Guidelines Issued for Antibiotic Prophylaxis With Implanted Heart Devices

Laird Harrison

February 17, 2011 — Dental patients should not take prophylactic antibiotics simply because they have pacemakers or implanted defibrillators, according to a new statement from the American Heart Association (AHA).

Although 2007 guidelines already exclude these patients from the list of those who need prophylactic antibiotics to prevent endocarditis,the AHA wanted to emphasize this point because many physicians are ignoring these guidelines,and because an increasing rate of infections related to the devices has raised concerns, coauthor Peter Lockhart, DDS, told Medscape Medical News.

summary of the dental aspects of the new guidelines is published in the February issue of the Journal of the American Dental Association. The full statement, which offers guidance on managing these infections, was previously published in Circulation.

Dr. Lockhart, chair of the Department of Oral Medicine at Carolinas Medical Center in Charlotte, North Carolina, estimates that dentists are unnecessarily prescribing antibiotics to millions of patients with implanted devices and many other conditions. “It’s quite a big problem,” he said.

There is no evidence that antibiotics can prevent infections of implanted devices caused by dental procedures, he said, but the antibiotics may cause allergic reactions and create resistant strains of bacteria. “There are deaths due to use of antibiotics,” said Dr. Lockhart.

According to the statement, prescription antibiotics would cost more than $80 million in the United States each year if given for all the cardiovascular conditions that might lead to infection.

Implanted heart devices are becoming more common, according to the statement. From 1997 to 2004, the rate of implantation increased 19% for permanent pacemakers and 60% for implantable cardioverter-defibrillators; despite improved methods for device implantation, the prevalence of infection has increased faster than the rate of implantation.

The notion of prescribing antibiotics to prevent infections from dental procedures dates back to a 1955 AHA statement, said Dr. Lockhart, but that recommendation was based on speculation at a time when antibiotics were seen as miracle drugs that could do no harm. Recommendations for prophylaxis for various conditions such as orthopedic implants proliferated after that, all without evidence to support them.

Since then, several studies, including some by Dr. Lockhart, have failed to show an advantage to the prophylaxis.

Bacteria do enter the bloodstream from dental procedures, and oral bacteria can cause endocarditis, explained Dr. Lockhart, but most endocarditits is not caused by these strains of bacteria. He has not been able to find an actual case in which a dental procedure led to a bloodborne infection, and daily tooth brushing and food chewing release far more bacteria into the bloodstream than procedures that take place in a dental office.

Michael A. Siegel, DDS, chair of oral medicine at Nova Southeastern University in Fort Lauderdale-Davie, Florida, told Medscape Medical News that the new guidelines increase the legal risks for dentists who prescribe antibiotics as prophylaxis in most heart patients. “These dentists who give it to everyone just in case are going to be hung out to dry,” he said.

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If physicians recommend antibiotics contrary to the guidelines, dentists should insist that the physicians write the prescriptions, he said.

So who should get antibiotics to prevent endocarditis during dental procedures? The 2007 guidelines list the following conditions:

  • prosthetic cardiac valve or prosthetic material used for cardiac valve repair,
  • previous infective endocarditis,
  • specific types of congenital heart disease, and
  • cardiac transplantation in patients who develop cardiac valvulopathy.

Patients with implanted devices probably do not run the risk of infection once their incisions are healed, said Dr. Siegel. “The long and the short of it is that once it’s put in, give them 30 days to heal, and then there’s no problem,” said Dr. Siegel.

J Am Dent Assoc. 2011;142:159-165. Full text

Circulation. 2010;121:458-477 Full text

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