New guidelines on preventing infective endocarditis end

2007;28;20AAP News Deborah Johnson

before dental treatment for most patientsNew guidelines on preventing infective endocarditis end routine antibiotic prophylaxis

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Volume 28 • Number 9September 2007www.aapnews.org

by Deborah Johnson • Correspondent

Very few patients will require antibioticsprior to dental treatment under new guide-lines from the American Heart Association(AHA).

For decades, it was believed that patientswith heart lesions or diseases needed antibi-otics prior to dental work to prevent infectiveendocarditis (IE), an uncommon but life-threatening infection of the heart’s valves.

The AHA guidelines, endorsed by the Acad-emy (Pediatrics. 2007;120: 649), were revisedin light of evidence that antibiotics prevent onlya small percentage of IE cases, if any at all, said

Jane Newburger, M.D.,M.P.H., FAAP, a Bostonpediatric cardiologist whoco-authored the guide-lines. In fact, she said, stud-ies show that IE is morelikely to result from thebacteria associated withdaily activities such aschewing food, using a

toothpick, flossing or brushing. “To some extent, it’s not always something

we can prevent,” Dr. Newburger said.The mucous membranes of the mouth are

host to bacterial organisms that can be dis-turbed by dental cleanings or surgeries, saidRobert S. Baltimore, M.D., FAAP, who servedas a liaison between the Academy and theAHA, and was a co-author of the guidelines.

However, the link between dental proce-dures and IE is circumstantial, and the num-ber of cases related to dental procedures hasbeen overestimated, according to the report inCirculation (http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.106.183095).

Dr. Baltimore said those who are at high risk

for infection will continue with the antibioticregimen under the new guidelines. However,the definition of “high risk” has been altered tomean that one could suffer a grave outcome asthe result of IE, not just that one might get it. Badoutcomes include severe cardiac disability anddeath.

High-risk patients include those who have:• cyanotic congenital heart defects that have

not been surgically repaired;• defects that have been repaired, but with

shunts or conduits;• cardiac defects repaired within the past six

months;• artificial heart valves;• previous episodes of IE; and• transplanted hearts that have developed

valve problems.In addition, the AHA guidelines have elim-

inated antibiotics for preventing IE in patientsundergoing surgeries in the gastrointestinal orgenitourinary tracts.

Antibiotics still are recommended for sur-geries in the upper respiratory tract where thereis danger of perforating a mucous membrane.

Drs. Baltimore and Newburger said that inrevising its guidelines, the AHA weighed thenegligible benefits of antibiotic prophylaxisagainst adverse effects, such as the emergenceof microorganisms resistant to antibiotics. Theallergic and toxic effects of antibiotics, as well

as cost, also were considered.Good oral hygiene to prevent infections

should be emphasized over the use of antibi-otics, the physicians said.

Now it’s a matter of educating the public.Many dentists are requesting letters from car-diologists to confirm that patients no longerneed antibiotics. Dentists and physicians willneed to communicate to see how each patient’scircumstances fit the recommendations. Thepediatric cardiologist should have the final say.

“We’re sending out tons of letters,” Dr. New-burger said. “We’re educating the families aswell.”

Dr. Baltimore said it’s possible some parentswill feel vulnerable when they learn antibioticsno longer are a part of their children’s dentalroutine.

“It’s definitely been a security blanket, andit’s being taken away,” he said. “There are par-ents of older children who had it drummedinto them that they needed to make sure thedentist provided antibiotics.”

For these families, re-education is the key,Dr. Baltimore said.

Dr. Newburger said parents understand thereasons for the changes once they are explained.

“It’s possible patients will be uncomfort-able,” she said, “but I have not found that tobe the case. All of my patients are extremelygrateful not to be taking antibiotics anymore.”

“It’s definitely been a security blanket, and it’sbeing taken away. There are parents of olderchildren who had it drummed into them thatthey needed to make sure the dentist pro-vided antibiotics.”

— Robert S. Baltimore, M.D., FAAP

Dr. Newburger

New guidelines on preventing infective endocarditis end routineantibiotic prophylaxis before dental treatment for most patients



©Copyright 2007 AAP News



2007;28;20AAP News Deborah Johnson

before dental treatment for most patientsNew guidelines on preventing infective endocarditis end routine antibiotic prophylaxis

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