Infective endocarditis prophylaxis

Year

Primary regimens for dental procedures

197210

Procaine penicillin G 600 000 U mixed with crystalline penicillin G 200 000 U IM 1 hour before procedure and once daily for the 2 days after the procedure Aqueous crystalline penicillin G (1 000 000 U IM) mixed with procaine penicillin G (600 000 U IM) 30 minutes to 1 hour before procedure and then penicillin V 500 mg orally every 6 hours for 8 doses. Penicillin V 2 g orally 1 hour before, then 1 g 6 hours after initial dose Amoxicillin 3 g orally 1 hour before procedure, then 1.5 g 6 hours after initial dose Amoxicillin 2 g orally 1 hour before procedure

Infective endocarditis prophylaxis – Current perspective 197711

Rajesh K Pandit, MD; Arif Mustaqueem, MD, DNB; Sameer Shrivastava, MD, DM Department of Cardiology, Fortis Escorts Heart Institute, Okhla Road, New Delhi, India 198412

Abstract Prevention of infective endocarditis (IE), potentially a lifethreatening condition, has been given serious consideration by the entire medical community. Guidelines for preventing IE have been developed by professional societies since the 1950s. These guidelines were empiric, formulated based more on pathophysiology and expert opinion and less on clinical evidence. For both practical and ethical reasons, no large, well-designed, randomised controlled trial has been conducted on IE prophylaxis. In last decade, analysis from various database showed significant advantage of IE prophylaxis. IE prophylaxis guidelines were altered toward a drastic reduction in antibiotic indications by International organisation. This article reviews these changed guidelines, and in the end the impact of these guidelines on incidence of IE.

Key Words Infective endocarditis ● Bacterial endocarditis ● Guidelines for IE prevention ●

199013

Introduction ■ Infective endocarditis (IE) is an uncommon but lifethreatening infection. While developments in cardiac imaging, therapeutics and surgical techniques have led to improved outcomes in individual patients, the overall incidence of infective endocarditis has remained relatively stable from 1950 through 2000, i.e., about 3.6–7.0 cases per 100,000 patient-years.1 IE Guidelines have been constantly under modifications ever since its first publication by AHA in 1955 (Table 1). ■ Table 1: Summary of 9 iterations of AHArecommended antibiotic regimens from 1955 to 1997 for dental/respiratory tract procedures Year

Primary regimens for dental procedures

6

1955

Aqueous penicillin 600 000 U and procaine penicillin 600 000 U in oil containing 2% aluminum monostearate administered IM 30 minutes before the procedure

19577

For 2 days before surgery, penicillin 200 000 to 250 000 U by mouth 4 times per day. On day of surgery, penicillin 200 000 to 250 000 U by mouth 4 times per day and aqueous penicillin 600 000 U with procaine penicillin 600 000 U IM 30 to 60 minutes before surgery. For 2 days after, 200 000 to 250 000 U by mouth 4 times per day.

19608

Step I: Prophylaxis 2 days before surgery with procaine penicillin 600 000 U IM on each day Step II: Day of surgery: Procaine penicillin 600 000 U IM supplemented by crystalline penicillin 600 000 U IM 1 hour before surgical procedure Step III: For 2 days after surgery; procaine penicillin 600 000 U IM each day

19659

Day of procedure: Procaine penicillin 600 000 U, supplemented by crystalline penicillin 600 000 U IM 1 to 2 hours before the procedure For 2 days after procedure: Procaine penicillin 600 000 U IM each day

Received: 22-06-12; Revised: 02-07-12; Accepted: 15-07-12 Disclosures: This article has not received any funding and has no vested commercial interest Acknowledgements: None

284

J. Preventive Cardiology

Vol. 2 ■ No. 2

■

November 2012

■

19971

IM indicates intramuscularly. * These regimens were for adults and represented the initial regimen listed in each version of the recommendations. in some versions, >1 regimen was included.

■ Evidence-based approach to infective

endocarditis prophylaxis While in theory, use of appropriate antibiotic prophylaxis for bacteraemia causing procedures in patients with cardiac risk factors should lead to decreased incidence of IE; this has not borne out in studies. Several factors contribute to the failure of this seemingly sound empirical approach. The common knowledge and studies have shown that procedures like dental extraction cause bacteremia, but so do everyday activities, like brushing teeth. While the degree of bacteremia caused by routine activities at a particular point in time may or may not be on the same magnitude as dental procedures, the overall burden of bacteremia over extended periods of time from daily activities would definitely surpass the transient bacteremia seen after medical procedures. The cumulative exposure to bacteremia from routine daily activities in 1 year may be as high as 5.6 x 106 times greater 2 as that resulting from a single tooth extraction. Studies have shown only a small fraction, if any, of the infective endocarditis cases were probably caused by 3,4 dental procedures. Another weak link is the efficacy of antibiotic prophylaxis in preventing or reducing bacteremia, as this is the main argument for empiric approach. The evidence for bacteremia reduction or prevention by antibiotic 2–5 prophylaxis is conflicting. Even studies which show reduction in bacteremia do not show reduction in infective endocarditis.6,7 While studies in dental procedures have 8,9 failed to show a clear benefit for antibiotic prophylaxis , J. Preventive Cardiology

Vol. 2 ■ No. 2

■

November 2012

■

studies in other procedures (respiratory, gastrointestinal, and genitourinary) are very limited. Since, American Heart Association (AHA) publication on 10 prevention of IE in 1997 , many authorities and societies, as well as the conclusions of published studies, have questioned the efficacy of antimicrobial prophylaxis to prevent IE in patients who undergo a dental, gastrointestinal (GI), or genitourinary (GU) tract procedure and have suggested that the AHA guidelines 11–14 should be revised. As a result, AHA/ACC along with their associates came out with IE guidelines in 2007. Subsequently, ACC/AHA 2008 Guideline Update on Valvular Heart Disease: Focused Update on Infective Endocarditis was published. Because no randomized clinical trial had been conducted to demonstrate the efficacy of such a strategy and because case-control studies had not found any relationship between dental procedures and IE, IE prophylaxis guidelines were altered toward a drastic reduction in antibiotic indications, in France as early as 2002 and in 15–20 other countries in 2007 to 2009. Scaling down antibiotic prophylaxis indications was not associated with an increased incidence of oral Streptococcal IE. A focus on avoidance of S. aureus bacteremia in all patients, including those with no previously known valve disease, will be required to improve IE prevention.21 ■ AHA 2007 Guidelines

Major reasons for the changes in recommendations in guidelines are summarized below (Table 2). From Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis (Circulation 116:1736, 2007). The major changes in the updated recommendations include the following: 1. The Committee concluded that only an extremely small number of cases of infective endocarditis might be prevented by antibiotic prophylaxis for dental procedures, even if such prophylactic therapy were 100% effective. 2. Infective endocarditis prophylaxis for dental procedures is reasonable only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis. 3. For patients with these underlying cardiac conditions, prophylaxis is reasonable for all dental procedures that involve manipulation of gingival tissue or the 285

Infective endocarditis prophylaxis

Year

Primary regimens for dental procedures

197210

Procaine penicillin G 600 000 U mixed with crystalline penicillin G 200 000 U IM 1 hour before procedure and once daily for the 2 days after the procedure Aqueous crystalline penicillin G (1 000 000 U IM) mixed with procaine penicillin G (600 000 U IM) 30 minutes to 1 hour before procedure and then penicillin V 500 mg orally every 6 hours for 8 doses. Penicillin V 2 g orally 1 hour before, then 1 g 6 hours after initial dose Amoxicillin 3 g orally 1 hour before procedure, then 1.5 g 6 hours after initial dose Amoxicillin 2 g orally 1 hour before procedure

Infective endocarditis prophylaxis – Current perspective 197711

Rajesh K Pandit, MD; Arif Mustaqueem, MD, DNB; Sameer Shrivastava, MD, DM Department of Cardiology, Fortis Escorts Heart Institute, Okhla Road, New Delhi, India 198412

Abstract Prevention of infective endocarditis (IE), potentially a lifethreatening condition, has been given serious consideration by the entire medical community. Guidelines for preventing IE have been developed by professional societies since the 1950s. These guidelines were empiric, formulated based more on pathophysiology and expert opinion and less on clinical evidence. For both practical and ethical reasons, no large, well-designed, randomised controlled trial has been conducted on IE prophylaxis. In last decade, analysis from various database showed significant advantage of IE prophylaxis. IE prophylaxis guidelines were altered toward a drastic reduction in antibiotic indications by International organisation. This article reviews these changed guidelines, and in the end the impact of these guidelines on incidence of IE.

Key Words Infective endocarditis ● Bacterial endocarditis ● Guidelines for IE prevention ●

199013

Introduction ■ Infective endocarditis (IE) is an uncommon but lifethreatening infection. While developments in cardiac imaging, therapeutics and surgical techniques have led to improved outcomes in individual patients, the overall incidence of infective endocarditis has remained relatively stable from 1950 through 2000, i.e., about 3.6–7.0 cases per 100,000 patient-years.1 IE Guidelines have been constantly under modifications ever since its first publication by AHA in 1955 (Table 1). ■ Table 1: Summary of 9 iterations of AHArecommended antibiotic regimens from 1955 to 1997 for dental/respiratory tract procedures Year

Primary regimens for dental procedures

6

1955

Aqueous penicillin 600 000 U and procaine penicillin 600 000 U in oil containing 2% aluminum monostearate administered IM 30 minutes before the procedure

19577

For 2 days before surgery, penicillin 200 000 to 250 000 U by mouth 4 times per day. On day of surgery, penicillin 200 000 to 250 000 U by mouth 4 times per day and aqueous penicillin 600 000 U with procaine penicillin 600 000 U IM 30 to 60 minutes before surgery. For 2 days after, 200 000 to 250 000 U by mouth 4 times per day.

19608

Step I: Prophylaxis 2 days before surgery with procaine penicillin 600 000 U IM on each day Step II: Day of surgery: Procaine penicillin 600 000 U IM supplemented by crystalline penicillin 600 000 U IM 1 hour before surgical procedure Step III: For 2 days after surgery; procaine penicillin 600 000 U IM each day

19659

Day of procedure: Procaine penicillin 600 000 U, supplemented by crystalline penicillin 600 000 U IM 1 to 2 hours before the procedure For 2 days after procedure: Procaine penicillin 600 000 U IM each day

Received: 22-06-12; Revised: 02-07-12; Accepted: 15-07-12 Disclosures: This article has not received any funding and has no vested commercial interest Acknowledgements: None

284

J. Preventive Cardiology

Vol. 2 ■ No. 2

■

November 2012

■

19971

IM indicates intramuscularly. * These regimens were for adults and represented the initial regimen listed in each version of the recommendations. in some versions, >1 regimen was included.

■ Evidence-based approach to infective

endocarditis prophylaxis While in theory, use of appropriate antibiotic prophylaxis for bacteraemia causing procedures in patients with cardiac risk factors should lead to decreased incidence of IE; this has not borne out in studies. Several factors contribute to the failure of this seemingly sound empirical approach. The common knowledge and studies have shown that procedures like dental extraction cause bacteremia, but so do everyday activities, like brushing teeth. While the degree of bacteremia caused by routine activities at a particular point in time may or may not be on the same magnitude as dental procedures, the overall burden of bacteremia over extended periods of time from daily activities would definitely surpass the transient bacteremia seen after medical procedures. The cumulative exposure to bacteremia from routine daily activities in 1 year may be as high as 5.6 x 106 times greater 2 as that resulting from a single tooth extraction. Studies have shown only a small fraction, if any, of the infective endocarditis cases were probably caused by 3,4 dental procedures. Another weak link is the efficacy of antibiotic prophylaxis in preventing or reducing bacteremia, as this is the main argument for empiric approach. The evidence for bacteremia reduction or prevention by antibiotic 2–5 prophylaxis is conflicting. Even studies which show reduction in bacteremia do not show reduction in infective endocarditis.6,7 While studies in dental procedures have 8,9 failed to show a clear benefit for antibiotic prophylaxis , J. Preventive Cardiology

Vol. 2 ■ No. 2

■

November 2012

■

studies in other procedures (respiratory, gastrointestinal, and genitourinary) are very limited. Since, American Heart Association (AHA) publication on 10 prevention of IE in 1997 , many authorities and societies, as well as the conclusions of published studies, have questioned the efficacy of antimicrobial prophylaxis to prevent IE in patients who undergo a dental, gastrointestinal (GI), or genitourinary (GU) tract procedure and have suggested that the AHA guidelines 11–14 should be revised. As a result, AHA/ACC along with their associates came out with IE guidelines in 2007. Subsequently, ACC/AHA 2008 Guideline Update on Valvular Heart Disease: Focused Update on Infective Endocarditis was published. Because no randomized clinical trial had been conducted to demonstrate the efficacy of such a strategy and because case-control studies had not found any relationship between dental procedures and IE, IE prophylaxis guidelines were altered toward a drastic reduction in antibiotic indications, in France as early as 2002 and in 15–20 other countries in 2007 to 2009. Scaling down antibiotic prophylaxis indications was not associated with an increased incidence of oral Streptococcal IE. A focus on avoidance of S. aureus bacteremia in all patients, including those with no previously known valve disease, will be required to improve IE prevention.21 ■ AHA 2007 Guidelines

Major reasons for the changes in recommendations in guidelines are summarized below (Table 2). From Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis (Circulation 116:1736, 2007). The major changes in the updated recommendations include the following: 1. The Committee concluded that only an extremely small number of cases of infective endocarditis might be prevented by antibiotic prophylaxis for dental procedures, even if such prophylactic therapy were 100% effective. 2. Infective endocarditis prophylaxis for dental procedures is reasonable only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis. 3. For patients with these underlying cardiac conditions, prophylaxis is reasonable for all dental procedures that involve manipulation of gingival tissue or the 285

Pandit RK, et al

Table 2: Primary reasons for revision of the IE prophylaxis guidelines IE is much more likely to result from frequent exposure to random bacteremia associated with daily activities than from bacteremia caused by a dental, GI, or GU tract procedure Prophylaxis may prevent an exceedingly small number of cases of IE, if any, in individuals who undergo a dental, GI tract, or GU tract procedure The risk of antibiotic associated adverse events exceeds the benefit, if any, from prophylactic antibiotic therapy Maintenance of oral optimal health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of IE

periapical region of teeth or perforation of the oral mucosa. 4. Prophylaxis is not recommended based solely on an increased lifetime risk of acquisition of infective endocarditis. 5. Administration of antibiotics solely to prevent endocarditis is not recommended for patients who undergo a genitourinary or gastrointestinal tract procedure. These changes are intended to define more clearly when infective endocarditis prophylaxis is or is not recommended and to provide more uniform and consistent global recommendations. Because this may cause consternation among patients, clinicians should be available to discuss the rationale for these new changes with their patients, including the lack of scientific evidence to demonstrate a proven benefit for infective endocarditis prophylaxis. In select circumstances, the committee also understands that some clinicians and some patients may still feel more comfortable continuing with prophylaxis for infective endocarditis, particularly for those with bicuspid aortic valve or co-arctation of the aorta, severe mitral valve prolapse, or hypertrophic obstructive cardiomyopathy. In those settings, the clinician should determine that the risks associated with antibiotics are low before continuing a prophylaxis regimen. Over time, and with continuing education, the committee anticipates increasing acceptance of the new guidelines among both provider and patient communities. Cardiac conditions and dental procedures for which antibiotic prophylaxis is recommended have significantly decreased in number, (Table 3). Regimens for prophylaxis against endocarditis: Use with dental, oral, and upper respiratory tract procedures are mentioned (Table 4). 286

■ National Institute for Health and Clinical

Excellence (NICE) Guidance NICE guidelines published in 2008 made an even more radical departure from the past.22 They do not recommend antibiotic prophylaxis for dental, or non-dental procedures (e.g., respiratory, gastrointestinal, and genitourinary).23 If a person at risk for infective endocarditis is receiving antibiotic therapy because they are undergoing a gastrointestinal or genitourinary procedure at a site with a suspected infection, antibiotics used should cover organisms that cause infective endocarditis (presumably Enterococci). The guidelines do not make explicit recommendations about procedures involving infected skin and musculoskeletal tissues. Chlorhexidine mouthwash prior to dental procedures is not Table 3: Cardiac conditions and dental procedures for which antibiotic prophylaxis is recommended A. Cardiac conditions associated with the highest risk of adverse outcome from endocarditis for which prophylaxis with dental procedures is recommended Prosthetic cardiac valve Previous infective endocarditis Congenital heart disease (CHD) • Unrepaired cyanotic CHD, including those with palliative shunts and conduits • Completely repaired CHD with prosthetic material or device either by surgery or by catheter intervention during the first 6 months after the procedure • Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which • inhibit endothelialization) • Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD Cardiac transplantation recipients who develop cardiac valvulopathy B. Dental procedures for which endocarditis prophylaxis is recommended for high-risk patients (refer A) All dental procedures and events that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa except the following: • Routine anesthetic injections through noninfected tissue • Taking dental radiographs • Placement of removable prosthodontic or orthodontic appliances • Adjustment of orthodontic appliances • Placement of orthodontic brackets • Shedding of deciduous teeth and bleeding from trauma to the lips or oral mucosa J. Preventive Cardiology

Vol. 2 ■ No. 2

■

November 2012

■

Infective endocarditis prophylaxis

Table 4: Regimens for prophylaxis against endocarditis: Use with dental, oral, and upper respiratory tract procedures Setting procedure

Regimen administered 30–60 minutes before*

Table 5: NICE guidelines for infective endocarditis prophylaxis Cardiac conditions at high risk for infective endocarditis: •

†

Amoxicillin 2.0 g PO Standard regimen Amoxicillin- or penicillin- Cephalexin 2 g PO† allergic patients OR Azithromycin or clarithromycin 500 mg PO OR Clindamycin 600 mg PO Patients unable to take oral Ampicillin 2.0 g IM or IV medications OR Cefazolin or ceftriaxone 1 g IV† Ampicillin-, amoxicillin-, or Clindamycin 300 mg IV 30 penicillin-allergic patients min before procedure, then unable to take oral medications 150 mg 6 hr after initial dose * Dosages for adults. Initial pediatric dosages are as follows: ampicillin or amoxicillin, 50 mg/kg; clindamycin, 20 mg/kg; azithromycin or clarithromycin, 15 mg/kg. † Cephalosporins are not used in patients with history of anaphylaxis, angioedema, or urticaria associated with penicillin, ampicillin, or cephalosporins. (Modified from Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: Guidelines from the American Heart Association. Circulation 116:1736, 2007.)

recommended. A list of cardiac conditions at high risk for developing infective endocarditis is provided primarily for advocating importance of maintaining oral hygiene and increased vigilance for incidence of infective endocarditis. Key points of NICE guidelines are mentioned below in (Table 5). The AHA guidelines (2007) and the NICE guidance (2008), as well as the British Society for Antimicrobial Chemotherapy (BSAC) guidelines (2005), represent significant departure from the traditional approach to infective endocarditis prophylaxis and have been received with initial apprehension among the medical 24,25 community. Later on, more professional societies have incorporated the recommendations of AHA guidelines into their advisory statements.26,27 The cause for dissent arises from two important aspects, one being the major departure from traditional recommendations. The second, and probably the most intriguing aspect, is that two professional societies (BSAC and AHA) and NICE have come with three significantly different sets of recommendations, even though all three recognize the paucity of evidence and aim to narrow the indication for prophylaxis. Based on the same body of evidence (lack of evidence for benefit in dental procedures and lack of good J. Preventive Cardiology

Vol. 2 ■ No. 2

■

November 2012

■

• •

• •

Acquired valvular heart disease with stenosis or regurgitation Valve replacement Structural congenital heart disease, including surgically corrected or palliated structural conditions, but excluding isolated atrial septal defect, fully repaired ventricular septal defect or fully repaired patent ductus arteriosus, and closure devices that are judged to be endothelialized Previous infective endocarditis Hypertrophic cardiomyopathy

Antibiotic prophylaxis is not recommended: • •

For people undergoing dental procedures For people undergoing non-dental procedures at these sites (upper and lower gastrointestinal; genitourinary tracturological, gynecological and obstetric procedures, and childbirth; upper and lower respiratory tract-includes ear, nose and throat procedures and bronchoscopy)

Chlorhexidine mouthwash is not recommended for infective endocarditis prophylaxis for dental procedures. Infections in patients at risk for infective endocarditis should be promptly treated to reduce risk of infective endocarditis developing. Anitibiotic therapy used for gastrointestinal or genitourinary procedures at a site with suspected infection in patients at risk of infective endocarditis, should cover organisms causing infective endocarditis. Patients should be educated on benefits and risks of antibiotic prophylaxis, recommendations against antibiotic prophylaxis, importance of oral hygiene, symptoms of infective endocarditis and risks of invasive procedures including non-medical procedures like body piercing and tattooing. Adopted from BMS Heart 2008;94:930–931.

epidemiological data for non-dental procedures), BSAC recommends prophylaxis for dental and non-dental (including gastrointestinal and genitourinary), AHA recommends prophylaxis for only dental and respiratory procedures and not gastrointestinal or genitourinary procedures, and NICE recommends prophylaxis for none of the procedures. While these three guidelines differ in their details, they all point toward a general trend against empiric use of antibiotic prophylaxis for infective endocarditis. With the rampant increase in incidence of multi-drug resistant organisms, an evidence-based approach to antibiotic prophylaxis is a healthy trend. Establishing the efficacy and safety of antibiotic prophylaxis with well-designed prospective studies, a yardstick used for acceptance of 287

Pandit RK, et al

Table 2: Primary reasons for revision of the IE prophylaxis guidelines IE is much more likely to result from frequent exposure to random bacteremia associated with daily activities than from bacteremia caused by a dental, GI, or GU tract procedure Prophylaxis may prevent an exceedingly small number of cases of IE, if any, in individuals who undergo a dental, GI tract, or GU tract procedure The risk of antibiotic associated adverse events exceeds the benefit, if any, from prophylactic antibiotic therapy Maintenance of oral optimal health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of IE

periapical region of teeth or perforation of the oral mucosa. 4. Prophylaxis is not recommended based solely on an increased lifetime risk of acquisition of infective endocarditis. 5. Administration of antibiotics solely to prevent endocarditis is not recommended for patients who undergo a genitourinary or gastrointestinal tract procedure. These changes are intended to define more clearly when infective endocarditis prophylaxis is or is not recommended and to provide more uniform and consistent global recommendations. Because this may cause consternation among patients, clinicians should be available to discuss the rationale for these new changes with their patients, including the lack of scientific evidence to demonstrate a proven benefit for infective endocarditis prophylaxis. In select circumstances, the committee also understands that some clinicians and some patients may still feel more comfortable continuing with prophylaxis for infective endocarditis, particularly for those with bicuspid aortic valve or co-arctation of the aorta, severe mitral valve prolapse, or hypertrophic obstructive cardiomyopathy. In those settings, the clinician should determine that the risks associated with antibiotics are low before continuing a prophylaxis regimen. Over time, and with continuing education, the committee anticipates increasing acceptance of the new guidelines among both provider and patient communities. Cardiac conditions and dental procedures for which antibiotic prophylaxis is recommended have significantly decreased in number, (Table 3). Regimens for prophylaxis against endocarditis: Use with dental, oral, and upper respiratory tract procedures are mentioned (Table 4). 286

■ National Institute for Health and Clinical

Excellence (NICE) Guidance NICE guidelines published in 2008 made an even more radical departure from the past.22 They do not recommend antibiotic prophylaxis for dental, or non-dental procedures (e.g., respiratory, gastrointestinal, and genitourinary).23 If a person at risk for infective endocarditis is receiving antibiotic therapy because they are undergoing a gastrointestinal or genitourinary procedure at a site with a suspected infection, antibiotics used should cover organisms that cause infective endocarditis (presumably Enterococci). The guidelines do not make explicit recommendations about procedures involving infected skin and musculoskeletal tissues. Chlorhexidine mouthwash prior to dental procedures is not Table 3: Cardiac conditions and dental procedures for which antibiotic prophylaxis is recommended A. Cardiac conditions associated with the highest risk of adverse outcome from endocarditis for which prophylaxis with dental procedures is recommended Prosthetic cardiac valve Previous infective endocarditis Congenital heart disease (CHD) • Unrepaired cyanotic CHD, including those with palliative shunts and conduits • Completely repaired CHD with prosthetic material or device either by surgery or by catheter intervention during the first 6 months after the procedure • Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which • inhibit endothelialization) • Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD Cardiac transplantation recipients who develop cardiac valvulopathy B. Dental procedures for which endocarditis prophylaxis is recommended for high-risk patients (refer A) All dental procedures and events that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa except the following: • Routine anesthetic injections through noninfected tissue • Taking dental radiographs • Placement of removable prosthodontic or orthodontic appliances • Adjustment of orthodontic appliances • Placement of orthodontic brackets • Shedding of deciduous teeth and bleeding from trauma to the lips or oral mucosa J. Preventive Cardiology

Vol. 2 ■ No. 2

■

November 2012

■

Infective endocarditis prophylaxis

Table 4: Regimens for prophylaxis against endocarditis: Use with dental, oral, and upper respiratory tract procedures Setting procedure

Regimen administered 30–60 minutes before*

Table 5: NICE guidelines for infective endocarditis prophylaxis Cardiac conditions at high risk for infective endocarditis: •

†

Amoxicillin 2.0 g PO Standard regimen Amoxicillin- or penicillin- Cephalexin 2 g PO† allergic patients OR Azithromycin or clarithromycin 500 mg PO OR Clindamycin 600 mg PO Patients unable to take oral Ampicillin 2.0 g IM or IV medications OR Cefazolin or ceftriaxone 1 g IV† Ampicillin-, amoxicillin-, or Clindamycin 300 mg IV 30 penicillin-allergic patients min before procedure, then unable to take oral medications 150 mg 6 hr after initial dose * Dosages for adults. Initial pediatric dosages are as follows: ampicillin or amoxicillin, 50 mg/kg; clindamycin, 20 mg/kg; azithromycin or clarithromycin, 15 mg/kg. † Cephalosporins are not used in patients with history of anaphylaxis, angioedema, or urticaria associated with penicillin, ampicillin, or cephalosporins. (Modified from Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: Guidelines from the American Heart Association. Circulation 116:1736, 2007.)

recommended. A list of cardiac conditions at high risk for developing infective endocarditis is provided primarily for advocating importance of maintaining oral hygiene and increased vigilance for incidence of infective endocarditis. Key points of NICE guidelines are mentioned below in (Table 5). The AHA guidelines (2007) and the NICE guidance (2008), as well as the British Society for Antimicrobial Chemotherapy (BSAC) guidelines (2005), represent significant departure from the traditional approach to infective endocarditis prophylaxis and have been received with initial apprehension among the medical 24,25 community. Later on, more professional societies have incorporated the recommendations of AHA guidelines into their advisory statements.26,27 The cause for dissent arises from two important aspects, one being the major departure from traditional recommendations. The second, and probably the most intriguing aspect, is that two professional societies (BSAC and AHA) and NICE have come with three significantly different sets of recommendations, even though all three recognize the paucity of evidence and aim to narrow the indication for prophylaxis. Based on the same body of evidence (lack of evidence for benefit in dental procedures and lack of good J. Preventive Cardiology

Vol. 2 ■ No. 2

■

November 2012

■

• •

• •

Acquired valvular heart disease with stenosis or regurgitation Valve replacement Structural congenital heart disease, including surgically corrected or palliated structural conditions, but excluding isolated atrial septal defect, fully repaired ventricular septal defect or fully repaired patent ductus arteriosus, and closure devices that are judged to be endothelialized Previous infective endocarditis Hypertrophic cardiomyopathy

Antibiotic prophylaxis is not recommended: • •

For people undergoing dental procedures For people undergoing non-dental procedures at these sites (upper and lower gastrointestinal; genitourinary tracturological, gynecological and obstetric procedures, and childbirth; upper and lower respiratory tract-includes ear, nose and throat procedures and bronchoscopy)

Chlorhexidine mouthwash is not recommended for infective endocarditis prophylaxis for dental procedures. Infections in patients at risk for infective endocarditis should be promptly treated to reduce risk of infective endocarditis developing. Anitibiotic therapy used for gastrointestinal or genitourinary procedures at a site with suspected infection in patients at risk of infective endocarditis, should cover organisms causing infective endocarditis. Patients should be educated on benefits and risks of antibiotic prophylaxis, recommendations against antibiotic prophylaxis, importance of oral hygiene, symptoms of infective endocarditis and risks of invasive procedures including non-medical procedures like body piercing and tattooing. Adopted from BMS Heart 2008;94:930–931.

epidemiological data for non-dental procedures), BSAC recommends prophylaxis for dental and non-dental (including gastrointestinal and genitourinary), AHA recommends prophylaxis for only dental and respiratory procedures and not gastrointestinal or genitourinary procedures, and NICE recommends prophylaxis for none of the procedures. While these three guidelines differ in their details, they all point toward a general trend against empiric use of antibiotic prophylaxis for infective endocarditis. With the rampant increase in incidence of multi-drug resistant organisms, an evidence-based approach to antibiotic prophylaxis is a healthy trend. Establishing the efficacy and safety of antibiotic prophylaxis with well-designed prospective studies, a yardstick used for acceptance of 287

Pandit RK, et al

Infective endocarditis prophylaxis

Table 7: Estimated annual change in IE hospitalizations

Table 6: Comparison of guidelines for infective endocarditis prophylaxis (1997–2008) Guidelines

AHA 1997

SPILF/SFC 2002

ESC 2004

BSAC 2005

AHA 2007

NICE 2008

Risk groups described based on cardiac conditions*

High, moderate, negligible

High, low

High, moderate

High

High

High

Risk groups where prophylaxis is recommended or optional†

High, moderate

High, low

High, moderate

High

High

–

After guidelines

Difference

P

+1.4% (-2.9% to +5.8%)

.54

+3.0% (-1.9% to +8.1%)

Patients with CHD only

-5.3% (-17.4% to +8.5%)

.43

-11.8% (-24.0% to +2.4%)

-6.8% (-27.7% to +20.1%)

.58

Age 5–18 years only

+1.8% (-5.9% to +10.1%)

.66

+1.4% (-7.3% to +10.8%)

-0.4% (-14.2% to +15.7%)

.96

-2.5% (-14.2% to +10.9%)

.70

-19.1% (-32.4% to -3.1%)

-17.1% (-36.9% to +9.0%)

.18

-5.9% (-9.9% to -1.8%)

.005

-11.5% (-15.7% to -7.1%)

-5.9% (-13.3% to +2.2%)

.15

No. of IE cases Overall

+1.6% (-6.4% to +10.3%) .70

Dental

Yes

Yes

Yes

Yes

Yes

No

Oral streptococcal only

Respiratory

Yes

Yes

Yes

Yes

Yes

No

No. of IE cases per 1000 hospital admissions

Gastrointestinal

Yes

Yes

Yes

Yes

No

No

Overall

Genitourinary

Yes

Yes

Yes

Yes

No

No

Patients with CHD only

-12.3% (-24.9% to +2.5%)

.10

-23.5% (-35.2% to -9.6%)

Infected skin/ musculoskeleta

Yes

N/A

N/A

N/A

Yes

N/A

Age 5–18 years only

-5.5% (-12.6% to +2.2%)

.15

-12.9% (-20.4% to -4.7%)

-7.8% (-20.7% to +7.2%)

.29

Oral streptococcal only

-9.2% (-20.2% to +3.2%)

.14

-30.9% (-42.3% to -17.1%)

-23.9% (-42.1% to +0.1%)

.05

Yes

Yes

Optional

Yes

No

No

Antiseptic rinse

* Individual guidelines have classified cardiac conditions into different groups based on their risk for IE. The cardiac conditions included, as well as the risk groups described, differ among individual guidelines. We have tabulated the risk groups described by these guidelines. † In the setting of a procedure causing bacteremia. ‡ In patients with cardiac risk factors. Yes: Prophylaxis recommended when criteria met; No: Prophylaxis not recommentded; N/A: No specific recommendation. Bold typeface used to emphasize U change in recommendations from yes to no.. AHA: American Heart Association: BSAC: British Society for Antimicriobial Chemotherapy; ESC: European Society of Cardiology; NICE: Niational Institute for Hoal and chinical Excellence; SPILF/SFC: Societe de Pathologie Infectieuse de Langue Francaise/ Societe Francaise de Cardiologie.

most medical interventions, should be required for antibiotic prophylaxis as well, considering the significant public health concerns discussed earlier. Subsequent to publishing these guidelines, a Cochrane database review on antibiotics for prophylaxis of bacterial endocarditis in dentistry showed no evidence as to whether penicillin prophylaxis is effective or ineffective against bacterial endocarditis in people at risk who are about to undergo an 28 invasive dental procedure. Below is tabulated difference in various guidelines in (Table 6). ■ Impact of guidelines up to 2012

Two of the recently published studies worth mentions here, to highlight the impact of revised guidelines. 1. Temporal trends in infective endocarditis in the context of prophylaxis guideline modifications: Three Successive Population-based Surveys Journal of the American College of Cardiology Vol. 59, No. 22, 2012 The study21, “Temporal trends in infective endocarditis in the context of prophylaxis guideline modifications: Three successive population-based surveys,” looked to evaluate 288

P

temporal trends in IE following 2002 French guideline modifications that recommended restricting the indications of antibiotic prophylaxis of IE. The study is based on three, one-year population-based surveys of 11 million people age 20 years and older from three regions in France in 1991, 1999 and 2008. Despite the general improvement in patients’ medical care, IE prognosis did not improve between 1991 and 2008, and the in-hospital mortality rate remained as high as 20%. It also found an increase of staphylococcal IE in a population of patients not identified as at-risk for IE. This study found that reducing antibiotic prophylaxis indications did not contribute to an increased occurrence of oral streptococcal infective endocarditis (IE). 2. Trends in endocarditis hospitalizations at US children’s hospitals: Impact of the 2007 AHA antibiotic prophylaxis guidelines American Heart Journal – Volume 163, Issue 5 (May 2012)29 In 2007, the American Heart Association recommended cessation of antibiotic prophylaxis for infective endocarditis (IE) before dental procedures for all but those at highest risk for adverse outcomes from IE. The impact of these guidelines is unclear. In this study, they evaluated IE J. Preventive Cardiology

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hospitalizations at US children’s hospitals during this period. Some of their key observations were (Table 7, Figure 1). 160

-12.8% (-34.5% to +16.2%) .35

reduction of antibiotic use, follow-up studies from France and US have not shown any increasing trend in IE. However, current studies recommend focusing on avoidance of Staphylococcus aureus bacteremia in all patients, including those with no previously known valve disease, in order to improve IE prevention.

140

We do not have any Indian data on this aspect of IE prophylaxis. We need to plan and carry out studies to analyse the impact of newer guidelines in Indian scenario.

120 Number of IE cases

Procedures with recommendation for prophylaxis‡

Before guidelines

100 80

■ References

60 40 20 0 2003

2004

2005

2006

2007

2008

2009

2010

Figure 1 Hospitalization for IE over period of time Number of IE cases over time. The gray boxes represent the number of total patients hospitalized with IE during the period specified. The solid lines represent 95% Poisson CIs. The dotted line represents when the new AHA guidelines were published.

In this multicenter, observational analysis, they did not detect a significant difference in hospitalizations for IE across 37 US children's hospitals before and after revision of the AHA antibiotic prophylaxis guidelines in 2007. Evaluation of prescribing patterns and more detailed assessment of high-risk patients are warranted to further characterize outcomes related to the new guidelines.

Conclusion ■ Despite marked modifications of IE prophylaxis recommendations between 1999 and 2008 toward a J. Preventive Cardiology

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1. Karchmer AW. Infective endocarditis. In: Libby P, Bonow RO, Mann DL, Zipes DP, eds. Braunwald’s heart disease: a textbook of cardiovascular medicine. 8th ed. Philadelphia, PA: Saunders Elsevier; 2007:1713–1738. 2. Roberts GJ. Dentists are innocent! “Everyday” bacteremia is the real culprit: a review and assessment of the evidence that dental surgical procedures are a principal cause of bacterial endocarditis in children. Pediatr Cardiol 1999;20:317–325. 3. Van der Meer JT, Thompson J, Valkenburg HA, Michel MF. Epidemiology of bacterial endocarditis in The Netherlands. II. Antecedent procedures and use of prophylaxis. Arch Intern Med 1992;152:1869–1873. 4. Strom BL, Abrutyn E, Berlin JA, Kinman JL, Feldman RS, Stolley PD, et al. Dental and cardiac risk factors for infective endocarditis. A population-based, case-control study. Ann Intern Med 1998;129:761–769. 5. Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et al. AHA Guideline—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: 1736–1754. 6. Shanson DC, Akash S, Harris M, Tadayon M. Erythromycin stearate, 1.5 g, for the oral prophylaxis of streptococcal bacteraemia in patients undergoing dental extraction: efficacy and tolerance. J Antimicrob Chemother 1985;15:83–90.

289

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Infective endocarditis prophylaxis

Table 7: Estimated annual change in IE hospitalizations

Table 6: Comparison of guidelines for infective endocarditis prophylaxis (1997–2008) Guidelines

AHA 1997

SPILF/SFC 2002

ESC 2004

BSAC 2005

AHA 2007

NICE 2008

Risk groups described based on cardiac conditions*

High, moderate, negligible

High, low

High, moderate

High

High

High

Risk groups where prophylaxis is recommended or optional†

High, moderate

High, low

High, moderate

High

High

–

After guidelines

Difference

P

+1.4% (-2.9% to +5.8%)

.54

+3.0% (-1.9% to +8.1%)

Patients with CHD only

-5.3% (-17.4% to +8.5%)

.43

-11.8% (-24.0% to +2.4%)

-6.8% (-27.7% to +20.1%)

.58

Age 5–18 years only

+1.8% (-5.9% to +10.1%)

.66

+1.4% (-7.3% to +10.8%)

-0.4% (-14.2% to +15.7%)

.96

-2.5% (-14.2% to +10.9%)

.70

-19.1% (-32.4% to -3.1%)

-17.1% (-36.9% to +9.0%)

.18

-5.9% (-9.9% to -1.8%)

.005

-11.5% (-15.7% to -7.1%)

-5.9% (-13.3% to +2.2%)

.15

No. of IE cases Overall

+1.6% (-6.4% to +10.3%) .70

Dental

Yes

Yes

Yes

Yes

Yes

No

Oral streptococcal only

Respiratory

Yes

Yes

Yes

Yes

Yes

No

No. of IE cases per 1000 hospital admissions

Gastrointestinal

Yes

Yes

Yes

Yes

No

No

Overall

Genitourinary

Yes

Yes

Yes

Yes

No

No

Patients with CHD only

-12.3% (-24.9% to +2.5%)

.10

-23.5% (-35.2% to -9.6%)

Infected skin/ musculoskeleta

Yes

N/A

N/A

N/A

Yes

N/A

Age 5–18 years only

-5.5% (-12.6% to +2.2%)

.15

-12.9% (-20.4% to -4.7%)

-7.8% (-20.7% to +7.2%)

.29

Oral streptococcal only

-9.2% (-20.2% to +3.2%)

.14

-30.9% (-42.3% to -17.1%)

-23.9% (-42.1% to +0.1%)

.05

Yes

Yes

Optional

Yes

No

No

Antiseptic rinse

* Individual guidelines have classified cardiac conditions into different groups based on their risk for IE. The cardiac conditions included, as well as the risk groups described, differ among individual guidelines. We have tabulated the risk groups described by these guidelines. † In the setting of a procedure causing bacteremia. ‡ In patients with cardiac risk factors. Yes: Prophylaxis recommended when criteria met; No: Prophylaxis not recommentded; N/A: No specific recommendation. Bold typeface used to emphasize U change in recommendations from yes to no.. AHA: American Heart Association: BSAC: British Society for Antimicriobial Chemotherapy; ESC: European Society of Cardiology; NICE: Niational Institute for Hoal and chinical Excellence; SPILF/SFC: Societe de Pathologie Infectieuse de Langue Francaise/ Societe Francaise de Cardiologie.

most medical interventions, should be required for antibiotic prophylaxis as well, considering the significant public health concerns discussed earlier. Subsequent to publishing these guidelines, a Cochrane database review on antibiotics for prophylaxis of bacterial endocarditis in dentistry showed no evidence as to whether penicillin prophylaxis is effective or ineffective against bacterial endocarditis in people at risk who are about to undergo an 28 invasive dental procedure. Below is tabulated difference in various guidelines in (Table 6). ■ Impact of guidelines up to 2012

Two of the recently published studies worth mentions here, to highlight the impact of revised guidelines. 1. Temporal trends in infective endocarditis in the context of prophylaxis guideline modifications: Three Successive Population-based Surveys Journal of the American College of Cardiology Vol. 59, No. 22, 2012 The study21, “Temporal trends in infective endocarditis in the context of prophylaxis guideline modifications: Three successive population-based surveys,” looked to evaluate 288

P

temporal trends in IE following 2002 French guideline modifications that recommended restricting the indications of antibiotic prophylaxis of IE. The study is based on three, one-year population-based surveys of 11 million people age 20 years and older from three regions in France in 1991, 1999 and 2008. Despite the general improvement in patients’ medical care, IE prognosis did not improve between 1991 and 2008, and the in-hospital mortality rate remained as high as 20%. It also found an increase of staphylococcal IE in a population of patients not identified as at-risk for IE. This study found that reducing antibiotic prophylaxis indications did not contribute to an increased occurrence of oral streptococcal infective endocarditis (IE). 2. Trends in endocarditis hospitalizations at US children’s hospitals: Impact of the 2007 AHA antibiotic prophylaxis guidelines American Heart Journal – Volume 163, Issue 5 (May 2012)29 In 2007, the American Heart Association recommended cessation of antibiotic prophylaxis for infective endocarditis (IE) before dental procedures for all but those at highest risk for adverse outcomes from IE. The impact of these guidelines is unclear. In this study, they evaluated IE J. Preventive Cardiology

Vol. 2 ■ No. 2

■

November 2012

■

hospitalizations at US children’s hospitals during this period. Some of their key observations were (Table 7, Figure 1). 160

-12.8% (-34.5% to +16.2%) .35

reduction of antibiotic use, follow-up studies from France and US have not shown any increasing trend in IE. However, current studies recommend focusing on avoidance of Staphylococcus aureus bacteremia in all patients, including those with no previously known valve disease, in order to improve IE prevention.

140

We do not have any Indian data on this aspect of IE prophylaxis. We need to plan and carry out studies to analyse the impact of newer guidelines in Indian scenario.

120 Number of IE cases

Procedures with recommendation for prophylaxis‡

Before guidelines

100 80

■ References

60 40 20 0 2003

2004

2005

2006

2007

2008

2009

2010

Figure 1 Hospitalization for IE over period of time Number of IE cases over time. The gray boxes represent the number of total patients hospitalized with IE during the period specified. The solid lines represent 95% Poisson CIs. The dotted line represents when the new AHA guidelines were published.

In this multicenter, observational analysis, they did not detect a significant difference in hospitalizations for IE across 37 US children's hospitals before and after revision of the AHA antibiotic prophylaxis guidelines in 2007. Evaluation of prescribing patterns and more detailed assessment of high-risk patients are warranted to further characterize outcomes related to the new guidelines.

Conclusion ■ Despite marked modifications of IE prophylaxis recommendations between 1999 and 2008 toward a J. Preventive Cardiology

Vol. 2 ■ No. 2

■

November 2012

■

1. Karchmer AW. Infective endocarditis. In: Libby P, Bonow RO, Mann DL, Zipes DP, eds. Braunwald’s heart disease: a textbook of cardiovascular medicine. 8th ed. Philadelphia, PA: Saunders Elsevier; 2007:1713–1738. 2. Roberts GJ. Dentists are innocent! “Everyday” bacteremia is the real culprit: a review and assessment of the evidence that dental surgical procedures are a principal cause of bacterial endocarditis in children. Pediatr Cardiol 1999;20:317–325. 3. Van der Meer JT, Thompson J, Valkenburg HA, Michel MF. Epidemiology of bacterial endocarditis in The Netherlands. II. Antecedent procedures and use of prophylaxis. Arch Intern Med 1992;152:1869–1873. 4. Strom BL, Abrutyn E, Berlin JA, Kinman JL, Feldman RS, Stolley PD, et al. Dental and cardiac risk factors for infective endocarditis. A population-based, case-control study. Ann Intern Med 1998;129:761–769. 5. Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et al. AHA Guideline—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: 1736–1754. 6. Shanson DC, Akash S, Harris M, Tadayon M. Erythromycin stearate, 1.5 g, for the oral prophylaxis of streptococcal bacteraemia in patients undergoing dental extraction: efficacy and tolerance. J Antimicrob Chemother 1985;15:83–90.

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7. Roberts GJ, Radford P, Holt R. Prophylaxis of dental bacteraemia with oral amoxycillin in children. Br Dent J 1987;162:179–182. 8. Hall G, Heimdahl A, Nord CE. Effects of prophylactic administration of cefaclor on transient bacteremia after dental extraction. Eur J Clin Microbiol Infect Dis 1996;15:646–649. 9. Hall G, Hedström SA, Heimdahl A, Nord CE. Prophylactic administration of penicillins for endocarditis does not reduce the incidence of postextraction bacteremia. Clin Infect Dis 1993;17:188–194. 10. Dajani AS, Taubert KA, Wilson W, Bolger AF, Bayer A, Ferrieri P, et al. Prevention of bacterial endocarditis: recommendations by the American Heart Association. JAMA. 1997;277:1794–1801. 11. Strom BL, Abrutyn E, Berlin JA, Kinman JL, Feldman RS, Stolley PD, et al. Dental and cardiac risk factors for infective endocarditis: a population-based, case-control study. Ann Intern Med. 1998;129:761–769. 12. Durack DT. Prevention of infective endocarditis. N Engl J Med. 1995;332:38–44. 13. Durack DT. Antibiotics for prevention of endocarditis during dentistry: time to scale back? Ann Intern Med. 1998;129:829–831. 14. Lockhart PB, Brennan MT, Fox PC, Norton HJ, Jernigan DB, Strausbaugh LJ. Decision-making on the use of antimicrobial prophylaxis for dental procedures: a survey of infectious disease consultants and review. Clin Infect Dis. 2002;34:1621–1626. 15. Duval X, Leport C. Prophylaxis of infective endocarditis: current tendencies, continuing controversies. Lancet Infect Dis 2008;8:225–32. 16. Duval X, Alla F, Hoen B, Danielou F, Larrieu S, Delahaye F, et al. Estimated risk of endocarditis in adults with predisposing cardiac conditions undergoing dental procedures with or without antibiotic prophylaxis. Clin Infect Dis 2006;42:e102–7. 17. Baddour LM. Prophylaxis of infective endocarditis: prevention of the perfect storm. Int J Antimicrob Agents 2007;30 Suppl 1:S37–41. 18. Danchin N, Duval X, Leport C. Prophylaxis of infective endocarditis: French recommendations 2002. Heart 2005; 91:715–8. 19. Gould FK, Elliott TS, Foweraker J, Fulford M, Perry JD, Roberts GJ, et al. Guidelines for the prevention of endocarditis: report of the Working Party of the British Society for Antimicrobial Chemotherapy. J Antimicrob Chemother 2006;57:1035–42.

20. Habib G, Hoen B, Tornos P, Thuny F, Prendergast B, Vilacosta I, et al. Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009):the Task Force on the Prevention, Diagnosis, and Treatment of Infective Endocarditis of the European Society of Cardiology (ESC). Eur Heart J 2009;30:2369–413. 21. Temporal Trends in Infective Endocarditis in the Context of Prophylaxis Guideline Modifications Three Successive Population-Based Surveys Xavier Duval et al on behalf of the AEPEI Study Group Paris, France. J Am Coll Cardiol 2012;59:1968–76. 22. Gibbs JL, Cowie M, Brooks N. Comment on: guidelines for the prevention of endocarditis: report of the Working Party of the British Society for Antimicrobial Chemotherapy. J Antimicrob Chemother 2006;58:896; author reply 896–898. 23. NICE Short Clinical Guidelines Technical Team. Prophylaxis against infective endocarditis: antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures. London: National Institute for Health and Clinical Excellence; 2008. NICE Clinical Guideline 64. 24. Ashrafian H, Bogle RG. Antimicrobial prophylaxis for endocarditis: emotion or science? Heart 2007;93:5–6. 25. Shanson D. New British and American guidelines for the antibiotic prophylaxis of infective endocarditis: do the changes make sense? A critical review. Curr Opin Infect Dis 2008;21:191–199. 26. Wright TI, Baddour LM, Berbari EF, Roenigk RK, Phillips PK, Jacobs MA, et al. Antibiotic prophylaxis in dermatologic surgery: advisory statement 2008. J Am Acad Dermatol 2008;59:464–473. 27. Wolf JS Jr, Bennett CJ, Dmochowski RR, Hollenbeck BK, Pearle MS, Schaeffer AJ. Urologic Surgery Antimicrobial Prophylaxis Best Practice Policy Panel. Best practice policy statement on urologic surgery antimicrobial prophylaxis. J Urol 2008;179: 1379–1390. 28. Oliver R, Roberts GJ, Hooper L, Worthington HV. Antibiotics for the prophylaxis of bacterial endocarditis in dentistry. Cochrane Database Syst Rev 2008;(4):CD003813. 29. Trends in endocarditis hospitalizations at US children's hospitals: Impact of the 2007 American Heart Association Antibiotic Prophylaxis Guidelines Sara K. Pasquali, MD, et al, American Heart Journal, Volume 163, Issue 5, 894–899. Address for correspondence Dr. Sameer Shrivastava: Email: [email protected]

Profiles in Preventive Cardiology

– Dr. Thomas Duckett Jones

Dr. Jones (1889–1954) was an American Physician whose professional life was essentially devoted to the problems associated with a single disease: Rheumatic Fever. Dr. Jones graduated from the Virginia Military Institute in 1919 and received his medical degree from the University of Virginia in 1923, where he served as an interne and resident. In 1925, he was a Dalton Fellow and cardiac resident at the Massachusetts General Hospital, and thereafter, spent a year as a National Research Council Fellow with Sir Thomas Lewis at University College Hospital in London. In 1928, he returned to the House of the Good Samaritan in Boston, where he organized the clinics and the research department, which he directed for the next twenty years. During this period, he was also an active member of the Harvard Medical School faculty and of the staff at the Massachusetts General Hospital, where under Dr. Paul D. White’s supervision he inaugurated and developed the rheumatic fever clinic. As a result of his many and important contributions, he became recognized internationally as an authority on this disease. In addition to his many responsibilities in this connection, he was president of the American Rheumatism Association, a vice-president of the American Heart Association and chairman of the association’s Council on Rheumatic Fever, president-elect of the National Health Council, president of the Protein Foundation, and chairman of the Committee on Plasma Fractionation and Related

Processes at the Laboratory of Physical Chemistry at Harvard University, and a member of the Advisory Council of the National Heart Institute. In retrospect, the achievements of Duckett Jones and his associates in searching for solutions to the problem of rheumatic fever have stood the test of time and have done so well. True, the credit for establishing the critical etiologic role of the hemolytic streptococcus belongs to others; however, Duckett Jones transformed the small, previously insignificant House of the Good Samaritan into a beacon in the recognition, treatment, and investigation of rheumatic fever. His role was not restricted to the research laboratory, but took in the wards, the clinics, and the community, as well as private and governmental bodies. His “Jones criteria” set a practical standard for diagnosis which proved durable with minor modifications over the decades. His vigorous efforts in conjunction with others helped to create an effective National Heart Institute. Dr. Floyd N. Denney has written, Duckett Jones was “the father of modem-day acute rheumatic fever in that he did more than any other one person to advance knowledge about its nature and diagnosis, and about care and prognosis of patients with this dread disease. A colleague wrote at the time of his death, that there remained in Boston alone “3000 patients who recall with gratitude and affection his careful and kindly guidance through their childhood rheumatism.’’

Received: NA; Revised: NA; Accepted: NA Disclosures: This article has not received any funding and has no vested commercial interest Acknowledgements: None

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