Recommendation:-

• • Infective endocarditis prophylaxis should be given only to a high-risk subgroup of patients prior to dental procedures that involve manipulation in gingival tissue or periapical region of the teeth or perforation of the oral mucosa.
• • High-risk patients include only those with a: 1) prosthetic cardiac valve; 2) previous infective endocarditis; 3) complex congenital heart disease; and 4) valvulopathy following cardiac transplantation.
• • Infective endocarditis prophylaxis is not recommended prior to gastrointestinal or genitourinary procedures.

These recommendations represented a major departure from the traditional practice of IE prophylaxis. The committee wanted to shift emphasis away from a focus on antibiotic prophylaxis prior to a single procedure to recommendations that place a much greater emphasis on improved access to dental care and oral health in patients with underlying cardiac conditions. "High-risk" patients were defined not on the basis of an increased risk for IE, but rather on an increased risk of an adverse outcome should they develop endocarditis.