Page 18 - GP Spring 2022

2021 Updates on Antibiotic Prophylaxis

By Marci Levine, DMD, MD and Analia Veitz-Keenan, DDS

Introduction and flossing of their teeth every day. Such The AHA did not recommend antibiotic
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Antibiotic prophylaxis (AP) for patients un- patients need to maintain good oral hygiene prophylaxis for patients undergoing he-
dergoing invasive dental treatments remains with regular dental examinations and pro- modialysis; consultation with the treating
a controversial topic. Often patients or cli- fessional cleanings to mitigate these risks. nephrologist before dental work is recom-
nicians follow outdated recommendations, mended to assess the patient’s risk for infec-
and conflicts arise between dentists and pa- The indications for the use of prophylaxis in tion as patients with end-stage renal disease
tients when updated, and often unfamiliar this patient group includes those with pros- have a higher risk for IE. 11-13
recommendations are advised to patients. thetic cardiac valves or materials for valve
repair, a history of IE, a cardiac transplant Therefore, obtaining a thorough medical
The overuse of antibiotics is a worldwide with structurally abnormal valves, a cya- risk assessment is paramount. Evaluating
concern because it may result in antibiotic notic congenital cardiac disease that is un- any prior history of IE, medical conditions
resistance. Several organizations, including repaired, or disease that is repaired but has such as uncontrolled diabetes, immunodefi-
the Centers for Disease Control and Preven- residual shunts or regurgitation. ciency, chronic steroid use, or neutropenia
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tion, advocate the use of antibiotics with secondary to chemotherapy are highly rel-
caution and favor their use to be reserved The first six months after cardiac transplan- evant to dental care and these risk factors
for situations in which antibiotics are neces- tation is associated with an increased risk of may make patients more susceptible to in-
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sary and essential. IE. At-risk patients should be managed in fections.
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consultation with their treating cardiology
The purpose of this review is to outline the team and recommendations for prophylax- Some dentists in practice may also encoun-
most current recommendations for antibi- is should be mutually agreed upon before ter pediatric patients with congenital cardiac
otic prophylaxis and to update the reader treatment. diseases who require antibiotic prophylaxis.
on the appropriate management of the use The categories for which conditions in chil-
of prophylactic antibiotics in some com- Miscellaneous Conditions/Non-Valvular dren warrant prophylaxis have not changed
monly seen scenarios encountered in clin- Considerations from prior recommendations. These include
ical practice, such as patients who have Some patients who have non-valvular con- unrepaired cyanotic congenital disease, re-
had joint replacements, those with cardiac siderations such as a history of heart failure paired disease within the first six months of
or non-valvular diseases, and patients who may require the installation of left ventric- surgery, and repaired disease with residual
need antibiotic premedication but are aller- ular assist devices (LVADs). Given that defects, leaks, or abnormal flow. It is im-
gic to amoxicillin. LVADs and implantable heart devices are portant to remember that children should
more commonly used now, dentists should receive antibiotic dosages based on their
The American Heart Association (AHA) be prepared to adequately manage these pa- body weight (unlike adults) and should be
guidelines for the use of antibiotic prophy- tients’ needs in the ambulatory setting. The checked for the presence of allergies or hy-
laxis to prevent infective endocarditis (IE) literature well supports the use of antibiotic persensitivity reactions as some children
before dental treatment were updated in prophylaxis for patients with LVADs. It is may be antibiotic naive.
May 2021. Compared to prior guidelines , reasonable given the significant risk of in-
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a revised group of patients now qualifies to fection in the face of a compromised cardio- As a dentist, it is essential to work with a
receive antibiotic prophylaxis. As we now vascular system. patient’s treating physicians to help balance
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know, the risks related to complications potential risks and benefits, especially when
secondary to antibiotic use may outweigh There are situations where an individual the indications for antibiotic prophylaxis
the benefits of prophylaxis for patients that may have a cardiac condition or an implant may be unclear. When using such a collab-
were previously covered. The definition of some sort that does not require antibiot- orative approach, it has been our experience
of invasive dental treatments is critical to ic prophylaxis. Patients with cardiovascu- that patients respond favorably when the
consider procedures in which the gingival lar pacemakers, implantable cardioverter providers are all working together in the pa-
tissues and/or oral mucosa are penetrated, stimulators, stents, shunts, filters, and septal tient’s best interest.
increasing the risk of bacteremia. 2,3 defects closure where complete closure has
been obtained, do not require antibiotic pro- In summary, the following cardiac condi-
Prevention of IE in Cardiac Conditions phylaxis. tions require the use of antibiotic prophy-
Most of the indications for antibiotic pro- laxis before invasive dental procedures :
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phylaxis for the prevention of IE from car- Other situations, such as patients who have
diac conditions listed by both the ADA and breast implants as well as different types of ● Prosthetic cardiac valve or other valve
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AHA (American Heart Association) remain implants 9,10 such as penile implants, do not material
unchanged from 2007 with some additions require antibiotic prophylaxis before dental ● Cardiac valve repaired with devices,
and modifications. treatment unless their medical condition(s) including annuloplasty, rings, or clips
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or medical histories warrant its use.
However, debate exists as to the timing of ● Transcatheter implantation of prosthet-
prophylaxis. Patients at the highest risk for The dentist should discuss with the patient’s ic valves
IE should continue to receive prophylaxis physician(s) the need for antibiotic prophy- ● Previous, relapse, or recurrent infec-
despite the concomitant risks of drug-to- laxis for immunocompromised patients or tious endocarditis
drug interactions and drug resistance. These patients with central venous access, depen-
patients are also susceptible to transient dent upon the dental procedures needed for ● Unrepaired congenital heart disease
bacteremia and IE during routine brushing the patient. (CHD), including palliative shunts and
conduits
www.nysagd.org l Spring 2022 l GP 18