CDA Essentials 2015 • Volume 2 • Issue 2

Volume 2 Issue 2

ews and

vents

A 2014 study

published in

The Lancet

shows the incidence of infective endocarditis (IE) grew following a sharp drop in

antibiotic prophylaxis prescriptions for patients at risk of developing this potentially fatal condition. The trend was observed

in England following a 2008 recommendation from the National Institute for Health and Care Excellence (NICE)

to stop

prescribing antibiotic prophylaxis solely for the prevention of IE.

UK study shows

Increase In Infective Endocarditis

After Drop In

Antibiotic Prophylaxis Prescriptions

“I think it’s important to understand that while this is a

well-conducted study, it does not causally link the drop

in antibiotic use with the increase in new cases of IE,”

says Dr. Carlos Quiñonez, chair of CDA’s Clinical and

Scientific Affairs Committee.

In contrast to the NICE guidance, CDA’s position on

prevention of IE

recommends the short-term use

of antibiotics prophylactically before routine dental

and medical procedures for patients at greatest risk

of developing IE. The CDA position aligns with 2007

guidelines from the American Heart Association (AHA).

“We recommend that Canadian dentists continue

following the 2007 AHA guidelines,” says Dr. Quiñonez.

“These guidelines identify those patients at greatest

risk of developing IE and provide information about the

appropriate antibiotic coverage needed.”

Dentists issue majority of

antibiotic prophylaxis

prescriptions

Before the NICE guidelines were introduced in

2008, prescribing of antibiotic prophylaxis for

prevention of IE had been fairly constant in

England: a single 3 g dose of oral amoxicillin

or, for patients allergic to penicillin, a

600 mg dose of oral clindamycin. Using

data on antibiotic prophylaxis prescribing

practices over roughly 9 years (4 years

before the NICE guidelines and 5 years

afterwards), researchers reported a dramatic decrease

in antibiotic prescribing. The mean number of antibiotic

prophylaxis prescriptions per month fell from 10,900

(pre-guidelines) to 2236 (post-guidelines), eventually

reaching a mean number of 1307 during the last

6 months of the study. Roughly 90% of the

prescriptions were issued by dentists and most were

for amoxicillin.

Only those at greatest risk of developing infective

endocarditis should receive short-term preventive

antibiotics before common, routine dental and medical

procedures. People who should take antibiotics include

those with:

1. prosthetic cardiac valve or prosthetic material used for

cardiac valve repair

2. a history of infective endocarditis

3. certain specific, serious congenital (present from birth)

heart conditions, including:

• unrepaired or incompletely repaired cyanotic

congenital heart disease, including

• those with palliative shunts and conduits

• a completely repaired congenital heart defect with

prosthetic material or device, whether placed by

surgery or by catheter intervention, during the first

six months after the procedure

• any repaired congenital heart defect with residual

defect at the site or adjacent to the site of a

prosthetic patch or a prosthetic device

4. a cardiac transplant that develops a problem in a

heart valve.

Antibiotic prophylaxis is recommended for patients with

the above conditions who undergo any dental procedure

that involves manipulation of gingival tissues or the

periapical region of a tooth and for those procedures that

perforate the oral mucosa. The following procedures and

events

do not need prophylaxis

• routine anesthetic through noninfected tissue

• dental radiographs

• placement of removable prosthodontic or

orthodontic appliances

• adjustment of orthodontic appliances

• placement of orthodontic brackets

• shedding of deciduous teeth

• bleeding from trauma to the lips or mucosa

Excerpt from CDA Position on

Prevention of Infective Endocarditis