Antibiotic Prophylaxis Against Infective Endocarditis Before Invasive Dental Procedures

Mapping Review of the Correlations Between Periodontitis, Dental Caries, and Endocarditis

Background/Objectives: The correlation between cardiovascular diseases, particularly infective endocarditis, and oral disorders such as periodontitis and dental caries has been widely discussed in the scientific literature. In this mapping review, we aim to examine the available evidence on the link between these conditions, focusing on the pathogenetic mechanisms that underlie the development of endocarditis in patients with oral diseases. Methods: A systematic search was conducted across three major databases-PubMed, Scopus, and ScienceDirect-as well as grey literature in Google Scholar. Relevant articles were selected based on inclusion and exclusion criteria, focusing primarily on systematic reviews. The data extracted included study characteristics, main outcomes, and risk-of-bias evaluations. Results: A total of 13 systematic reviews were included in this mapping review. The findings suggest there is a significant connection between periodontal disease, dental caries, and the incidence of infective endocarditis. The evidence highlights that oral bacteria, particularly Streptococcus species, can enter the bloodstream during daily activities and invasive dental procedures, contributing to the development of endocarditis in susceptible individuals. However, the role of antibiotic prophylaxis in preventing endocarditis following dental procedures remains controversial. Conclusions: This review reinforces the importance of oral health in preventing cardiovascular complications, especially infective endocarditis. Although antibiotic prophylaxis may reduce the risk in high-risk individuals, further research is needed to clarify its effectiveness. Enhanced awareness of and education on the shared risks between oral and cardiovascular health could improve prevention strategies and patient outcomes.

Global Trends and Regional Differences in the Burden of Infective Endocarditis, 1990-2021: An Analysis of the Global Burden of Disease Study 2021

BACKGROUND

The study aimed to offer detailed insights into the global, regional, and national burden of IE in 2021, while also examining the temporal trends of IE from 1990 to 2021.

METHODS

Data on the absolute numbers and age-standardized rates (ASR) of incidence, deaths, and disability-adjusted life years (DALYs) related to IE were sourced from the Global Burden of Disease Study (GBD) 2021. The estimated annual percentage changes (EAPC) of ASR were calculated to quantify the temporal trends. Furthermore, joinpoint regression models were used to identify the temporal trends and the primary joinpoint year of ASR.

RESULTS

Globally, the age-standardized incidence rate (ASIR) for IE increased with an EAPC of 1.00 (95%CI: 0.93-1.08) from 9.35 per 100 000 population in 1990 to 12.61 per 100 000 population in 2021. Despite a rise in the absolute number of death cases and DALYs related to IE, the age-standardized mortality rate (ASMR) has remained stable (EAPC 0.06, 95%CI: -0.10-0.22), and the age-standardized DALYs rate (ASDR) has exhibited a decline (EAPC - 0.34, 95%CI: -0.45-0.24) between 1990 and 2021. Males bore a higher burden of IE compared to females, with the peak burden gradually shifting towards older individuals. In 2021, the ASIR for IE exhibited an increase with the rise in socio-demographic index (SDI) quintiles, with the highest ASIR observed in the high SDI region (15.77 per 100 000 population). Moreover, the highest growth rates of ASIR, ASMR, and ASDR were also noted in the high SDI region. On the other hand, the ASMR (1.34 per 100 000 population) and ASDR (40.71 per 100 000 population) for IE were relatively high in the low SDI region. Joinpoint analysis demonstrated that the ASIR, ASMR, and ASDR did not experience any sudden surges either globally or across different SDI regions after 2007.

CONCLUSIONS

The burden of IE remained relatively high, characterized by a rising ASIR and a stable ASMR on a global scale. This burden was notably prominent among males, the elderly, and in the high and low SDI regions. Region-specific prevention and management strategies might be warranted to reduce the burden of IE.

Infectious Endocarditis Is Associated with Dental Treatment or Poor Dental Status-Results from the Brandenburg Endocarditis Registry (B.E.R.)

Background: While the relationship between recent dental treatment and the development of endocarditis is largely undisputed, the relationship between poor dental status and the development of infective endocarditis has not yet been proven beyond doubt. We have therefore analyzed this hypothetical connection using our established endocarditis register (B.E.R.). Patients and Methods: A total of 72 patients who underwent dental treatment (TREAT) and 55 patients with a desolate dental status (DESOLATE) were found in our database of 530 patients subsequently developing infective endocarditis necessitating valve surgery. A propensity score analysis was performed comparing TREAT as well as DESOLATE with matched patients without these conditions as CONTROL. Results: TREAT showed significantly more often Strept. mitis (26.9%) as well as other Streptococci (36.54%, p = 0.001) compared to CONTROL (3.51% and 10.53%, respectively), whereas Staphylococci and E. faecalis were found more often in CONTROL than in TREAT (S. aureus: 22.81% vs. 15.38%, n.s.; other Staphylococci 14.04% vs. 1.92%, p = 0.033; E. faec.: 26.32% vs. 9.62%, p = 0.045). DESOLATE showed significantly more Strept. mitis compared to CONTROL (27.91% vs. 4.88%, p = 0.007). Early mortality was 23.7% in the TREAT group, while it was 15.25% in the CONTROL group and 17.02% in the DESOLATE group vs. 20.83% in the CONTROL patients. Conclusions: The current results suggest that adequate endocarditis prophylaxis to prevent bacteremia may not be carried out in patients undergoing dental treatment and may occur spontaneously in patients with poor dental care. Both situations require new strategies to avoid such severe consequences.

Current trends and challenges in infective endocarditis

PURPOSE OF REVIEW

Infective endocarditis (IE) is a complex disease with increasing global incidence. This review explores recent trends in IE infection patterns, including healthcare-associated IE (HAIE), drug-use-associated IE (DUA-IE), multidrug-resistant organisms (MDROs), and challenges in managing prosthetic valve and device-related infections.

RECENT FINDINGS

Staphylococcus aureus has emerged as the leading cause of IE, especially in HAIE and DUA-IE cases. Increasingly prevalent MDROs, such as methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci, pose further clinical challenges. Advances in molecular diagnostics have improved the detection of culture-negative endocarditis. The introduction of the AngioVAC percutaneous aspiration device promises to change the management of right and possibly some left sided IE. Multidisciplinary team management and early surgery have demonstrated improved outcomes including partnerships with psychiatry and addictions services for those with intravenous DUA-IE.

SUMMARY

IE presents significant diagnostic and therapeutic challenges due to evolving infection patterns, MDROs, and HAIE. Early diagnosis using advanced imaging, appropriate early antimicrobial therapy, and multidisciplinary care, including timely surgery, are critical for optimizing patient outcomes.

Impact of Mandatory Preoperative Dental Screening on Infective Endocarditis in Patients Undergoing Surgical Valve Replacement

Background

Guidelines recommend preoperative dental screening (PDS) prior to surgical valve replacement (SVR) to reduce risk of prosthetic valve infective endocarditis (IE). Nonetheless, limited data support these recommendations.

Objectives

The objective of this study was to investigate the impact of mandatory preoperative dental screening (MPDS) on risk of IE in patients undergoing SVR.

Methods

Patients undergoing SVR in Western Denmark from 2020 to 2022 were included in this observational study. Patients were considered based on 2 applied PDS practices: MPDS, and no routine referral to preoperative dental screening (NPDS). Data were retrieved from Danish registries and adjudicated using medical records. The primary endpoint was incidence of IE. Secondary endpoints were all-cause mortality, and the composite endpoint of IE and all-cause mortality.

Results

A total of 1,207 patients undergoing SVR were included. Of 805 patients in the MPDS, 93% (n = 751) underwent subsequent PDS, compared to 5% (n = 21) among 402 patients in the NPDS. Patients in the MPDS were older with higher rates of coexisting comorbidities. During a median follow-up of 2.6 years, 3.3% (n = 40) developed IE. The IE incidence rate for MPDS and NPDS was 16.0 (95% CI: 11.3-22.6) and 8.0 (95% CI: 4.0-16.0) per 1,000 person-years, respectively. Mortality rate was higher in MPDS (2-year mortality: 6.2% (95% CI: 4.7-8.1) vs 2.8% (95% CI: 1.6-5.0). Differences in IE rates, all-cause mortality but not composite endpoint were abolished in 370 propensity score-matched patients.

Conclusions

Risk of IE was low regardless of PDS practice. MPDS prior to surgery did not alter the risk of IE or all-cause mortality in patients undergoing SVR in Denmark.

Accuracy of Large Language Models for Infective Endocarditis Prophylaxis in Dental Procedures

PURPOSE

Infective endocarditis (IE) is a serious, life-threatening condition requiring antibiotic prophylaxis for high-risk individuals undergoing invasive dental procedures. As LLMs are rapidly adopted by dental professionals for their efficiency and accessibility, assessing their accuracy in answering critical questions about antibiotic prophylaxis for IE prevention is crucial.

METHODS

Twenty-eight true/false questions based on the 2021 American Heart Association (AHA) guidelines for IE were posed to 7 popular LLMs. Each model underwent five independent runs per question using two prompt strategies: a pre-prompt as an experienced dentist and without a pre-prompt. Inter-model comparisons utilised the Kruskal-Wallis test, followed by post-hoc pairwise comparisons using Prism 10 software.

RESULTS

Significant differences in accuracy were observed among the LLMs. All LLMs had a narrower confidence interval with a pre-prompt, and most, except Claude 3 Opus, showed improved performance. GPT-4o had the highest accuracy (80% with a pre-prompt, 78.57% without), followed by Gemini 1.5 Pro (78.57% and 77.86%) and Claude 3 Opus (75.71% and 77.14%). Gemini 1.5 Flash had the lowest accuracy (68.57% and 63.57%). Without a pre-prompt, Gemini 1.5 Flash's accuracy was significantly lower than Claude 3 Opus, Gemini 1.5 Pro, and GPT-4o. With a pre-prompt, Gemini 1.5 Flash and Claude 3.5 were significantly less accurate than Gemini 1.5 Pro and GPT-4o. None of the LLMs met the commonly used benchmark scores. All models provided both correct and incorrect answers randomly, except Claude 3.5 Sonnet with a pre-prompt, which consistently gave incorrect answers to eight questions across five runs.

CONCLUSION

LLMs like GPT-4o show promise for retrieving AHA-IE guideline information, achieving up to 80% accuracy. However, complex medical questions may still pose a challenge. Pre-prompts offer a potential solution, and domain-specific training is essential for optimizing LLM performance in healthcare, especially with the emergence of models with increased token limits.

The oral-gut microbiota axis: a link in cardiometabolic diseases

The oral-gut microbiota axis plays a crucial role in cardiometabolic health. This review explores the interactions between these microbiomes through enteric, hematogenous, and immune pathways, resulting in disruptions in microbial balance and metabolic processes. These disruptions contribute to systemic inflammation, metabolic disorders, and endothelial dysfunction, which are closely associated with cardiometabolic diseases. Understanding these interactions provides insights for innovative therapeutic strategies to prevent and manage cardiometabolic diseases.

Risk of Infective Endocarditis Following Invasive Dental Procedures: A Systematic Review and Meta-Analysis

Objectives

This systematic review and meta-analysis aimed to synthesize evidence and determine the association between IE and dental procedures, including invasive and non-invasive procedures.

Methods

We conducted a systematic search of PubMed, Google Scholar, and Cochrane databases for studies involving procedures such as tooth extraction, scaling, endodontic treatment, oral surgery, and periodontal treatment involving individuals aged ≥15 years. The primary outcome was the incidence of IE following these procedures.

Results

An association was found between IE and invasive dental procedures (OR 1.49, 95% CI 1.25-1.76; p < 0.00001). Subgroup analysis showed an increased risk of IE following tooth extraction (OR 2.73, 95% CI 1.46-5.11; p = 0.002) and oral surgery (OR 6.33, 95% CI 2.43-16.49; p = 0.0002) in high-risk patients.

Conclusion

Our study found a strong association between invasive dental procedures and increased IE risk, particularly for tooth extraction and oral surgery in high-risk individuals.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023488546, Identifier CRD42023488546.

Antibiotic prophylaxis for patients undergoing dental care: a multi-centre evaluation in community and hospital dental services

Background Infective endocarditis (IE) is a life-threatening condition known to be associated with transient bacteraemia, the source of which can be the oral cavity. Scottish Dental Clinical Effectiveness Programme (SDCEP) 2018 implementation advice was introduced to provide practical guidance on National Institute for Health and Care Excellence Clinical Guideline 64 (2016) for management of patients at risk of IE undergoing dental treatment.Aims To assess current compliance with SDCEP's Antibiotic prophylaxis against infective endocarditis in six UK special care dentistry services.Method Four specific standards were set based on current guidance. Retrospective data were collected (from 01/01/2019 to 01/04/23) across six special care dentistry services in the UK, with an aim of 50 episodes of antibiotic prophylaxis (AP) in each service.Results In total, 248 episodes of care were included from dental services in London, East Surrey, Birmingham, Newcastle and North East England, Greater Glasgow and Clyde, and Newport (Wales). In 78% of episodes of care (n = 193), AP was administered to patients within SDCEP's special consideration sub-group. Additionally, 91% of patients outside the SDCEP sub-group had a justified reason recorded for AP. In all but three cases (99%), patients had an invasive dental procedure following AP. In 92% of cases, antibiotics were administered as per SDCEP 2018 advice.Conclusion Even with national implementation advice, this evaluation demonstrates inconsistencies in provision of AP throughout the UK. Practitioners prescribing and administering AP should remain aware of the changing aetiology of IE, as well as the reasons for and against prophylaxis, so that patients can make an informed decision.

Exploring links between oral health and infective endocarditis

Infective endocarditis (IE) is a bacterial infection of the heart's inner lining. A low incidence rate combined with a high mortality rate mean that IE can be difficult to treat effectively. There is currently substantial evidence supporting a link between oral health and IE with the oral microbiome impacting various aspects of IE, including pathogenesis, diagnosis, treatment, and mortality rates. The oral microbiome is highly diverse and plays a crucial role in maintaining oral health by providing protective functions. However, when dysbiosis occurs, conditions such as periodontal or peri-implant disease can arise, offering a pathway for bacteraemia to develop. The role of the oral microbiome as a coloniser, facilitator and driver of IE remains to be uncovered by next-generation sequencing techniques. Understanding the dysbiosis and ecology of the oral microbiome of IE patients will allow improvements into the diagnosis, treatment, and prognosis of the disease. Furthermore, an increased awareness amongst those at high-risk of developing IE may encourage improved oral hygiene methods and lower incidence rates. This narrative review examines current findings on the relationship between oral health and IE. It draws from key studies on both topics, with manuscripts selected for their pertinence to the subject. It highlights the link between the oral microbiome and IE by exploring diagnostic techniques and treatments for IE caused by oral commensals.

Advancements and Challenges in the Management of Prosthetic Valve Endocarditis: A Review

Prosthetic valve endocarditis (PVE) is the medical term used to describe a focus of infection involving a valvular substitute within the heart. It is a significant concern in the field of cardiology, and the epidemiology of PVE has seen notable developments over the last five decades. The disease currently affects an older demographic and is becoming increasingly prevalent in patients with transcatheter-implanted valves. It is imperative that we urgently address the significant challenges posed by PVE. It is a disease that has a wide range of potential aetiologies, clinical presentations, and courses. In developed countries, Staphylococcus aureus is now the predominant causative organism, resulting in an aggressive form of disease that frequently afflicts vulnerable or elderly populations. However, it is clear that Enterococcus species present a significant challenge in the context of PVE following TAVR procedures, given their elevated prevalence. The 2023 Duke/International Society for Cardiovascular Infectious Diseases infective endocarditis diagnostic criteria now include significant developments in microbiological and image-based techniques for diagnostic purposes, specifically the incorporation of fluorine-18 fluorodeoxyglucose positron emission tomography and computed tomography. These developments unequivocally enhance the diagnostic sensitivity for PVE, while maintaining the specificity. They do so in accordance with the results of studies conducted specifically for the purpose of validation. The lack of rigorous scientific studies and a shortage of funding and resources for research have led to a significant gap in our understanding. Randomized controlled trials could provide invaluable insight and guidance for clinical practice, but they are missing, which represents a major gap. It is clear that there is an urgent need for more research. PVE is a life-threatening condition that must be handled by a multidisciplinary endocarditis team at a cardiac centre in order to improve outcomes. The emergence of innovative surgical techniques has empowered clinicians to steer more patients away from surgical procedures, despite the presence of clear indications for them. A select group of patients can now complete parenteral or oral antimicrobial treatment at home. Additionally, antibiotic prophylaxis is the best option for individuals with prosthetic valves who are going to have invasive dental procedures. These individuals should be given antibiotics beforehand.

Risk of infective endocarditis in patients with mitral valve prolapse: Systematic review with meta-analysis

Aims

Infective endocarditis (IE) is a serious heart valvular condition. While mitral valve prolapse (MVP) has been associated with an increased risk of IE, the magnitude of this association remains poorly quantified. This systematic review aimed to better estimate the risk of developing IE among MVP patients compared with the general population.

Methods

MEDLINE, Cochrane Library (CENTRAL) and Web of Science databases were searched electronically to find all the relevant cohort and case-control studies. Pooled estimates of odds ratios (ORs) and 95 % confidence intervals (CIs) were derived by random effects meta-analysis. Heterogeneity was assessed using the I2 test.

Results

A total of six studies were considered eligible, and the obtained results showed that MVP patients had a higher risk of IE when compared to the general population (OR 7.83, 95 % CI 5.11, 12.02; I2 = 0 %). Posterior analysis according to the risk of bias and study design didn't show any significant variations in the direction and magnitude of the effect.

Conclusion

The magnitude of increased risk of IE of 7-fold warrants further attention for patients with MVP. Further contemporary studies and prophylaxis studies should be considered.

Update on the epidemiology, diagnosis, and management of infective endocarditis: A review

Despite advancements in the diagnosis and treatment of infective endocarditis (IE), the burden of IE has remained relatively high over the past decade. With an ageing population and an increasing proportion of healthcare-associated IE, the epidemiology of IE has undergone significant changes. Staphylococcus aureus has evolved as the most common causative microorganism, even in most low- and middle-income countries. Several imaging modalities and novel microbiological tests have emerged to facilitate the diagnosis of IE. Outpatient parenteral antibiotic treatment and oral step-down antibiotic treatment have become new trends for the management of IE. Early surgical intervention, particularly within seven days, should be considered in cases of IE with appropriate surgical indications. We comprehensively review the updated epidemiology, microbiology, diagnosis, and management of IE.

Clinical profile, microbiology and outcomes in infective endocarditis treated with aortic valve replacement: a multicenter case-control study

BACKGROUND

Aortic valve infective endocarditis (IE) is associated with significant morbidity and mortality. We aimed to describe the clinical profile, risk factors and predictors of short- and long-term mortality in patients with aortic valve IE treated with aortic valve replacement (AVR) compared with a control group undergoing AVR for non-infectious valvular heart disease.

METHODS

Between January 2008 and December 2013, a total of 170 cases with IE treated with AVR (exposed cohort) and 677 randomly selected non-infectious AVR-treated patients with degenerative aortic valve disease (controls) were recruited from three tertiary hospitals with cardiothoracic facilities across Scandinavia. Crude and adjusted hazard ratios (HR) were estimated using Cox regression models.

RESULTS

The mean age of the IE cohort was 58.5 ± 15.1 years (80.0% men). During a mean follow-up of 7.8 years (IQR 5.1-10.8 years), 373 (44.0%) deaths occurred: 81 (47.6%) in the IE group and 292 (43.1%) among controls. Independent risk factors associated with IE were male gender, previous heart surgery, underweight, positive hepatitis C serology, renal failure, previous wound infection and dental treatment (all p < 0.05). IE was associated with an increased risk of both short-term (≤ 30 days) (HR 2.86, [1.36-5.98], p = 0.005) and long-term mortality (HR 2.03, [1.43-2.88], p < 0.001). In patients with IE, chronic obstructive pulmonary disease (HR 2.13), underweight (HR 4.47), renal failure (HR 2.05), concomitant mitral valve involvement (HR 2.37) and mediastinitis (HR 3.98) were independent predictors of long-term mortality. Staphylococcus aureus was the most prevalent microbe (21.8%) and associated with a 5.2-fold increased risk of early mortality, while enterococci were associated with the risk of long-term mortality (HR 1.78).

CONCLUSIONS

In this multicenter case-control study, IE was associated with an increased risk of both short- and long-term mortality compared to controls. Efforts should be made to identify, and timely treat modifiable risk factors associated with contracting IE, and mitigate the predictors of poor survival in IE.

Endocarditis in Adult Congenital Heart Disease Patients: Prevention, Recognition, and Management

PURPOSE OF REVIEW

Present an updated overview of the prevention, diagnosis, and management of infective endocarditis in adult patients with congenital heart disease.

RECENT FINDINGS

Care for patients with infective endocarditis is changing in the areas of specialized teams, diagnostics, and prevention. Endocarditis teams should be involved in the care of ACHD patients. The 2023 Duke Criteria for Infective Endocarditis and the 2023 European Society of Cardiology Guidelines have updated the criteria for diagnosis including new major criteria such as CT and positron emission computed tomography with 18F-fluorodeoxyglucose (FDG) scans. Immunological, PCR, and nucleic acid-based tests are now acceptable means to isolate infective organisms. Clindamycin is no longer recommended for antibiotic prophylaxis due to resistance and side effect profile. Special considerations for antibiotic prophylaxis and management must be made for specific congenital heart diseases in adulthood and pregnant ACHD patients. Infective endocarditis (IE), a potentially devastating clinical entity, is a feared threat to the health of adults with congenital heart disease (ACHD). IE needs a systematic approach for its prevention, early diagnosis and management with a multidisciplinary IE team's involvement. There have been changes in the diagnostics and management of IE, which is reflected in updated diagnostic criteria. Timely blood cultures and imaging continue to be the mainstay of diagnosis, however the timing of blood cultures, microbiological testing, and types of diagnostic imaging such as the positron emission computed tomography with 18F-fluorodeoxyglucose (FDG) scan are new. Bicuspid aortic valves, ventricular septal defects, transcatheter pulmonary valve replacements, and tetralogy of Fallot are diagnoses at higher risk for IE in the ACHD population. The following article will focus on the preventive strategies, in addition to novel diagnostic and therapeutic approaches of IE in ACHD patients.

Infective endocarditis

First described more than 350 years ago, infective endocarditis represents a global health concern characterised by infections affecting the native or prosthetic heart valves, the mural endocardium, a septal defect, or an indwelling cardiac device. Over recent decades, shifts in causation and epidemiology have been observed. Echocardiography remains pivotal in the diagnosis of infective endocarditis, with alternative imaging modalities gaining significance. Multidisciplinary management requiring expertise of cardiologists, cardiovascular surgeons, infectious disease specialists, microbiologists, radiologists and neurologists, is imperative. Current recommendations for clinical management often rely on observational studies, given the limited number of well conducted randomised controlled trials studying infective endocarditis due to the rarity of the disease. In this Seminar, we provide a comprehensive overview of optimal clinical practices in infective endocarditis, highlighting key aspects of pathophysiology, pathogens, diagnosis, management, prevention, and multidisciplinary approaches, providing updates on recent research findings and addressing remaining controversies in diagnostic accuracy, prevention strategies, and optimal treatment.

Infective Endocarditis Caused by Streptococcus Sinensis in a Patient with Bioprosthetic Aortic Valve: A Case Report and Literature Review

Background

Infective endocarditis caused by Streptococcus sinensis is exceedingly rare, with only limited cases reported. Here, we present the first documented case of prosthetic valve endocarditis attributed to Streptococcus sinensis.

Case Presentation

A 40-year-old Chinese female was admitted with a 45-day history of intermittent fever. The presumed diagnosis was a pulmonary infection and antibiotic therapies failed to alleviate her symptoms. On admission, infective endocarditis was suspected, considering the history of aortic valve replacement and recent dental procedure without prophylactic antibiotics. Transesophageal echocardiography disclosed a 3-millimeter vegetation in the prosthetic aortic valve, and metagenomic next-generation sequencing and mass spectrometry identified Streptococcus sinensis. The patient was diagnosed with infective endocarditis. Antibiotic treatments resulted in temporary clinical improvements, although fluctuations in temperature and inflammatory markers led to multiple attempts at antibiotic therapies. At last, the patient underwent an elective aortic valve replacement with a favorable prognosis.

Conclusion

In this case, we demonstrated prosthetic valve endocarditis caused by Streptococcus sinensis, which is an extremely rare pathogen. All reported endocarditis cases caused by Streptococcus sinensis were reviewed and summarized. Most of these patients had rheumatic heart diseases or congenital heart diseases. Antibiotic prophylaxis is important for high-risk procedures. Timely identification of the bacterium is crucial for diagnosis and treatment. Overall, infective endocarditis caused by this bacterium had a good prognosis.

Antibiotic Prophylaxis and Infective Endocarditis Incidence Following Invasive Dental Procedures: A Systematic Review and Meta-Analysis

Importance

The association between antibiotic prophylaxis and infective endocarditis after invasive dental procedures is still unclear. Indications for antibiotic prophylaxis were restricted by guidelines beginning in 2007.

Objective

To systematically review and analyze existing evidence on the association between antibiotic prophylaxis and infective endocarditis following invasive dental procedures.

Data Sources

PubMed, Cochrane-CENTRAL, Scopus, Web of Science, Proquest, Embase, Dentistry and Oral Sciences Source, and ClinicalTrials.gov were systematically searched from inception to May 2023.

Study Selection

Studies on the association between antibiotic prophylaxis and infective endocarditis following invasive dental procedures or time-trend analyses of infective endocarditis incidence before and after current antibiotic prophylaxis guidelines were included.

Data Extraction and Synthesis

Study quality was evaluated using structured tools. Data were extracted by independent observers. A pooled relative risk (RR) of developing infective endocarditis following invasive dental procedures in individuals who were receiving antibiotic prophylaxis vs those who were not was computed by random-effects meta-analysis.

Main Outcomes and Measures

The outcome of interest was the incidence of infective endocarditis following invasive dental procedures in relation to antibiotic prophylaxis.

Results

Of 11 217 records identified, 30 were included (1 152 345 infective endocarditis cases). Of them, 8 (including 12 substudies) were either case-control/crossover or cohort studies or self-controlled case series, while 22 were time-trend studies; all were of good quality. Eight of the 12 substudies with case-control/crossover, cohort, or self-controlled case series designs performed a formal statistical analysis; 5 supported a protective role of antibiotic prophylaxis, especially among individuals at high risk, while 3 did not. By meta-analysis, antibiotic prophylaxis was associated with a significantly lower risk of infective endocarditis after invasive dental procedures in individuals at high risk (pooled RR, 0.41; 95% CI, 0.29-0.57; P for heterogeneity = .51; I2, 0%). Nineteen of the 22 time-trend studies performed a formal pre-post statistical analysis; 9 found no significant changes in infective endocarditis incidence, 7 demonstrated a significant increase for the overall population or subpopulations (individuals at high and moderate risk, streptococcus-infective endocarditis, and viridans group streptococci-infective endocarditis), whereas 3 found a significant decrease for the overall population and among oral streptococcus-infective endocarditis.

Conclusions and Relevance

While results from time-trend studies were inconsistent, data from case-control/crossover, cohort, and self-controlled case series studies showed that use of antibiotic prophylaxis is associated with reduced risk of infective endocarditis following invasive dental procedures in individuals at high risk, while no association was proven for those at low/unknown risk, thereby supporting current American Heart Association and European Society of Cardiology recommendations. Currently, there is insufficient data to support any benefit of antibiotic prophylaxis in individuals at moderate risk.

Prevention of infective endocarditis in at-risk patients: how should dentists proceed in 2024?

National Institute for Health and Care Excellence (NICE) guidelines are ambiguous over the need for patients at increased risk of infective endocarditis (IE) to receive antibiotic prophylaxis (AP) prior to invasive dental procedures (IDPs), and this has caused confusion for patients and dentists alike. Moreover, the current law on consent requires clinicians to ensure that patients are made aware of any material risk they might be exposed to by any proposed dental treatment and what can be done to ameliorate this risk, so that the patient can decide for themselves how they wish to proceed. The aim of this article is to provide dentists with the latest information on the IE-risk posed by IDPs to different patient populations (the general population and those defined as being at moderate or high risk of IE), and data on the effectiveness of AP in reducing the IE risk in these populations. This provides the information dentists need to facilitate the informed consent discussions they are legally required to have with patients at increased risk of IE about the risks posed by IDPs and how this can be minimised. The article also provides practical information and advice for dentists on how to manage patients at increased IE risk who present for dental treatment.

New evidence calls into question NICE's endocarditis prevention guidance

In 2008, National Institute for Health and Care Excellence (NICE) guidelines recommended against the use of antibiotic prophylaxis (AP) before invasive dental procedures (IDPs) to prevent infective endocarditis (IE). They did so because of lack of AP efficacy evidence and adverse reaction concerns. Consequently, NICE concluded AP was not cost-effective and should not be recommended. In 2015, NICE reviewed its guidance and continued to recommend against AP. However, it subsequently changed its wording to 'antibiotic prophylaxis against infective endocarditis is not routinely recommended'. The lack of explanation of what constituted routinely (and not routinely), or how to manage non-routine patients, caused enormous confusion and NICE remained out of step with all major international guideline committees who continued to recommend AP for those at high risk.Since the 2015 guideline review, new data have confirmed an association between IDPs and subsequent IE and demonstrated AP efficacy in reducing IE risk following IDPs in high-risk patients. New evidence also shows that in high-risk patients, the IE risk following IDPs substantially exceeds any adverse reaction risk, and that AP is therefore highly cost-effective. Given the new evidence, a NICE guideline review would seem appropriate so that UK high-risk patients can receive the same protection afforded high-risk patients in the rest of the world.

The Clinical Challenge of Prosthetic Valve Endocarditis: JACC Focus Seminar 3/4

During the past 6 decades, there have been numerous changes in prosthetic valve endocarditis (PVE), currently affecting an older population and increasing in incidence in patients with transcatheter-implanted valves. Significant microbiologic (molecular biology) and imaging diagnostic (fluorine-18 fluorodeoxyglucose-positron emission tomography/computed tomography) advances have been incorporated into the 2023 Duke-International Society for Cardiovascular Infectious Diseases infective endocarditis diagnostic criteria, thus increasing the diagnostic sensitivity for PVE without sacrificing specificity in validation studies. PVE is a life-threatening disease requiring management by multidisciplinary endocarditis teams in cardiac centers to improve outcomes. Novel surgical options are now available, and an increasing set of patients may avoid surgical intervention despite indication. Selected patients may complete parenteral or oral antimicrobial treatment at home. Finally, patients with prosthetic valves implanted surgically or by the transcatheter approach are candidates for antibiotic prophylaxis before invasive dental procedures.

Recent Insights Into Native Valve Infective Endocarditis: JACC Focus Seminar 4/4

This focused review highlights the latest issues in native valve infective endocarditis. Native valve disease moderately increases the risk of developing infective endocarditis. In 2023, new diagnostic criteria were published by the Duke-International Society of Cardiovascular Infectious Diseases group. New pathogens were designated as typical, and findings on computed tomography imaging were included as diagnostic criteria. It is now recognized that a multidisciplinary approach to care is vital, and the role of an "endocarditis team" is highlighted. Recent studies have suggested that a transition from intravenous to oral antibiotics in selected patients may be reasonable, and the role of long-acting antibiotics is discussed. It is also now clear that an aggressive surgical approach can be life-saving in some patients. Finally, results of several recent studies have suggested there is an association between dental and other invasive procedures and an increased risk of developing infective endocarditis. Moreover, data indicate that antibiotic prophylaxis may be effective in some scenarios.

Insights into microorganisms, associated factors, and the oral microbiome in infective endocarditis patients

Introduction

Infective Endocarditis (IE) is a rare, life-threatening infection of the endocardium with multisystem effects. Culprit microorganisms derived from different niches circulate through the bloodstream and attach to the endocardium, particularly the heart valves. This study aimed to investigate culprit microorganisms among a cross-sectional cohort of IE patients, their associated factors, and to explore the potential relationship to the oral microbiome.

Methods

In this observational study, we undertook a cross-sectional analysis of 392 medical records from patients diagnosed with IE. The primary outcome of this study was to analyse the association between the IE culprit microorganisms and the underlying anatomical types of IE (native valve (NVE), prosthetic valve (PVE), or cardiac device-related (CDE)). Secondary outcomes encompassed a comparative analysis of additional factors, including: the treatment approaches for IE, and the categorisation of blood cultures, extending to both genus and species levels. Additionally, we cross-referenced and compared the species-level identification of IE bacteraemia outcome measures with data from the expanded Human Oral Microbiome Database (eHOMD).

Results

A culprit microorganism was identified in 299 (76.28%) case participants. Staphylococcal infections were the most common (p < 0.001), responsible for 130 (33.16%) hospitalisations. There were 277 (70.66%) cases of NVE, 104 (26.53%) cases of PVE, and 11 (2.81%) cases of CDE. The majority of PVE occurred on prosthetic aortic valves (78/104, 75%), of which 72 (93.5%) were surgical aortic valve replacements (SAVR), 6 (7.8%) were transcatheter aortic valve implants, and one transcatheter pulmonary valve implant. Overall, underlying anatomy (p = 0.042) as well as the treatment approaches for IE (p < 0.001) were significantly associated with IE culprit microorganisms. Cross-reference between IE bacteraemia outcomes with the eHOMD was observed in 267/392 (68.11%) cases.

Conclusions

This study demonstrated that IE patients with a history of stroke, smoking, intravenous drug use, or dialysis were more likely to be infected with Staphylococcus aureus. CDE case participants and patients who had previous SAVR were most associated with Staphylococcus epidermidis. IE patients aged 78+ were more likely to develop enterococci IE than other age groups. Oral microorganisms indicated by the eHOMD are significantly observed in the IE population. Further research, through enhanced dental and medical collaboration, is required to correlate the presence of oral microbiota as causative factor for IE.

Are Dental Procedures Associated With Pyogenic Vertebral Osteomyelitis?

BACKGROUND

Dental procedures can lead to bacteremia and have been considered a potential risk factor for pyogenic vertebral osteomyelitis (PVO). However, data on the association between dental procedures and PVO are limited.

QUESTIONS/PURPOSES

(1) After controlling for relevant confounding variables, are dental procedures associated with an increased risk of PVO? (2) Does antibiotic prophylaxis before dental procedures effectively decrease the risk of PVO?

METHODS

A case-crossover study was conducted to investigate the association between dental procedures and PVO using a Japanese claims database. The advantage of this study design is that confounding factors that do not vary over time are automatically adjusted for, because cases act as their own controls. From April 2014 to September 2021, the database included 8414 patients who were hospitalized for PVO. Of these, 50% (4182 of 8414) were excluded because they had not undergone any dental procedures before the index date, a further 0.1% (10 of 8414) were excluded because they were younger than 18 years at the index date, and a further 7% (623 of 8414) were excluded because they did not have at least 20 weeks of continuous enrollment before the index date, leaving 43% (3599 of 8414) eligible for analysis here. The mean age was 77 ± 11 years, and 55% (1985 of 3599) were men. Sixty-five percent (2356 of 3599) of patients had a diagnosis of diabetes mellitus, and 42% (1519 of 3599) of patients had a diagnosis of osteoporosis. We compared the frequency of dental procedures between a 4-week hazard period before the admission date for PVO and two control periods, 9 to 12 weeks and 17 to 20 weeks before the admission date for PVO, within individuals. We calculated odds ratios and 95% confidence intervals using conditional logistic regression analysis.

RESULTS

Comparing the hazard and matched control periods within individuals demonstrated that dental procedures were not associated with an increased risk of PVO (OR 0.81 [95% CI 0.72 to 0.92]; p < 0.001). Additional analysis stratified by antibiotic prophylaxis use showed that antibiotic prophylaxis was not associated with a lower OR of developing PVO after dental procedures (with antibiotic prophylaxis: OR 1.11 [95% CI 0.93 to 1.32]; p < 0.26, without antibiotic prophylaxis: OR 0.72 [95% CI 0.63 to 0.83]; p < 0.001). Our sensitivity analyses, in which the exposure assessment interval was extended from 4 to 8 or 12 weeks and exposure was stratified by whether the dental procedure was invasive, demonstrated results that were consistent with our main analysis.

CONCLUSION

Dental procedures were not associated with an increased risk of subsequent PVO in this case-crossover study. The effectiveness of antibiotic prophylaxis was not demonstrated in the additional analysis that categorized exposure according to the use of antibiotic prophylaxis. Our results suggest that the association between dental procedures and PVO may have been overestimated. Maintaining good oral hygiene may be important in preventing the development of PVO. The indications for antibiotic prophylaxis before dental procedures should be reconsidered in view of the potential risk of adverse drug reactions to antibiotic prophylaxis and the emergence of drug-resistant pathogens. Larger randomized controlled trials are needed to confirm these findings and assess the role of antibiotic prophylaxis.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Endocarditis, invasive dental procedures, and antibiotic prophylaxis efficacy in US Medicaid patients

OBJECTIVE

Antibiotic prophylaxis is recommended before invasive dental procedures to prevent endocarditis in those at high risk, but supporting data are sparse. We therefore investigated any association between invasive dental procedures and endocarditis, and any antibiotic prophylaxis effect on endocarditis incidence.

SUBJECTS AND METHODS

Cohort and case-crossover studies were performed on 1,678,190 Medicaid patients with linked medical, dental, and prescription data.

RESULTS

The cohort study identified increased endocarditis incidence within 30 days of invasive dental procedures in those at high risk, particularly after extractions (OR 14.17, 95% CI 5.40-52.11, p < 0.0001) or oral surgery (OR 29.98, 95% CI 9.62-119.34, p < 0.0001). Furthermore, antibiotic prophylaxis significantly reduced endocarditis incidence following invasive dental procedures (OR 0.20, 95% CI 0.06-0.53, p < 0.0001). Case-crossover analysis confirmed the association between invasive dental procedures and endocarditis in those at high risk, particularly following extractions (OR 3.74, 95% CI 2.65-5.27, p < 0.005) and oral surgery (OR 10.66, 95% CI 5.18-21.92, p < 0.0001). The number of invasive procedures, extractions, or surgical procedures needing antibiotic prophylaxis to prevent one endocarditis case was 244, 143 and 71, respectively.

CONCLUSIONS

Invasive dental procedures (particularly extractions and oral surgery) were significantly associated with endocarditis in high-risk individuals, but AP significantly reduced endocarditis incidence following these procedures, thereby supporting current guideline recommendations.

Penicillin Allergy Testing and Delabeling for Patients Who Are Prescribed Penicillin: A Systematic Review for a World Health Organization Guideline

Secondary prevention with penicillin aims to prevent further episodes of acute rheumatic fever and subsequent development of rheumatic heart disease (RHD). Penicillin allergy, self-reported by 10% of the population, can affect secondary prevention programs. We aimed to assess the role for (i) routine penicillin allergy testing and the (ii) safety of penicillin allergy delabeling approaches in this context. We searched MEDLINE, Embase, CENTRAL, ClinicalTrials.gov, WHO ICTRP, ISRCTN, and CPCI-S to identify the relevant reports. We found 2419 records, but no studies addressed our initial question. Following advice from the WHO-Guideline committee and experts, we identified 6 manuscripts on allergy testing focusing on other populations showing that the prevalence of allergy confirmed by testing was low and the incidence of life-threatening reactions to BPG was very low (< 1-3/1000 individuals treated). A subsequent search addressed penicillin allergy delabeling. This found 516 records, and 5 studies addressing the safety of direct oral drug challenge vs. skin testing followed by drug administration in patients with suspected penicillin allergy. Immediate allergic reactions of minor severity were observed for a minority of patients and occurred less frequently in the direct drug challenge group: 2.3% vs. 11.5%; RR = 0.25, 95%CI 0.15-0.45, P < 0.00001, I2 = 0%. No anaphylaxis or deaths were observed. Severe allergic reactions to penicillin are extremely rare and can be recognized and dealt by trained healthcare workers. Confirmation of penicillin allergy diagnosis or delabeling using direct oral drug challenge or penicillin skin testing seems to be safe and is associated with a low rate of adverse reactions.

The interplay among a dental procedure, infective endocarditis, and an acute ischemic stroke

BACKGROUND

This case report highlights the rare association among a dental procedure, infective endocarditis, and an acute ischemic stroke.

CASE DESCRIPTION

A 54-year-old woman who experienced an acute ischemic stroke 5 weeks after a tooth extraction is described. The initial symptoms of this patient included mild to moderate word-finding difficulty and right facial droop. Computed tomographic angiography revealed a left M1 segment middle cerebral artery occlusion (thrombolysis in cerebral infarction scale, 0) with reconstitution of the distal middle cerebral branches through arterial collaterals. After initial administration of tissue plasminogen activator, endovascular thrombectomy was successfully performed with thrombolysis in cerebral infarction scale 3 (complete) recanalization. After the procedure, the patient showed improvement in language and neurologic deficits. Imaging showed multifocal, bilateral, cortical, and deep brain hemorrhages. Blood cultures grew Streptococcus mitis, ultimately leading to the diagnosis of endocarditis. Echocardiographic imaging revealed moderate to severe aortic insufficiency, a mitral valve vegetation, and mild mitral valve regurgitation. After evaluation by the cardiothoracic surgery team, the patient was discharged with intravenous antibiotics and short-term outpatient follow-up with the cardiothoracic surgery team.

PRACTICAL IMPLICATIONS

Dental procedures, although generally safe, can introduce oral bacteria into the bloodstream, leading to bacterial seeding of cardiac valves and subsequent infective endocarditis. Recognizing infective endocarditis subsequent to a dental procedure, including a tooth extraction, as a potential cause of an acute ischemic stroke is vital so that prompt treatment can be initiated.

Healthcare exposures and associated risk of endocarditis after open-heart cardiac valve surgery

BACKGROUND

Infective endocarditis (IE) following cardiac valve surgery is associated with high morbidity and mortality. Data on the impact of iatrogenic healthcare exposures on this risk are sparse. This study aimed to investigate risk factors including healthcare exposures for post open-heart cardiac valve surgery endocarditis (PVE).

METHODS

In this population-linkage cohort study, 23,720 patients who had their first cardiac valve surgery between 2001 and 2017 were identified from an Australian state-wide hospital-admission database and followed-up to 31 December 2018. Risk factors for PVE were identified from multivariable Cox regression analysis and verified using a case-crossover design sensitivity analysis.

RESULTS

In 23,720 study participants (median age 73, 63% male), the cumulative incidence of PVE 15 years after cardiac valve surgery was 7.8% (95% CI 7.3-8.3%). Thirty-seven percent of PVE was healthcare-associated, which included red cell transfusions (16% of healthcare exposures) and coronary angiograms (7%). The risk of PVE was elevated for 90 days after red cell transfusion (HR = 3.4, 95% CI 2.1-5.4), coronary angiogram (HR = 4.0, 95% CI 2.3-7.0), and healthcare exposures in general (HR = 4.0, 95% CI 3.3-4.8) (all p < 0.001). Sensitivity analysis confirmed red cell transfusion (odds ratio [OR] = 3.9, 95% CI 1.8-8.1) and coronary angiogram (OR = 2.6, 95% CI 1.5-4.6) (both p < 0.001) were associated with PVE. Six-month mortality after PVE was 24% and was higher for healthcare-associated PVE than for non-healthcare-associated PVE (HR = 1.3, 95% CI 1.1-1.5, p = 0.002).

CONCLUSIONS

The risk of PVE is significantly higher for 90 days after healthcare exposures and associated with high mortality.

[ESC guidelines 2023 on the management of endocarditis : What is new?]

In August 2023 the new European guidelines on the management of infective endocarditis were published by the European Society of Cardiology (ESC). Numerous recommendations were revised and supplemented by new ones. This review article outlines the essential modifications of the current ESC guidelines focusing on the prevention including antibiotic prophylaxis, the role of the endocarditis team, the revision of the diagnostic criteria, the paradigm shift towards oral antibiotic treatment, the timing and the indications for surgical treatment as well as the relevance of infections of cardiovascular implantable electronic devices.

Guideline concordance and antibiotic-associated adverse events between Veterans administration and non-Veterans administration dental settings: a retrospective cohort study

Background: Antibiotics prescribed as infection prophylaxis prior to dental procedures have the potential for serious adverse drug events (ADEs). However, the extent to which guideline concordance and different dental settings are associated with ADEs from antibiotic prophylaxis is unknown. Aim: The purpose was to assess guideline concordance and antibiotic-associated ADEs and whether it differs by VA and non-VA settings. Methods: Retrospective cohort study of antibiotic prophylaxis prescribed to adults with cardiac conditions or prosthetic joints from 2015 to 2017. Multivariable logistic regression models were fit to assess the impact of ADEs, guideline concordance and dental setting. An interaction term of concordance and dental setting evaluated whether the relationship between ADEs and concordance differed by setting. Results: From 2015 to 2017, 61,124 patients with antibiotic prophylaxis were identified with 62 (0.1%) having an ADE. Of those with guideline concordance, 18 (0.09%) had an ADE while 44 (0.1%) of those with a discordant antibiotic had an ADE (unadjusted OR: 0.84, 95% CI: 0.49-1.45). Adjusted analyses showed that guideline concordance was not associated with ADEs (OR: 0.78, 95% CI: 0.25-2.46), and this relationship did not differ by dental setting (Wald χ^2 p-value for interaction = 0.601). Conclusion: Antibiotic-associated ADEs did not differ by setting or guideline concordance.

Impact of mandatory preoperative dental screening on post-procedural risk of infective endocarditis in patients undergoing transcatheter aortic valve implantation: a nationwide retrospective observational study

Background

Guidelines recommend preoperative dental screening (PDS) prior to cardiac valve surgery, to reduce the incidence of prosthetic valve infective endocarditis (IE). However, limited data support these recommendations, particular in patients undergoing transcatheter aortic valve implantation (TAVI). We aimed to investigate the effect of mandatory PDS on risk of IE in patients undergoing TAVI.

Methods

In this observational study, a total of 1133 patients undergoing TAVI in Western-Denmark from 2020 to 2022 were included. Patients were categorized based on two implemented PDS practices: mandatory PDS (MPDS group), and no referral for PDS (NPDS group). Outcome data were retrieved from Danish registries and confirmed using medical records. The primary outcome was incidence of IE. Secondary outcomes were all-cause mortality and composite outcome of all-cause mortality and IE.

Findings

Of 568 patients in the MPDS group 126 (22.2%) underwent subsequent oral dental surgery, compared to 8 (1.4%) among 565 patients in the NPDS group. During a median follow-up of 1.9 years (interquartile range 1.4-2.5 years), 31 (2.7%) developed IE. The yearly incidence IE rate was 1.4% (0.8-2.3) and 1.5% (0.8-2.4) in MPDS and NPDS, respectively, p = 0.86. All-cause mortality rates were similar between groups (estimated 2-year overall mortality of 6.7% (4.8-9.2) vs. 4.7% (3.2-6.9), MPDS and NPDS, respectively, p = 0.15). Consistent findings were found in 712 propensity score-matched patients.

Interpretation

Mandatory PDS did not demonstrate reduced risk of IE or all-cause mortality compared to targeted PDS in patients undergoing TAVI.

Funding

The funder had no role in the study design, data management, or writing.

Infective Endocarditis Antibiotic Prophylaxis: Review of the Evidence and Guidelines

PURPOSE OF REVIEW

The question of antibiotic prophylaxis and its role in prevention of infective endocarditis (IE) remains controversial, with differing recommendations from international societies. The aim of this review was to compare and contrast current recommendations on antibiotic prophylaxis for IE by the American Heart Association (AHA), the European Society of Cardiology (ESC), and the National Institute for Health and Care Excellence (NICE) and highlight the evidence supporting these recommendations.

RECENT FINDINGS

International guidelines for administration of antibiotic prophylaxis for prevention of IE are largely unchanged since 2009. Studies on the impact of the more restrictive antibiotic prophylaxis recommendations are conflicting, with several studies suggesting lack of adherence to current guidance from the ESC (2015), NICE (2016), and AHA (2021). The question of antibiotic prophylaxis in patients with IE remains controversial, with differing recommendations from international societies. Despite the change in guidelines more than 15 years ago, lack of adherence to current guidelines persists. Due to the lack of high-quality evidence and the conflicting results from observational studies along with the lack of randomized clinical trials, the question of whether to recommend antibiotic prophylaxis or not in certain patient populations remains unanswered and remains largely based on expert consensus opinion.

Access to Specialized Care Across the Lifespan in Tetralogy of Fallot

Individuals living with tetralogy of Fallot require lifelong specialized congenital heart disease care to monitor for and manage potential late complications. However, access to cardiology care remains a challenge for many patients, as does access to mental health services, dental care, obstetrical care, and other specialties required by this population. Inequities in health care access were highlighted by the COVID-19 pandemic and continue to exist. Paradoxically, many social factors influence an individual's need for care, yet inadvertently restrict access to it. These include sex and gender, being a member of a racial or ethnic historically excluded group, lower educational attainment, lower socioeconomic status, living remotely from tertiary care centres, transportation difficulties, inadequate health insurance, occupational instability, and prior experiences with discrimination in the health care setting. These factors may coexist and have compounding effects. In addition, many patients believe that they are cured and unaware of the need for specialized follow-up. For these reasons, lapses in care are common, particularly around the time of transfer from paediatric to adult care. The lack of trained health care professionals for adults with congenital heart disease presents an additional barrier, even in higher income countries. This review summarizes challenges regarding access to multiple domains of specialized care for individuals with tetralogy of Fallot, with a focus on the impact of social determinants of health. Specific recommendations to improve access to care within Canadian and American systems are offered.

Nondental Invasive Procedures and Risk of Infective Endocarditis: Time for a Revisit: A Science Advisory From the American Heart Association

There have been no published prospective randomized clinical trials that have: (1) established an association between invasive dental and nondental invasive procedures and risk of infective endocarditis; or (2) defined the efficacy and safety of antibiotic prophylaxis administered in the setting of invasive procedures in the prevention of infective endocarditis in high-risk patients. Moreover, previous observational studies that examined the association of nondental invasive procedures with the risk of infective endocarditis have been limited by inadequate sample size. They have typically focused on a few potential at-risk surgical and nonsurgical invasive procedures. However, recent investigations from Sweden and England that used nationwide databases and demonstrated an association between nondental invasive procedures, and the subsequent development of infective endocarditis (in particular, in high-risk patients with infective endocarditis) prompted the development of the current science advisory.

Bioactive Peptides Derived from Edible Insects: Effects on Human Health and Possible Applications in Dentistry

Novel foods, including edible insects, are emerging because of their nutritional characteristics and low environmental impacts and could represent a valid alternative source of food in a more sustainable way. Edible insects have been shown to have beneficial effects on human health. Insect-derived bioactive peptides exert antihypertensive, antioxidant, anti-inflammatory, and antimicrobial properties and have protective effects against common metabolic conditions. In this review, the roles of edible insects in human health are reported, and the possible applications of these peptides in clinical practice are discussed. A special mention is given to the role of antimicrobial peptides and their potential applications in controlling infections in orthodontic procedures. In this context, insects' antimicrobial peptides might represent a potential tool to face the onset of infective endocarditis, with a low chance to develop resistances, and could be manipulated and optimized to replace common antibiotics used in clinical practice so far. Although some safety concerns must be taken into consideration, and the isolation and production of insect-derived proteins are far from easy, edible insects represent an interesting source of peptides, with beneficial effects that may be, in the future, integrated into clinical and orthodontic practice.

The Bacterial Oral Microbiome in Children with Congenital Heart Disease: An Extensive Review

Children with congenital heart disease have poorer oral health compared with healthy children. Oral diseases, such as dental caries and gingivitis, are associated with the oral microbiome. The objective of this review was to find evidence of differences in the bacterial colonization of the oral cavity of children with congenital heart disease (CHD) versus healthy children. A literature review was conducted according to predetermined criteria, including the need for controlled clinical trials. Half of the 14 studies that met the inclusion criteria reported significant differences in bacterial colonization in children with congenital heart disease. A variety of influencing factors were discussed. There is some evidence for alterations in the oral microflora as a result of physiopathological and treatment-related factors in children with CHD, but additional research is required to validate these findings.

Oral streptococcal infective endocarditis among individuals at high risk following dental treatment: a nested case-crossover and case-control study

Background

It is not clear whether Viridans Group Streptococcal Infective Endocarditis (VGS-IE) among individuals at high risk is more frequent following bacteraemia caused by invasive dental procedures (IDPs) than after daily bacteraemia caused by chewing and tooth brushing. The aim of this nested study was to assess if VGS-IE was temporally associated with IDPs in a national cohort of individuals at high risk.

Methods

This nested case-control and case-crossover study was based on a Swedish national cohort study of 76,762 individuals at high risk of IE due to complex congenital heart disease, prosthetic heart valve or previous IE. Participants were living in Sweden between July 1st, 2008 and January 1st, 2018. The frequency of IDPs during the 3 months before VGS-IE was calculated and compared to controls (sampled 1:10). A case-crossover study was conducted to account for residual confounders. Participants were identified using the national patient register, and IDPs were identified using the national dental health register.

Findings

98,247 IDPs were carried out in the cohort during the study period: 624 occasions of oral surgery, 44,190 extractions and 53,433 sessions of subgingival scaling. The study could not confirm that IDPs were more common among cases (4.6%) than controls (4.1%), OR = 1.22 [95% Confidence Interval (CI) 0.64-2.3], or during case- (3.3%) than reference periods (3.8%), OR = 0.89 [95% CI: 0.68-1.17]. Restricting the analysis to the period when cessation of antibiotic prophylaxis for the prevention of IE in Swedish dentistry was recommended, from the 1st of October 2012 to the 1st of January 2018, did not alter the results of the case-control study: OR 0.64, 95% CI: 0.20-2.09, or the case-crossover study: OR 0.58, 95% CI: 0.15-2.19.

Interpretation

The study could not confirm that VGS-IE is associated with IDPs among individuals at high risk. A study with larger sample size could clarify whether there is a lack of association. The finding of a small (<5%) proportion of cases temporally associated with IDPs is similar to that of the previous large-scale study on IDPs and VGS-IE.

Funding

Funding was provided by the Board of doctoral education at Karolinska Institutet, the Public Health Agency of Sweden, Folktandvården Stockholm AB, Steering Group for Collaborative Odontological Research at Karolinska Institutet and Stockholm City County, and the Swedish Dental Association.

Prophylactic antibiotic use for infective endocarditis: a systematic review and meta-analysis

OBJECTIVES

Infective endocarditis (IE) is a devastating disease with a 50% 1-year mortality rate. In recent years, medical authorities across the globe advised stricter criteria for antibiotic prophylaxis in patients with high risk of IE undergoing dental procedures. Whether such recommendations may increase the risk of IE in at-risk patients must be investigated.

DESIGN

Prospectively registered systematic review and meta-analysis.

DATA SOURCES

Medline, Embase, Scopus and ClinicalTrials.gov were searched through 23 May 2022, together with an updated search on 5 August 2023.

ELIGIBILITY CRITERIA

All primary studies reporting IE within 3 months of dental procedures in adults >18 years of age were included, while conference abstracts, reviews, case reports and case series involving fewer than 10 cases were excluded.

DATA EXTRACTION AND SYNTHESIS

All studies were assessed by two reviewers independently, and any discrepancies were further resolved through a third researcher.

RESULTS

Of the 3771 articles screened, 38 observational studies fit the inclusion criteria and were included in the study for subsequent analysis. Overall, 11% (95% CI 0.08 to 0.16, I2=100%) of IE are associated with recent dental procedures. Streptococcus viridans accounted for 69% (95% CI 0.46 to 0.85) of IE in patients who had undergone recent dental procedures, compared with only 21% (95% CI 0.17 to 0.26) in controls (p=0.003). None of the high-risk patients developed IE across all studies where 100% of the patients were treated with prophylactic antibiotics, and IE patients are 12% more likely to have undergone recent dental manipulation compared with matched controls (95% CI 1.00 to 1.26, p=0.048).

CONCLUSIONS

Although there is a lack of randomised control trials due to logistic difficulties in the literature on this topic, antibiotic prophylaxis are likely of benefit in reducing the incidence of IE in high-risk patients after dental procedures. Further well-designed high-quality case-control studies are required.

TRIAL REGISTRATION NUMBER

CRD42022326664.

Infective Endocarditis among Pediatric Patients with Prosthetic Valves and Cardiac Devices: A Review and Update of Recent Emerging Diagnostic and Management Strategies

Infective endocarditis (IE) is a disease of the endocardium, which leads to the appearance of vegetation on the valves, cardiac structures, or, potentially, vascular endothelium of the heart. The risk of IE can be increased more than 140 times by congenital heart disease (50-59% of all IE), particularly if cyanotic. An increase in mortality may result from IE in patients with a complex cardiac pathology or patients with an implanted prosthetic material, most frequently conduits in a pulmonary position. Cardiac implantable electronic devices (CIED) infective endocarditis is a life-threatening complication representing 10% of all cases of endocarditis. Common signs of presentation are often fever and chills; redness and swelling at the pocket of the pacemaker, including the erosion and exteriorization of the device; and life-threatening sepsis. The use of intracardiac echocardiography for the diagnosis of IE is an innovative method. This may be needed, especially in older children undergoing complex cardiac surgery, when transthoracic echocardiography (TTE) and transesophageal echocardiography (TOE) failed to provide a reliable diagnosis. The 2018 European Heart Rhythm Association (EHRA) experts' consensus statement on transvenous lead extraction recommends complete device removal and antimicrobial therapy for any device-related infection, including CIED-IE. The most detected microorganism was Staphylococcus Aureus. In addition, cardiac surgery and interventional cardiology associated with the placement of prostheses or conduits may increase the risk of IE up to 1.6% for Melody valve implantation. Our manuscript presents a comprehensive review of infective endocarditis associated with cardiac devices and prostheses in the pediatric population, including recent advances in diagnosis and management.

World Workshop on Oral Medicine VIII: Dentists' compliance with infective endocarditis prophylaxis guidelines for patients with high-risk cardiac conditions: a systematic review

OBJECTIVE

To determine dentists' awareness and/or adherence to antibiotic prophylaxis (AP) guidelines for preventing infective endocarditis (IE) in patients with high-risk heart conditions.

STUDY DESIGN

A systematic literature review was performed on MEDLINE/PubMed, Scopus, Web of Science, Cochrane Library, Proquest, Embase, Dentistry, and Oral Sciences Source databases, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Nationwide studies based on questionnaires, surveys, and interviews completed by dentists and published since 2007 were included.

RESULTS

From 2907 articles screened, 28 studies were selected (across 20 countries). The quality of included studies was poor due to a lack of standard evaluation tools, low response rates, and lack of questionnaire validity and/or reliability. Approximately 75% of surveyed dentists reported being knowledgeable about AP guidelines, but only ∼25% complied. Reported compliance with American Heart Association (AHA) guidelines was 4 times higher than with the National Institute for Health and Care Excellence (NICE) recommendations. Some of the highest adherence rates were reported for other national AP guidelines. Significant geographic differences were observed in the estimated adherence to AHA guidelines and the percentage of dentists who reported seeking advice from physicians and/or cardiologists.

CONCLUSION

Rates of compliance and/or adherence were substantially different from rates of knowledge and/or awareness, including relevant geographic dissimilarities. Compliance/adherence was higher for AHA than NICE.

New pharmacological agents and novel cardiovascular pharmacotherapy strategies in 2022

Cardiovascular diseases (CVD) remain the leading cause of death worldwide and pharmacotherapy of most of them is suboptimal. Thus, there is a clear unmet clinical need to develop new pharmacological strategies with greater efficacy and better safety profiles. In this review, we summarize the most relevant advances in cardiovascular pharmacology in 2022 including the approval of first-in-class drugs that open new avenues for the treatment of obstructive hypertrophic cardiomyopathy (mavacamten), type 2 diabetes mellitus (tirzepatide), and heart failure (HF) independent of left ventricular ejection fraction (sodium-glucose cotransporter 2 inhibitors). We also dealt with fixed dose combination therapies repurposing different formulations of "old" drugs with well-known efficacy and safety for the treatment of patients with acute decompensated HF (acetazolamide plus loop diuretics), atherosclerotic cardiovascular disease (moderate-dose statin plus ezetimibe), Marfan syndrome (angiotensin receptor blockers plus β-blockers), and secondary cardiovascular prevention (i.e. low-dose aspirin, ramipril and atorvastatin), thereby filling existing gaps in knowledge, and opening new avenues for the treatment of CVD. Clinical trials confirming the role of dapagliflozin in patients with HF and mildly reduced or preserved ejection fraction, long-term evolocumab to reduce the risk of cardiovascular events, vitamin K antagonists for stroke prevention in patients with rheumatic heart disease-associated atrial fibrillation, antibiotic prophylaxis in patients at high risk for infective endocarditis before invasive dental procedures, and vutrisiran for the treatment of hereditary transthyretin-related amyloidosis with polyneuropathy were also reviewed. Finally, we briefly discuss recent clinical trials suggesting that FXIa inhibitors may have the potential to uncouple thrombosis from hemostasis and attenuate/prevent thromboembolic events with minimal disruption of hemostasis.

Editor-in-Chief's Top Picks From 2022

Each week, I record audio summaries for every paper in JACC, as well as an issue summary. This process has become a true labor of love due to the time they require, but I am motivated by the sheer number of listeners (16 million plus), and it has allowed me to familiarize myself with every paper that we publish. Thus, I have selected the top 100 papers (both Original Investigations and Review Articles) from distinct specialties each year. In addition to my personal choices, I have included papers that have been the most accessed or downloaded on our websites, as well as those selected by the JACC Editorial Board members. In order to present the full breadth of this important research in a consumable fashion, we will present these abstracts in this issue of JACC, as well as their Central Illustrations and podcasts. The highlights comprise the following sections: Basic & Translational Research, Cardiac Failure & Myocarditis, Cardiomyopathies & Genetics, Cardio-Oncology, Congenital Heart Disease, Coronary Disease & Interventions, Coronavirus, Hypertension, Imaging, Metabolic & Lipid Disorders, Neurovascular Disease & Dementia, Promoting Health & Prevention, Rhythm Disorders & Thromboembolism, and Valvular Heart Disease.^1-100.