Q&A: New analysis upholds dental antibiotic prophylaxis guidelines in patients with CVD
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The 2007 decision to no longer advise antibiotic prophylaxis to prevent viridans group streptococcal infective endocarditis in many patients with CVD having invasive dental procedures was correct, according to a new scientific statement.
The 2007 American Heart Association guidelines scaled back the underlying conditions for which antibiotic prophylaxis was recommended, leaving the recommendation intact for only four categories of high-risk patients. For the new scientific statement from the AHA, produced in conjunction with the American Dental Association, the Infectious Diseases Society of America and the American Academy of Pediatrics, the writing group reviewed available evidence and decided not to change the 2007 guidelines.
“We continue to recommend viridans group streptococcal infective endocarditis (VGS IE) prophylaxis only for categories of patients at highest risk for adverse outcome while emphasizing the critical role of good oral health and regular access to dental care for all,” Walter Wilson, MD, professor of medicine at Mayo Clinic College of Medicine and Science, who holds the Edward C. Rosenow III, MD Professorship in the Art of Medicine, and colleagues wrote in Circulation.
Healio spoke with Wilson about the new document.
Healio: What was the rationale behind the changes in 2007?
Wilson: The document that was published in 2007 was a groundbreaking departure from all of the previous AHA recommendations for prophylaxis for endocarditis going back more than 50 years.
Up until that time, emphasis from the AHA statements on antibiotic prophylaxis always emphasized prevention of endocarditis by giving prophylaxis antibiotics.
To me and others on the writing committee, that did not make sense to us because there was no evidence to support that it worked.
People have transient bacteria in their blood, all sorts of activity during their daily lives such as brushing teeth and chewing food, and we do not recommend antibiotic prophylaxis for that, so why would we recommend antibiotic prophylaxis for a dental procedure that may occur once or twice a year?
For the 2007 document, we undertook a very careful and deliberate review of what we had done before and why we had done it. We convened a group of 33 experts from 11 different countries from around the world.
We had a meeting in Chicago. We wanted to get everybody’s input, and we all came to the conclusion that previous recommendations, while well intended, did not make sense.
So, the 2007 document dramatically changed the way that the AHA recommended antibiotics prophylaxis to prevent streptococci endocarditis.
Before, these other documents emphasized prevention of endocarditis with antibiotic prophylaxis for a dental procedure and for other procedures as well.
In 2007, we changed that from the risk of acquiring endocarditis to the risk from complications in patients from dying of endocarditis.
We ought to give it to patients most likely at risk for a bad outcome, should they get it.
That was the major change that drove everything else in our decision-making and in preparation of that 2007 document, that change was two different words, the risk of, to the risk from.
So, we reserved the recommendations for four separate groups of patients who if they got endocarditis were at risk for the worst outcomes.
Healio: What are the biggest consequences of contracting VGS IE?
Wilson: The biggest risk is death. Infective endocarditis is a universally fatal condition.
There are not many patients who, if no treatment is available, will do well.
If endocarditis is not treated with antibiotics, everybody will die. The worst outcome is death.
But in addition to those, other bad outcomes include HF and valve replacement — which is risky in itself.
Pieces of the valve could break off and go to the brain and other parts of the body, causing a stroke or MI.
There are multiple other complications such as kidney failure and lung emboli derived from endocarditis. It is a very serious infection.
Healio: What are the most important take-home messages from the new scientific statement?
Wilson: Between the publication in 2007 and this one, it took us over 4 years, with very careful due diligence. This was not done in haste.
The recommendations that we made in 2007 were such a landmark departure from all the previous ones and dramatically reduced the number of people that got antibiotic prophylaxis. The writing group had to make sure of the following things best as we could:
- Did we write them in a way that was easy to understand? Did we communicate them correctly?
- Was there acceptance of our recommendations among health care providers?
- Was there an increase in the frequency of endocarditis after these recommendations were published?
- Was there an increase in the morbidity and mortality since the 2007 recommendations?
Those are the four things that drove us.
Healio: Were the 2007 recommendations effective?
Wilson: Yes, they were. I think that we communicated them effectively.
The next question is, did they comply with the messages? That was variable.
The dentists complied. They recognized the importance in their practice.
Among cardiologists, it was not so great, but in general, cardiologists agreed with the recommendations.
Among the other health care practitioners, there was actually good compliance, although it was a little variable.
Healio: Who should receive VGS IE antibiotic prophylaxis and why?
Wilson: We reviewed the four groups that we recommended prophylaxis for in 2007.
Should we eliminate one or two? Should we add some?
The consensus opinion was that we chose the correct four groups.
And those four groups are:
No. 1, people who have a prosthetic heart valve.
Practice has changed since 2007. There is now increased use of transcatheter aortic valve replacement and other minimally invasive procedures to treat structural heart disease.
We do not have any real data. We made the assumption that those valves are just like prosthetic heart valves.
If the logic held to recommend prophylaxis for a prosthetic heart valve, we should recommend it for those valves as well.
No. 2, people who already had streptococcal infective endocarditis.
No. 3, people with congenital heart disease. There is a whole variety of those listed in the document.
No. 4, and these are rare, are people who undergo a heart transplantation and then develop valve disease. Obviously, they would be at high risk.
Healio: Were any other categories of patients seriously considered as candidates for VGS IE antibiotic prophylaxis?
Wilson: In the 2007 document, that was one of the most criticized decisions that we made.
We eliminated a large group of underlying cardiac conditions for which the documents from the previous 50 years, recommended antibiotic prophylaxis.
Those included mitral valve prolapse, rheumatic heart disease, bicuspid aortic valve, atherosclerotic valve disease and other valvular disease.
We eliminated those from those groups that had the worse outcomes because we analyzed the data, and their outcomes were simply not as bad as in those other four groups.
We had no evidence that antibiotic prophylaxis was preventing endocarditis in that group, so we no longer recommended it for these patients.
That created a lot of controversy, criticism and pushback.
We had all this time from 2007 to review.
Did we hurt anybody?
Did eliminating those groups result in the higher frequency of endocarditis in these groups or a greater incidence of morbidity or mortality?
We reviewed a lot of published data from 2007 to the present, and we found no evidence to support that.
So, we felt comfortable with our recommendations to exclude those patients from those for whom we recommended prophylaxis. That was a big decision; we were a little uneasy about it ourselves.
Healio: What can cardiologists do to emphasize the CV implications of oral health to their patients?
Wilson: We recognize not everybody has access to regular dental care and not everybody can afford it. People live in underserved areas both in the United States and in other places in the world.
But we still strongly believe that for those who do have access to good and regular dental care and oral health, that is more important than any other factor that we could recommend, especially more important than giving antibiotic prophylaxis.
That is the major message from this document and from the previous one.
The second one is that we strongly emphasize the importance of shared decision-making. We did not emphasize this enough in the 2007 document.
Shared decision-making is a broad term. It also implies not only that the health care provider and the patient participate in the decision to receive or not receive an antibiotic, but it also implies that there is education; that the health care provider can provide education as to why we do or why we do not recommend.
Patients have a say in this. A patient may come into the office and say that for 40 years my dentist and cardiologist recommend that I get prophylaxis. If in fact the patient is convinced that he or she should get that prophylaxis, we did not suggest that you try and argue or talk the patient out of that.
Try to educate the patient as best you can and make a decision together about what is best for the patient. Sometimes that may mean just go ahead and give the antibiotic prophylaxis.
Healio: Is there anything else you would like to mention?
Wilson: I hope people have confidence that our recommendations do not cause harm.
For more information:
Walter Wilson, MD, can be reached at wilson.walter@mayo.edu.
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