ada guidelines.pdf

7/27/2019 ada guidelines.pdf

1/42

Guidelines for

Antibiotic Prophylaxis

Rachel Miller, M.D.Clinical Professor

Dept. of Internal Medicine

April 27, 2012


2/42

Areas of Focus

Antibiotic prophylaxis forinfective endocarditis

Antibiotic prophylaxis forindividuals withprosthetic joints

Antibiotic use for open

wounds


3/42

Objectives

Review and apply the new AHA practice guidelines forthe prevention of infective endocarditis.

Discuss the current recommendations for the preventionof prosthetic joint infections.

Identify the risk factors for infection after traumatic skinlacerations and the scenarios where antibioticprophylaxis is indicated.

Evaluate the risk of administering prophylactic antibioticsvs. the scientific evidence for benefit into clinicaldecision-making.


4/42

Guidelines for the Prevention ofInfective Endocarditis


5/42

Theoretical Basis for

Endocarditis ProphylaxisPathogenesis of endocarditis:

Formation of non-infected thrombus on an abnormalendothelial surface

Secondary infection of this thrombus occurs during

transient bacteremia with bacterial adherence Proliferation of bacteria within thrombus with vegetation

formation

Prevention/prompt tx of transient bacteremiainterrupts this sequence


6/42

The History of Antibiotic Prophylaxis

to Prevent Endocarditis

1930: Antibiotic prophylaxis for IE becomes standardpractice

1955: 1stAHA document on IE prophylaxis

19901984

1977 Several iterations of AHA guidelines documents19721965

1957

2007: Newest revision by AHA in conjunction with ADA,IDSA, AAP


7/42

Time for a Change.

Rationale for change:

Only an extremely small # of cases may be prevented byantibiotic prophylaxis, even if it was 100% protective

IE is more likely to result from frequent exposure to randombacteremias associated with daily activities.

Antibiotic-associated adverse effects exceed the benefits ofprophylaxis

PRACTICE GUIDELINE: FOCUSED UPDATE

ACC/AHA 2008 Guideline Update on Valvular Heart Disease:

Focused Update on Infective Endocarditis

A Report of the American College of Cardiology/American Heart Association

Task Force on Practice Guidelines

Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular

Angiography and Interventions, and Society of Thoracic Surgeons


8/42

Does antibiotic prophylaxis really

prevent endocarditis?

It does in animal models of valvular heartdisease with induced bacteremia.

It can reduce bacteremia associated with dentalprocedures.

No study in humans has definitively

demonstrated IE prevention after invasiveprocedures.

Prophylaxis failures occur.


9/42

Bacteremia is a Common

Occurrence in Daily LifeIncidence of bacteremia after various procedures

Dental extraction 18-85% Chewing 32-88%

Tooth brushing 20-40%

(higher if sonicating) EGD 8-12%

Colonoscopy 0-10%

Urethral dilatation 18-33% Urethral catheterization 8%

Nasotracheal suctioning 16%

Estimated 5370 min (~90 hrs) of bacteremia/mo in dentulouspersons who chew and practice standard oral hygiene


10/42

Estimated Endocarditis Risk

Associated with Dental Procedures

Underlying Heart Dx

# Dental Procedures/

1 Case of Endocarditis

None 14 million

Congenital Heart Dx 475,000

Rheumatic Heart Dx 142,000

Prosthetic Heart Valve 114,000

Previous Endocarditis 95,000

AHA Guidelines, Circulation, May 2007


11/42

the focus on the frequency of bacteremia

associated with a specific dental procedure and theAHA guidelines for prevention of IE have resulted inan overemphasis on antibiotic prophylaxis and an

under-emphasis on maintenance of good oralhygiene and access to routine dental care, whichare likely more important in reducing the lifetime riskof IE than the administration of antibiotic prophylaxisfor a dental procedure.



12/42

The Major Changes in the

Updated AHA Guidelines

Prophylaxis is aimed at those at highest risk foran adverse outcome of IE, rather than solelybased on an increased lifetime risk of IE.

Significant simplification of conditions andprocedures that warrant prophylaxis.

Overall, more evidence based, rather than

opinion based.


13/42

Conditions of Highest Risk

Included

Prosthetic heart valves

Prior endocarditis

Cyanotic heart disease Unrepaired

Repaired congenital heartdx with prosthetic materialor device x6 mo

Repaired with residual

defects Heart transplant with

valvulopathy

Not included

Bicuspid aortic valve

Acquired aortic or mitralvalve disease MVP with regurgitation

Prior valve repair Hypertrophic

cardiomyopathy with

latent or restingobstruction



14/42

Procedures Warranting Antibiotic

Prophylaxis to Prevent IEDental Procedures:

All dental procedures that

involve manipulation ofgingival tissue, periapicalregion of the teeth, orperforation of the oral

mucosa.

Dental extractions

Periodontal procedures Endodontic instrumentation

Prophylactic cleaning

Initial placement of orthodontic

bands (not brackets)

Respiratory procedures: Procedures involving

incision/ biopsy of themucosa

Removal of tonsils/adenoids

TBBX but NOTbronchoscopy only

GU procedures:

ONLY during activeenterococcal infection

GI procedures:

NO LONGER INCLUDED



15/42

IE Prophylaxis Regimens

for Dental ProceduresSituation Agent Adults* Children*

Oral Amoxicillin 2 g 50 mg/kg

Unable to takeoral meds

Ampicillin

Cefazolin orCeftriaxone

2 gm IM/IV

1 gm IM/IV

50 mg/kg IM/IVfor all

PCN Allergy-

oral

Cephalexin

Clindamycin

Azithromycin

2 gm

600 mg

500 mg

50 mg/kg

20 mg/kg

15 mg/kgPCN Allergy-unable to takeoral meds

Cefazolin orCeftriaxone

Clindamycin

1 gm IM/IV

600 mg IM/IV

50 mg/kg IM/IV

20 mg/kg IM/IV

* Single dose given 30-60 min before procedure


16/42

Endocarditis and Pharyngitis


17/42

Should patients with valvular heart disease and

pharyngitis be treated more readily with antibiotics?Proposed rationale #1:

Streptococci are a common cause of IE, thusantibiotic therapy will prevent bacteremia andsubsequent IE.

The Facts: Streptococci account for 60-80% of IE cases

Group A Streptococci (GAS) IE is extremely rare

Ratio of IE to non-IE bacteremia cases for GAS is 1:32

Conclusion: Persons with pharyngitis and valvular heart dxdo not require Abx tx on the basis of preventing GAS IE.


18/42

Should patients with valvular heart disease andpharyngitis be treated more readily with antibiotics?

Proposed rationale #2:

Streptococcal pharyngitis can predispose to rheumatic

fever and subsequent rheumatic heart disease, which maymake underlying valvular disease worse.

The facts:

GAS pharyngitis is a known trigger of rheumatic fever (RF) Recurrent GAS pharyngitis can lead to recurrent episodes of RF

and eventual valvular heart disease (


19/42

Infective Endocarditis Prophylaxis

Summary of Major Points Only an extremely small # of IE cases will likely

be prevented by antibiotic prophylaxis forprocedures (dental).

The latest AHA guidelines have significantlytrimmed the indications for antibiotic prophylaxis.

The treatment approach to GAS pharyngitisshould not be altered on the basis on underlyingvalvular heart disease.


20/42

Antibiotic Prophylaxis for Patients

with Total Joint Replacements


21/42

The Clinical Landscape

More than 750,000 total joint arthroplasties doneannually in the US

As the US population ages, demand is expected to riseby 200-600% over the next 25 yrs

Prosthetic joint infections (PJIs) cause significant

morbidity and mortality

Attributable cost of a single PJI episode is 3-4x the cost

of the primary arthroplasty (usually >$50,000)


22/42

The Gray Zone of Antibiotic

Prophylaxis to Prevent PJIs

Purposefully omittedfrom AHA IE preventionguidelines

The analogy of PJIswith IE is invalid

No convincing evidencethat prophylaxis duringdental procedures

prevents PJIs


23/42

Advisory Statement of the

ADA and AAOS Oral bacteremias induced by daily events are

more common than dental-treatment induced

Critical period for PJI is up to 2 yrs after surgery

No prophylaxis is needed for patients with pins,screws and plates

Good dental health PRIOR to joint replacementhighly encouraged

JADA 134:895, 2003


24/42

Summarized Recommendations from

the ADA/ AAOS Advisory Statement

Antibiotic prophylaxis is not routinely indicated for most

dental patients with TJRs. However, it is advisable toconsider pre-medication in a small number of patientswho may be at potential increased risk.*

JADA 134:895, 2003

High risk ~


25/42

.but the debate continued.


26/42

2009 Information Statement from

AAOS safety committee

http://www.aaos.org/about/papers/advistmt/1033.asp

Prior 2 yr designation now removed


27/42

Dental Procedures & PJIs

Counterpoint #1 Study Design:

Single center, prospective case-control study of 339 inpatients

w/wo hip or knee PJI from 2001-2006 at the Mayo Clinic Findings:

No

risk of PJIs in pts undergoing high or low risk dental

procedures without antibiotic prophylaxis

Antibiotic prophylaxis did not

the risk of PJIs

No difference with subset analysis of PJIs of potential dental/oralorigin

Trend toward

PJIs in pts with >1 dental hygiene visit

Conclusions: Data refute the AAOS recommendation of universal antibiotic

prophylaxis for dental procedures in pts with arthroplasties

Berbari EF, Clin Inf Dis 50:8, 2010


28/42

Dental Procedures & PJIs

Counterpoint #2 Study Design:

Data from Medicare Current Beneficiary Survey (1997-2006)

1000 participants with JR, identified those with PJI (42 pts) andcompared them with matched controls

Findings:

No association between dental procedures and PJIs in eithertime-to-event analysis nor the case-control analysis

Trend toward more dental procedures in preceding 90 days incontrol pts than those with PJIs

Conclusions: Dental procedures not associated with a higher risk of PJIs

The 2009 AAOS Information Statement should be reconsidered

Skaar DD, JADA 142:1343, 2011


29/42

The Final Recommendations

Remain Gray.

Not intended as standard of care or substitute for clinicaljudgment.

Practitioners must exercise their own clinical judgmentin determining whether or not antibiotic prophylaxis isappropriate.

JADA 134:895, 2003

http://www.aaos.org/about/papers/advistmt/1033.asp


30/42


31/42

Antibiotic Prophylaxis for

Traumatic Lacerations & Open Wounds


32/42

Background

Lacerations and open wounds are the 3rd mostcommonly encountered problems in the ED

Account for 8% of the 95 million ED visits in US/ year

Variable risk of infection depending on type of injury

Incised, puncture, bites, abrasions

Common Goals of Treatment: Avoiding infection Optimal functional and cosmetic result


33/42

General Principles of Initial

Traumatic Wound Management Wound cleansing

Use tap water or normal salineFor contaminated wounds, use pressure irrigation

Keep the wound moist

Topical antimicrobial agents

Cover with an occlusive dressing

Ascertain tetanus immunization status

Dire DJ,Acad Emer Med 2:4, 1995Singer AJ, NEJM 359:10, 2008


34/42

Risk Factors for Infection in Patients

with Traumatic Lacerations Study Design:

Cross-sectional, prospective

Data sheets collected at time of repair & suture removal

Study Population: Univ Med Center at Stony Brook, 1992-1996

All pts with traumatic lacerations eligible, without standardizingwound tx

Results: 5521 pts enrolled, 194 infections (3.5%) over 4 yrs Mean time of presentation: 2.1 (+/- 3.6 hrs after injury) Foreign body/bite wounds accounted for


35/42

Risk Factors for Infection in Patientswith Traumatic Lacerations

Hollander JE,Acad Emer Med 8:716, 2001

Characteristic Relative Risk of Infection

Risk of Infection

Age* OR 1.01 per yr of lifeDiabetes* 3.9

Longer, wider, deeper, jagged* 1.6-1.8

Foreign body identified* 2.9Visible contamination 1.8

Risk of Infection

Head/scalp wounds* 0.3Blunt mechanism of injury 0.5

* Remained significant by multivariate modelingAdjustment for systemic antibiotic prophylaxis did not alter results


36/42

High-Risk Wounds where Antibiotic

Prophylaxis Recommended Significant immunocompromise

DM, PVD, AIDS, lymphedema, steroid use

Open fractures or wounds into joints

Wounds involving tendons or cartilage

Gross contamination & cannot be adequatelycleaned

Puncture or crush injuries

Bite wounds Oral wounds

>18 hr delay in presentation

Moran GJ, Infect Dis Clin No Amer22:117, 2008


37/42

Antibiotic Recs for High-Risk Wounds

Clinical Scenario Recommended Antibiotic

Most settings 1st generation cephalosporin

Intra-oral wounds Penicillin

Bite woundsGrossly contaminated or devitalized

Amoxicillin-clavulanate


Additional Points:

Parenteral antibiotics not shown to more effective than oral antibiotics It is not necessary to include activity against CA-MRSA For most cutaneous wounds, 24 hrs of antibiotics after wound closure

is sufficient


38/42

Plantar Puncture Wounds

Superficial infection rate is 2-10% Staph, Strep

Pseudomonas (tennis shoes)

risk for deep, forefoot

wounds, delayed presentation

No randomized trials haveevaluated the benefits of

prophylactic Abx Prospective, observational

study suggests cleansing alonelikely adequate with close f/u

Singer AJ, NEJM 359:1037, 2008


39/42

Mammalian Bite Wounds

Risk of Infection Dog: 3-18%, usu. lacerations

Human: up to 50%, MC joints

Cat: 28-80%, puncture

Bacteriology Primarily mixed anaerobes and

aerobes

Cats: Pasteurella multocida

Dogs: P. multocida,Capnocytophaga canimorsus

Humans: HBV, HIV




40/42

Mammalian Bite Wounds

Rec prophylactic antibiotics

Amoxicillin-clavulanate Cipro + clindamycin (adults)

Cipro + TMP-SMX (peds)

Duration: 3-5 days

Systematic data reviewconcludes benefit of

antibiotic prophylaxis onlyfor hand bites andcat/human bites




41/42

One More Point.

The Negative Aspects of Antibiotic Prophylaxis

Non-fatal adverse reactionsRash, GI sxms, C. difficile colitis

Stevens-Johnson syndrome, TENS

Fatal anaphylactic reactionsEst. 15-25 rxns/ 1million treated with PCN

Drug interactions

Adding to the resistance burden The hassle factor

A large # of pts need to be treated to prevent a single case of infection.The risk of antibiotic associated adverse events exceeds the benefit, if any.


42/42

Take Home Points

The data on which antibiotic prophylaxis

recommendations are based is limited andinconclusive.

Less is (likely) more

Antibiotic prophylaxis guidelines are onlyguidelines. They are no substitute for clinical

judgment.

Documents

ada guidelines.pdf