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ENDOCARDITIS Powered By Docstoc

Endocarditis is a bacterial infection involving the valves or components of the heart. Generally
this can occur whenever bacteria enter the bloodstream and lodge on injured areas of the heart.
Usually the body’s normal defense mechanisms are adequate to destroy these bacteria. In some
instances, injured areas of the heart allow greater numbers of bacteria to accumulate and the
body is less successful in warding off an infection. Although endocarditis may occur in patients
with normal hearts, it is unusual in comparison to those with some type of heart disease. All
individuals are exposed to transient mild increases in bacteria in the blood. However, this
increase in bacteria is higher following procedures that cause some type of bleeding in areas that
cannot be adequately cleansed or sterilized. For instance, there may be an increase in bacteria
from procedures as simple as teeth cleaning.

In 2007, the American Heart Association issued new recommendations for the prevention of
endocarditis. In general, these recommendations markedly reduce the number of individuals
that require the use of antibiotics prior to most procedures. The prior philosophy was that
antibiotics were indicated because it was “the right thing to do.” On the other hand, there had
not been extensive studies that documented either the need for these antibiotics nor the fact that
they were beneficial. As an example, bacteria frequently enters the bloodstream following
routine daily activities such as chewing food, flossing, the use of toothpicks, brushing your teeth,
and the use of water irrigation devices. Since these activities occur on almost a daily basis, there
may be a higher risk during a lifetime than there is in frequent professional dental cleaning or
dental work. For most patients, recommendations for antibiotics prior to routine dental work are
not recommended.

These new guidelines also have common sense recommendations. Maintaining good dental care
to reduce gum infections and other dental problems would seem much more effective in reducing
the release of bacteria into the blood than the use of infrequent antibiotics during teeth cleaning.
The other concern that has arisen with the use of antibiotics prior to dental care is the
development of strains of bacteria that are resistant to antibiotics. In this instance, when you
truly need an antibiotic for a major infection, it may no longer have the desired benefit. In
patients with infections of their bowel or urinary and bladder systems, it would be appropriate to
treat the underlying infection prior to any surgical procedures that might increase the entrance of
bacteria into the bloodstream. In treatment of these infections, your physician should use an
antibiotic to treat the infection but also include a method that is active against the bacteria that
can cause endocarditis. Usually Amoxicillin or Ampicillin is the preferred antibiotic.

In the past, many cardiac conditions were felt to be susceptible to endocarditis. The new
guidelines changed this to only those conditions which are higher risk of major adverse outcome
from endocarditis might benefit from antibiotics prior to the procedures.

         1.          Prosthetic cardiac valve
         2.          History of prior or previous infective endocarditis
         3.          Congenital heart disease (CHD)
                         Unrepaired cyanotic CHD including shunts and conduits.

DCC, December 2007
                           Completely repaired congenital heart disease with prosthetic material or
                            device, either placed by surgery or catheter intervention during the first six
                            months after the procedure. (After six months, it is felt that the body has
                            coated the material with a thin layer of protective cells)
                         Repaired CHD with an underlying residual defect at the site or adjacent to
                            the site of the artificial patch or device.
         4.          Cardiac transplantation patients who develop cardiac valve abnormalities.

An antibiotic used for the prevention of endocarditis should be administered in a single dose
before the procedure. If it has been forgotten it may be administered up to 2 hours after the
procedure but this is not the ideal situation.

Antibiotics are RECOMMENDED for patients:

              o Prior to all dental procedures involving cutting or manipulation of gum tissue or
                the tip region of the teeth or cutting or perforation of the lining of the mouth.
              o Surgical procedures of the lining of the lungs or throat including tonsillectomy
                and adenoidectomy.
              o Bronchoscopy only if biopsy or cutting is involved.
              o Any surgery on the throat, lungs, infected skin structures, or muscles that are also

Antibiotics that are useful for endocarditis should be part of the program for treatment when
surgery is performed on infections of the bladder, urinary tract, bowel, respiratory tract or lung.

Common conditions for which antibiotic prophylaxis is NOT NECESSARY:

              o Routine anesthetic injections                          o Intracoronary stent
                through non-infected tissue                            o Coronary artery bypass
              o Taking dental x-rays                                     surgery
              o Placement of removable
                prosthodontic or orthodontic
              o Adjustment of orthodontic
              o Placement of orthodontic
              o Shedding of baby teeth
              o Bleeding for trauma to the
                lips or mouth
              o Normal vaginal deliveries
              o Colonoscopy or endoscopy
              o Cystoscopy
              o TEE (transesophageal
              o Cardiac catheterization

DCC, December 2007
SUMMARY: It is your responsibility to notify surgeons and dentists if you have any cardiac
problems that would require the use of antibiotics. In general, these new recommendations limit
the number of conditions that require antibiotics and also limits the number of procedures for
which antibiotic protection is required.

DCC, December 2007

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