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No increase in infective endocarditis in US

The incidence of infective endocarditis among dental patients did not increase after new guidelines called for giving preventive antibiotics before dental procedures only to those at greatest risk of complications, according to independent research published in Circulation.1

In 2007, the American Heart Association changed its guidelines,2 recommending patients take antibiotics before invasive dental procedures only if they are at risk of complications from infective endocarditis. This includes patients with artificial heart valves, transplanted hearts with abnormal heart valve function, previous infective endocarditis and people born with specific heart defects.

“We were giving preventive antibiotics like we were treating an entire iceberg, when we only needed to treat the very tip of that iceberg,” said Dr Daniel C DeSimone, study lead author and an internal medicine resident at the Mayo Clinic in Rochester, Minnesota. “Millions of people once getting antibiotics now are not”.

In the first US study examining viridans group streptococci (VGS) -related infective endocarditis rates after the guidelines changed, investigators found a slight decline in the number of patients diagnosed.

dentalTo compare infective endocarditis rates, researchers analysed local hospital discharge records in the Rochester Epidemiology Project and national rates using the Nationwide Inpatient Sample. Olmstead County was used because of its unique medical records-linkage system that encompasses all residents of the county.

From January 1st, 1999 to December 31st, 2010, 22 patients in Olmsted County, Minn., were diagnosed with the heart infection. These patients represent two to three of every 100,000 people in the United States before updated guidelines, and one of every 100,000 after the updated guidelines.

The percentage of Olmsted county dentists following the new association guidelines represented the percentage of dentists using them nationally, researchers said.

The national annual infective endocarditis diagnosis rates showed no increase, ranging from:

  • 15,300-17,400 in 1999-2006 (before the updated guideline)
  • 14,700-15,500 in 2007-09 (after the updated guideline)

“These findings are reassuring, but additional studies are needed to further support our findings,” DeSimone said.

“There’s still a concern among many healthcare providers over whether we are leaving certain people at risk of getting a potentially lethal infection just from a dental cleaning or tooth extraction,” he said. “This study should reduce some fears. It will allow dentists to become more comfortable when they tell a patient, ‘You’ve been getting this antibiotic for years. Now, it’s not recommended anymore, and here is data showing you why’”.

Among other limitation, the lack of diversity in Olmstead means these results may not hold true for non-Caucasian populations.

References

1. DeSimone DC, Tleyjeh IM, Correa de Sa DD, et al. Incidence of infective endocarditis caused by viridans group streptococci before and after publication of the 2007 American Heart Association’s Endocarditis Prevention Guidelines. Circulation 2012;126.  doi: 10.1161/CIRCULATIONAHA.112.095281

2. 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;116:1736–54. doi: 10.1161/CIRCULATIONAHA.106.183095

Published on: June 25, 2012

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