Topical antibiotic prophylaxis for bacteremia after dental extractions

Impact of antibiotic prophylaxis on the incidence, nature, magnitude, and duration of bacteremia associated with dental procedures: A systematic review

BACKGROUND

Antibiotic prophylaxis (AP) is used routinely in high-risk groups of patients to reduce bacteremia and the risk of developing infective endocarditis (IE). In this systematic review, the authors evaluated the efficacy of AP on the incidence, nature, magnitude, and duration of post-dental procedure bacteremia.

METHODS

The authors conducted a systematic search of the literature using MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials up to and including May 2019. They included randomized clinical trials in which researchers compared antibiotics with a placebo or no treatment (as the control). They undertook random-effects meta-analyses to evaluate the incidence of bacteremia after dental procedures.

RESULTS

The authors included 12 studies in the review. The studies evaluated the incidence of bacteremia after AP with American Heart Association (AHA) protocol antibiotics (amoxicillin, clindamycin, cephalosporin, and azithromycin) or non-AHA protocol antibiotics (moxifloxacin and intravenous [IV] amoxicillin-clavulanic acid). The pooled analysis revealed that antibiotics significantly reduced the bacteremia incidence, but their effectiveness was moderate (risk ratio, 0.50; 95% confidence interval, 0.38 to 0.67). IV amoxicillin-clavulanic acid promoted a considerable reduction in bacteremia. However, in patients with penicillin allergies, antibiotics (that is, clindamycin and cephalosporin) had lower efficacy.

PRACTICAL IMPLICATIONS

Oral amoxicillin is still the antibiotic of choice to reduce bacteremia. IV amoxicillin-clavulanic acid could be used for patients at high risk of developing IE who require invasive dental procedures, have high levels of dental infection, and are to be treated under general anesthesia. In patients with penicillin allergies, oral azithromycin showed a higher efficacy for the reduction of bacteremia and the use of clindamycin should be reviewed. Antibiotic premedication should be limited to patients at high risk of developing IE, according to the indications of the AHA guide.

Prevention of Postdental Procedure Bacteremia: A Network Meta-analysis

Postdental procedure bacteremia is common and troublesome. The comparative efficacy of multiple prophylactic interventions is unclear. We compared the efficacy of interventions for the prevention of postdental procedure bacteremia. We conducted a review of ClinicalKey, Cochrane CENTRAL, Embase, ProQuest, PubMed, ScienceDirect, Web of Science, and ClinicalTrials.gov from inception to December 4, 2018. Randomized controlled trials that evaluated prophylactic interventions for the prevention of postdental procedure bacteremia were eligible. The primary outcome was the incidence of postdental procedure bacteremia. A total of 24 trials were included with 2,147 participants. Our network meta-analysis demonstrated that intravenous administration of 1,000/200 mg of amoxicillin/clavulanate provided the least incidence of postdental procedure bacteremia among all the prophylactic interventions (odds ratio = 0.03, 95% CI = 0.00 to 0.63) as compared with the placebo/controls. Oral 3 g of amoxicillin had the least incidence of postdental procedure bacteremia among all oral or topical forms of prophylactic interventions (odds ratio = 0.10, 95% CI = 0.02 to 0.44) as compared with the placebo/controls. No serious adverse events, such as anaphylactic shock, mortality, and the development of antibiotic-resistant bacteria, were reported. None of the included subjects were of high risk of infectious endocarditis. Our network meta-analysis demonstrates that intravenous amoxicillin/clavulanate and oral amoxicillin might be the best prophylactic interventions in preventing postdental procedure bacteremia among all the oral/topical forms of interventions for the overall populations.

Topical antimicrobial therapy: Current status and challenges

Topically applied antibacterial agents are widely used. Opinions regarding the clinical efficacy of topical antibiotics are conflicting, and for most indications, alternative oral therapies are available. Topical application has many potential advantages over systemic therapy that includes high and sustained concentrations of drug directly at the infected site, low quantity of antibiotic needed, better compliance, fewer systemic side effects and potentially less chance of antimicrobial resistance. Despite these advantages, an important concern has been the difficulty in monitoring antibiotic dosage and duration of therapy. Most topical preparations are applied on sites with pre-existing normal bacterial flora, and the detrimental effect of antibiotic on the 'good' bacteria is difficult to control. Unnecessary exposure of the resident microflora to high drug levels may select drug-resistant phenotypes. The number of antibiotics available and the quality and composition of the formulations recommended for topical drug delivery are improving. Their role in the prevention and treatment of locally invasive infections is established for many clinical conditions. However, there is still a lacuna in the availability of pharmacokinetic (PK) knowledge of these topical preparations and translation of the same to clinical practice. In addition, reporting the clinical outcome following the use of these agents and its analysis considering the recently proposed epidemiological cut-off value-based cut-offs are also areas which merit further research. In this review, we highlight the clinical utility and the PK aspects of topical antimicrobials in various infections. We also discuss the limitations of the current antimicrobial susceptibility testing (AST) protocols and new methods for AMST for topical agents.

Bacteremia Associated With Oral Surgery: A Review

OBJECTIVES

Bacterial (infective) endocarditis, a microbial infection of the endocardium surfaces after bacteremia, causes significant morbidity and mortality. Recent epidemiologic studies have reported a prevalence of 2-8 cases per 100,000 individuals per year, with the highest incidence in those aged 70-80 years and those living in developed countries. We systematically reviewed the literature on several critical aspects regarding the development of bacteremia after oral surgery. The purpose of this work is to assess the controversy regarding antibiotic prophylaxis before oral surgery.

MATERIALS AND METHODS

Publications between 1976 and 2015 were included. Clinical studies focusing on oral surgery as the underlying cause were included.

RESULTS

Among the 32 clinical studies reviewed, 3564 cases, accounting for 12,839 blood cultures, were evaluated. In 10 of these studies, amoxicillin usefulness was studied. Antimicrobial prophylaxis before an invasive dental procedure does not prevent bacteremia, although it can decrease both its magnitude and its persistence.

CONCLUSIONS

The highly conflicting data and conclusions of the analyzed work highlight the need for new approaches to the study of bacteremia that would provide reliable evidence and thus appropriate prophylactic and therapeutic standards. Many reports have explored the occurrence of bacteremia after dental procedures, but the results have been conflicting.

Efficacy of Antibiotic Prophylactic Regimens for the Prevention of Bacterial Endocarditis of Oral Origin

Despite the controversy about the risk of individuals developing bacterial endocarditis of oral origin, numerous Expert Committees in different countries continue to publish prophylactic regimens for the prevention of bacterial endocarditis secondary to dental procedures. In this paper, we analyze the efficacy of antibiotic prophylaxis in the prevention of bacteremia following dental manipulations and in the prevention of bacterial endocarditis (in both animal models and human studies). Antibiotic prophylaxis guidelines remain consensus-based, and there is scientific evidence of the efficacy of amoxicillin in the prevention of bacteremia following dental procedures, although the results reported do not confirm the efficacy of other recommended antibiotics. The majority of studies on experimental models of bacterial endocarditis have verified the efficacy of antibiotics administered after the induction of bacteremia, confirming the efficacy of antibiotic prophylaxis in later stages in the development of bacterial endocarditis. There is no scientific evidence that prophylaxis with penicillin is effective in reducing bacterial endocarditis secondary to dental procedures in patients considered to be "at risk". It has been suggested that there is a high risk of severe allergic reactions secondary to prophylactically administered penicillins, but, in reality, very few cases have been reported in the literature. It has been demonstrated that antibiotic prophylaxis could contribute to the development of bacterial resistance, but only after the administration of several consecutive doses. Future research on bacterial endocarditis prophylactic protocols should involve the re-evaluation of the time and route of administration of antibiotic prophylaxis, and a search for alternative antimicrobials.

Antimicrobial prophylaxis in dentistry

Use of antibiotics both in humans and animals runs along with effects that can contribute to the spread of antibiotic resistance. Although several available guidelines for antibiotic treatment have been published to date, clinical practice in dentistry and particularly in oral surgery is not free from controversies regarding antibiotic prophylaxis. Antibiotic coverage to prevent infectious endocarditis, joint prostheses infections or local infections requires a careful evaluation of the patient condition, associated risks and other aspects that could influence the decision. It is of great relevancy for oral surgeons and for dentists in general to know exactly what they are up against. Here we review the literature regarding prophylactic use of antimicrobials in dentistry.

Dental disease and periprosthetic joint infection

➤ The number of patients with end-stage osteoarthritis is increasing, and treatment with hip and knee arthroplasty is expected to increase over the next several decades. ➤ Dental disease has long been anecdotally associated with increased periprosthetic joint infections, although case-control studies do not support this relationship. ➤ While most recent guidelines for the prevention of endocarditis have favored treatment of fewer patients, the most recent recommendations for prevention of periprosthetic joint infection have increased the number of patients who would receive antibiotics before a dental procedure. ➤ Antibiotics given before a dental procedure decrease the risk of bacteremia from the oral cavity, but this is of uncertain clinical importance. ➤ The number of patients who would require antibiotics before dental procedures to prevent one periprosthetic joint infection greatly outnumbers the number of patients who would experience an adverse event associated with antibiotics given before a dental procedure.

A comparative study of amoxicillin, clindamycin and chlorhexidine in the prevention of post-extraction bacteraemia

We evaluated some of the regimens recommended for the antimicrobial prophylaxis of infective endocarditis prior to dental extraction in 160 patients. Group A patients served as the control group, group B subjects rinsed their mouths with chlorhexidene, group C subjects took 3 g amoxicillin orally and group D patients took 600 mg clindamycin orally. The proportion of patients who had post-extraction bacteraemia in groups A, B, C and D was 35, 40, 7.5 and 20%, respectively. The differences between the control and amoxicillin groups (p = 0.003) and between the chlorhexidine and amoxicillin groups (p = 0.0006) were statistically significant. Streptococci were not isolated in any patients in the amoxicillin and clindamycin groups. In our study, none of the regimens were effective in preventing post-extraction bacteraemia.

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures

The Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures evidence-based clinical practice guideline was codeveloped by the American Academy of Orthopaedic Surgeons (AAOS) and the American Dental Association. This guideline replaces the previous AAOS Information Statement, "Antibiotic Prophylaxis in Bacteremia in Patients With Joint Replacement," published in 2009. Based on the best current evidence and a systematic review of published studies, three recommendations have been created to guide clinical practice in the prevention of orthopaedic implant infections in patients undergoing dental procedures. The first recommendation is graded as Limited; this recommendation proposes that the practitioner consider changing the long-standing practice of routinely prescribing prophylactic antibiotic for patients with orthopaedic implants who undergo dental procedures. The second, graded as Inconclusive, addresses the use of oral topical antimicrobials in the prevention of periprosthetic joint infections. The third recommendation, a Consensus statement, addresses the maintenance of good oral hygiene.

Antibiotic prophylaxis to reduce the risk of joint implant contamination during dental surgery seems unnecessary

INTRODUCTION

Joint implant infection rates range between 0.5% and 3%. Contamination may be hematogenous, originating in oro-dental infection and, as in endocarditis, antibiotic prophylaxis has been recommended to cover oro-dental surgery in immunodepressed patients with joint implants less than 2 years old, despite the lack of any formal proof of efficacy. In this context, the cost and side effects of such prophylaxis raise the question of its real utility.

MATERIALS AND METHODS

A search of Pubmed was performed using the following keywords: prosthetic joint infection, dental procedure, antibiotic prophylaxis, hematogenous infection, dental infection, bacteremia, and endocarditis. Six hundred and fifty articles were retrieved, 68 of which were analyzed in terms of orthopedic prosthetic infection and/or endocarditis and oro-dental prophylaxis, as relevant to the following questions: frequency and intensity of bacteremia of oro-dental origin, frequency of prosthetic joint infection secondary to dental surgery, and objective efficacy of antibiotic prophylaxis in dental surgery in patients with joint implants.

RESULTS

Bacteremia of oro-dental origin is more frequently associated with everyday activities such as mastication than with tooth extraction. Isolated cases of prosthetic contamination from dental infection have been reported, but epidemiological studies in joint implant bearers found that absence of antibiotic prophylaxis during oro-dental surgery did not increase the rate of prosthetic infection. The analysis was not able to answer the question of the efficacy of dental antibiotic prophylaxis in immunodepressed patients; however, oro-dental hygiene and regular dental treatment reduce the risk of prosthetic infection by 30%.

DISCUSSION AND CONCLUSION

The present update is in agreement with the conclusions of ANSM expert group, which advised against antibiotic prophylaxis in oro-dental surgery in implant bearers, regardless of implant duration or comorbidity: the associated costs and risks are disproportional to efficacy. LEVEL OF EVIDENCE AND TYPE OF STUDY: Level V; expert opinion.

Characterization of aortic aneurysms in cardiovascular disease patients harboring Porphyromonas gingivalis

OBJECTIVE

Porphyromonas gingivalis was recently shown to cause intimal hyperplasia in a mouse model by a novel cholesterol-independent mechanism, suggesting to be a pathogen-specific feature of cardiovascular diseases. The aim of this study was to characterize the clinical and histopathological features of aortic aneurysms in cardiovascular disease patients harboring oral P. gingivalis.

SUBJECT AND METHODS

Aortic aneurysm specimens were collected from 76 Japanese patients who underwent surgery, of whom dental plaque specimens were also collected from 31 patients. Bacterial DNA was extracted from each specimen to detect P. gingivalis by polymerase chain reaction. Histopathological analyses of the aortic aneurysm specimens, including immunohistochemical staining for embryonic myosin heavy chain isoform (SMemb) and S100 calcium-binding protein A9 (S100A9), were also performed.

RESULTS

The number of aneurysms occurring in the distal aorta was significantly higher in subjects positive for P. gingivalis in dental plaque compared with those who were negative. The expressions of S100A9 and SMemb were also significantly greater in the subjects positive for P. gingivalis in dental plaque. On the other hand, there were no significant differences in adipocellular accumulation between the groups.

CONCLUSIONS

These results suggest that aortic aneurysms in patients harboring oral P. gingivalis have greater expression of S100A9 and proliferative smooth muscle cells, which was different from the present patients without oral P. gingivalis.

Roles of oral bacteria in cardiovascular diseases--from molecular mechanisms to clinical cases: Involvement of Porphyromonas gingivalis in the development of human aortic aneurysm

Accumulating evidence suggests the involvement of Porphyromonas gingivalis (P. gingivalis), a periodontal pathogen, in cardiovascular diseases. Clinical specimens of aneurysmal tissue and dental plaque collected from patients infected with or without P. gingivalis were analyzed. The number of aneurysms in the distal aorta in the P. gingivalis-infected group was significantly higher than that in the non-infected group. Cellular accumulation of adipocytes in aneurysms was less frequently identified in the infected group. The expression of embryonic myosin heavy chain isoform, a phenotypic marker for proliferative smooth muscle cells, was higher in the P. gingivalis-infected group than the non-infected group. Clinical and histopathological features of aortic aneurysms associated with P. gingivalis infection are different from those present in non-infected patients. The major characteristic of P. gingivalis infection associated with aneurysms is smooth muscle cell proliferation in the distal aorta.

Microbiology of odontogenic bacteremia: beyond endocarditis

SUMMARY

The human gingival niche is a unique microbial habitat. In this habitat, biofilm organisms exist in harmony, attached to either enamel or cemental surfaces of the tooth as well as to the crevicular epithelium, subjacent to a rich vascular plexus underneath. Due to this extraordinary anatomical juxtaposition, plaque biofilm bacteria have a ready portal of ingress into the systemic circulation in both health and disease. Yet the frequency, magnitude, and etiology of bacteremias due to oral origin and the consequent end organ infections are not clear and have not recently been evaluated. In this comprehensive review, we address the available literature on triggering events, incidence, and diversity of odontogenic bacteremias. The nature of the infective agents and end organ infections (other than endocarditis) is also described, with an emphasis on the challenge of establishing the link between odontogenic infections and related systemic, focal infections.

Antibiotic prophylaxis before invasive dental procedures in patients with arthroplasties of the hip and knee

More than a million hip replacements are carried out each year worldwide, and the number of other artificial joints inserted is also rising, so that infections associated with arthroplasties have become more common. However, there is a paucity of literature on infections due to haematogenous seeding following dental procedures. We reviewed the published literature to establish the current knowledge on this problem and to determine the evidence for routine antibiotic prophylaxis prior to a dental procedure.

We found that antimicrobial prophylaxis before dental interventions in patients with artificial joints lacks evidence-based information and thus cannot be universally recommended.

Antibiotic prophylaxis and postoperative complications after tooth extraction and implant placement: A review of the literature

OBJECTIVES

To assess published evidence regarding the use of preoperative antibiotic prophylaxis among children and adults undergoing dental extraction or implant placement.

DATA

Research published between 12/31/97 and 6/30/07 in English.

SOURCES

MEDLINE, PUBMED, EMBASE, EBM Reviews, and Cochrane Central Register for Controlled Trials using the following search terms linked with Boolean AND logic: prophylactic antibiotics, dentistry, tooth, third molar, extraction, implant, endosseous, prophylaxis, prophylactic, infective endocarditis, bacterial, infection, and bacteremia.

STUDY SELECTION

Eight randomized clinical trials and one retrospective study was found involving preoperative use of antibiotics before tooth extraction. Four additional non-randomized intervention studies among patients undergoing implant placement were found. These 13 studies comprised all of the published research found that met our inclusion criteria. Overall, this body of literature was limited and of poor quality. In general, sample sizes were small and provided insufficient statistical power to avoid type II, or false-negative errors. In some studies no comparison group was included and/or it was difficult to determine the extent to which the intervention had actually been implemented.

CONCLUSION

With the recent improvements in the current standards of antibiotic prophylaxis in dentistry, further monitoring of antibiotic use among dental practitioners as well as continuing education for practitioners concerning the public health risks related to the over-prescription of antibiotics are needed.

Periodontopathic microorganisms in peripheric blood after scaling and root planing

AIM

The objective of this study was to evaluate the frequency of periodontopathic and other subgingival anaerobic and facultative bacteria in the bloodstream following scaling and root planing (SRP).

MATERIAL AND METHODS

Forty-two patients with severe generalized chronic periodontitis (GChP) and generalized aggressive periodontitis (GAgP) were included in the study. Four samples of peripheric blood were drawn from the cubital vein at different times: Pre-treatment: immediately before the SRP procedure (T1), immediately after treatment (T2), 15 min. post-treatment (T3) and 30 min. post-treatment (T4). In order to identify the presence of microorganisms in blood, subcultures were conducted under anaerobic conditions.

RESULTS

80.9% of the patients presented positive cultures after SRP and it occurred more frequently immediately after treatment; however, 19% of the patients still had microorganisms in the bloodstream 30 min. after the procedure. The periodontopathic microorganisms more frequently identified were Porphyromonas gingivalis and Micromonas micros. Campylobacter spp., Eikenella corrodens, Tannerella forsythensis, Fusobacterium spp. and Prevotella intermedia were isolated less often. Actinomyces spp. were also found frequently during bacteraemia after SRP.

CONCLUSIONS

SRP induced bacteraemia associated with anaerobic bacteria, especially in patients with periodontal disease.

Comparative efficacies of amoxicillin, clindamycin, and moxifloxacin in prevention of bacteremia following dental extractions

We evaluated the efficacies of oral prophylactic treatment with amoxicillin (AMX), clindamycin (CLI), and moxifloxacin (MXF) in the prevention of bacteremia following dental extractions (BDE). Two hundred twenty-one adults who required dental extractions under general anesthesia were randomly assigned to a control group, an AMX group, a CLI group, and an MXF group (the individuals in the drug treatment groups received 2 g, 600 mg, and 400 mg, respectively, 1 to 2 h before anesthesia induction). Venous blood samples were collected from each patient at the baseline and 30 s, 15 min, and 1 h after the dental extractions. The samples were inoculated into BACTEC Plus aerobic and anaerobic blood culture bottles and were processed in a BACTEC 9240 instrument. Subculture and the further identification of the isolated bacteria were performed by conventional microbiological techniques. The prevalences of BDE in the control group, AMX group, CLI group, and MXF group were 96, 46, 85, and 57%, respectively, at 30 s; 64, 11, 70, and 24%, respectively, at 15 min; and 20, 4, 22, and 7%, respectively, at 1 h. Streptococcus spp. were the most frequently identified bacteria in all groups (44 to 68%), with the lowest percentage being detected in the AMX group (44%). AMX and MXF prophylaxis showed high efficacies in reducing the prevalence and duration of BDE, but CLI prophylaxis was noneffective. As a consequence, MXF prophylaxis is a promising antibiotic alternative for the prevention of BDE when beta-lactams are not indicated.

Dentistry and endocarditis

Bacterial endocarditis (BE), a rare heart infection caused by a bacteremia, has frequently been blamed on but rarely caused by dental procedures. Viridans group streptococci are found abundantly in the mouth and the gingival sulcus but have been surpassed by staphylococci as the leading cause of BE. Antibiotic prophylaxis has been recommended before dental procedures in patients at risk for BE, but it remains controversial because studies have failed to show that antibiotic prophylaxis is an effective preventive for BE or that dental procedures are an important cause of BE. The risks and costs of antibiotic prophylaxis, including antibiotic resistance, cross-reactions with other drugs, allergy, anaphylaxis, and even death, may exceed the benefits in preventing BE. The rationale for the use of antibiotic prophylaxis to prevent BE allegedly caused by dental procedure bacteremias must be seriously reexamined based on recent evidence, particularly the absolute risk rates for endocarditis after a given dental procedure.

An update on the controversies in bacterial endocarditis of oral origin

OBJECTIVES

The aim of this review was to evaluate the evidence implicating dental procedures in bacterial endocarditis (BE) development and the basis for antimicrobial prophylaxis (AP).

STUDY DESIGN

In this article, the literature is reviewed and meaningful findings about epidemiology, pathogenesis, and AP guidelines for BE of oral origin are highlighted. Available results are used to formulate clinical recommendations for the dental practitioner.

RESULTS

The nature of dental procedures that cause bacteremia, patients at risk for BE, and the effectiveness of AP guidelines, continue to be points of controversy. There appears to be further evidence to support the important role of oral health status in the prevention of BE of dental origin.

CONCLUSIONS

One objective of the dental practitioner in caring for patients at risk for BE should be to promote oral health care. There are no hard data on which to scientifically base the need for AP in patients at risk for BE. However, it would appear prudent, at least from the medicolegal perspective, to provide AP, at least to persons with previous BE or prosthetic heart valves and to those undergoing oral surgery, periodontal treatment, or implant placement.