Interactive clinical case: To give, or not to give, infective endocarditis prophylaxis

A 52 year old woman is scheduled to undergo double valve replacement surgery for severe mitral stenosis and severe aortic regurgitation. She has no other comorbidities. As part of the routine preoperative evaluation a dental consultation is obtained.  She is found to have dental caries in one premolar and the dentist advises extraction of the tooth. Would you advise periprocedural infective endocarditis prophylaxis?

Approach 1: Prophylaxis not recommended

Kathryn Taubert and Walter Wilson

American Heart Association and Mayo Clinic

In patients with a variety of cardiac conditions, the use of antibiotic prophylaxis before certain dental procedures was recommended in most parts of the world for the last half of the 20th century.  For the purposes of this debate, we will couch our comments around the recommendations made by the American Heart Association with regard to prophylaxis before dental procedures. Beginning in the latter part of the 20th century, however, questions were increasingly raised about the rationale for the use of periprocedural antibiotics. Groups of experts in Europe and the US recognized there were not any clinical trials showing the effectiveness, or lack thereof, of antibiotic prophylaxis. Additionally, there is the potential of adverse reactions associated with antibiotic use. Further, it is much more likely to acquire endocarditis due to frequent bacteremia associated with normal daily activities such as chewing food and brushing teeth. We emphasize that maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from these daily activities and thus would be more important than antimicrobial prophylaxis for a dental procedure to reduce the risk of infective endocarditis.

In the past 10 years or so, several organizations have recommended either no antibiotic prophylaxis (e.g., British National Institute for Health and Care Excellence) or recommended significantly limited antibiotic prophylaxis (e.g., American Heart Association) for patients who undergo a dental procedure. The American Heart Association recommended that only patients at the highest risk of serious adverse outcomes from endocarditis receive prophylaxis prior to invasive dental procedures. According to this, the only individuals for whom we would recommend antimicrobial prophylaxis are those with: a prosthetic cardiac valve or prosthetic material used for cardiac valve repair; previous infective endocarditis; certain congenital heart disease conditions; or, cardiac transplantation recipients who develop cardiac valvulopathy.

In the current clinical case presented here, the patient has severe mitral stenosis and severe aortic regurgitation. She does not have a cardiac condition which is considered to put her at highest risk of serious adverse outcomes from endocarditis. Therefore, she is not a candidate for antibiotic prophylaxis before her dental procedure to prevent infective endocarditis according to the criteria discussed above and thus we would not advise periprocedural infective endocarditis prophylaxis.


Approach 2: Prophylaxis is recommended

Shyam S Kothari

All India Institute of Medical sciences, New Delhi

Guidelines have acquired a statutory status despite reiterations that these are recommendations to help physicians make appropriate clinical decisions. In hindsight, the previous guidelines for infective endocarditis (IE) prophylaxis possibly represented an overkill, and were without evidence of efficacy. Since 2007, in a thoughtful departure from the past, the American heart association guidelines were revised to include prophylaxis only for those situations where the risk of serious adverse outcomes was highest in the event of IE. These include patients with prosthetic heart valves, cyanotic congenital heart disease, and a few others, but donot include patients with rheumatic heat disease (RHD). Most western societies endorsed these guidelines with some variations. However, their deemphasising RHD as a `not high risk lesion` is based on the perceptions that might not reflect ground realities, unfortunately. RHD in many parts of the world continue to be a disease with high morbidity and mortality, even in the current era.

Although, theoretically, community acquired native valve IE is treatable with reasonable success, experience from many parts of the world continue to report high morbidity and mortality in patients with RHD and IE. The issues of access, delay in diagnosis and other socioeconomic factors influence the outcome of IE, and consequently render the prophylaxis question more complex. The importance of maintaining good oral health and hygiene in these patients cannot be overemphasised, but may not be easily achieved. Thus, in general, patients with RHD should be included amongst the `high risk of adverse outcome lesions`. Furthermore, in a patient scheduled to undergo a prosthetic valve replacement sooner, one would be even more keen on avoiding IE(one  example of  individual patient factors that are often not considered in algorithmic exercises).

In sum, based on the above considerations, I would advocate pre-procedural antibiotics for this patient of RHD awaiting double valve replacement surgery. Prophylaxis of IE, like most other clinical decisions, should be individualised.

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