1
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Thornhill MH, Gibson TB, Yoon F, Dayer MJ, Prendergast BD, Lockhart PB, O'Gara PT, Baddour LM. Endocarditis, invasive dental procedures, and antibiotic prophylaxis efficacy in US Medicaid patients. Oral Dis 2024; 30:1591-1605. [PMID: 37103475 DOI: 10.1111/odi.14585] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 03/27/2023] [Accepted: 04/07/2023] [Indexed: 04/28/2023]
Abstract
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.
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Affiliation(s)
- Martin H Thornhill
- Unit of Oral & Maxillofacial Medicine, Surgery and Pathology, School of Clinical Dentistry, University of Sheffield, Sheffield, UK
- Department Oral Medicine/Oral & Maxillofacial Surgery, Atrium Health - Carolinas Medical Center, Charlotte, North Carolina, USA
| | | | - Frank Yoon
- IBM Watson Health, Ann Arbor, Michigan, USA
| | - Mark J Dayer
- Department of Cardiology, Somerset Foundation Trust, Taunton, UK
- Faculty of Health, University of Plymouth, Plymouth, UK
| | | | - Peter B Lockhart
- Department Oral Medicine/Oral & Maxillofacial Surgery, Atrium Health - Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Patrick T O'Gara
- Cardiovascular Medicine Division, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts, USA
| | - Larry M Baddour
- Division of Infectious Diseases, Departments of Medicine and Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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2
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Baddour LM, Janszky I, Thornhill MH, Esquer Garrigos Z, DeSimone DC, Welty-Wolf K, Baker AL, Jone PN, Prendergast B, Dayer MJ. Nondental Invasive Procedures and Risk of Infective Endocarditis: Time for a Revisit: A Science Advisory From the American Heart Association. Circulation 2023; 148:1529-1541. [PMID: 37795631 DOI: 10.1161/cir.0000000000001180] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
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.
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3
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Delgado V, Ajmone Marsan N, de Waha S, Bonaros N, Brida M, Burri H, Caselli S, Doenst T, Ederhy S, Erba PA, Foldager D, Fosbøl EL, Kovac J, Mestres CA, Miller OI, Miro JM, Pazdernik M, Pizzi MN, Quintana E, Rasmussen TB, Ristić AD, Rodés-Cabau J, Sionis A, Zühlke LJ, Borger MA. 2023 ESC Guidelines for the management of endocarditis. Eur Heart J 2023; 44:3948-4042. [PMID: 37622656 DOI: 10.1093/eurheartj/ehad193] [Citation(s) in RCA: 123] [Impact Index Per Article: 123.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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4
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Al-Qaysi A, Sayeh N, Al-Qaysi Z, Al Ghoul Y, Elhouni E. Quadricuspid Aortic Valve: A Case Report of an Asymptomatic Middle-Aged Man. Cureus 2023; 15:e45262. [PMID: 37846259 PMCID: PMC10576656 DOI: 10.7759/cureus.45262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2023] [Indexed: 10/18/2023] Open
Abstract
A quadricuspid aortic valve (QAV) is a rare congenital anomaly characterized by the presence of four leaflets in the aortic valve. We are reporting a case of a 59-year-old male who presented to the emergency department with non-cardiac chest pain. The discovery of QAV during the evaluation highlights the importance of considering cardiac causes, even in cases where the presenting symptoms may not appear directly related to the heart.
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Affiliation(s)
| | - Naser Sayeh
- Cardiology, University of British Columbia, Vancouver, CAN
| | - Zainab Al-Qaysi
- Internal Medicine/Mountain Vista Medical Centre, Avalon University School of Medicine, Mesa, USA
| | - Yussef Al Ghoul
- Pulmonary Disease and Critical Care Medicine, Virginia Commonwealth University, Richmond, USA
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5
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Shapero K, El-Dalati S, Berlacher K, Megli C. Outcomes of Endocarditis in Pregnancy: A Single-Center Experience. Open Forum Infect Dis 2023; 10:ofad470. [PMID: 37779596 PMCID: PMC10538254 DOI: 10.1093/ofid/ofad470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 09/18/2023] [Indexed: 10/03/2023] Open
Abstract
Background The incidence of infective endocarditis (IE) in pregnancy is rare (0.006%), with increasing prevalence during the opioid epidemic. IE in pregnancy is associated with high rates of mortality and morbidity, and existing data on outcomes in pregnancy are limited. Our study compares the outcomes of pregnant patients with IE with those of nonpregnant patients. Methods Patients diagnosed with IE during pregnancy and 30 days postpartum between 2014 and 2021 were identified by International Classification of Diseases, Clinical Modification, Ninth and Tenth Edition codes. Pregnant cases were matched to nonpregnant reproductive-age endocarditis patients in a 1:4 ratio. Data were collected and validated through chart review. Results One hundred eighty patients with IE were identified; 34 were pregnant or within 30 days postpartum at diagnosis. There were higher rates of hepatitis C and opioid maintenance therapy in the pregnant patients. The etiology of IE in pregnant patients was predominantly S. aureus (methicillin-resistant/sensitive S. aureus), whereas nonpregnant woman had greater microbiological variation. We observed comparable rates of valve replacement (32.4% vs 29%; P = .84) and 2-year mortality (20.6% vs 17.8%; P > .99) in pregnant patients. There were nonsignificantly higher rates of pulmonary emboli (17.6% vs 7.5%; P = .098) and arrhythmia (17.6% vs 9.6%; P = .222) among pregnant patients. There were high rates of intravenous drug use relapse in both groups (>40%). Conclusions We observed similar rates of mortality in the pregnant IE patients. We observed a microbial predilection for S. aureus in pregnancy, suggesting that the pregnancy physiology may select for this microbiologic etiology. This study, which represents the largest single-center retrospective review of IE in pregnancy, suggests that surgical intervention may be performed safely in the postpartum period.
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Affiliation(s)
- Kayle Shapero
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Sami El-Dalati
- Department of Infectious Disease, University of Kentucky Medical Center, Lexington, Kentucky, USA
| | - Kathryn Berlacher
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Christina Megli
- Department of Obstetrics, Gynecology and Reproductive Sciences University of Pittsburgh School of Medicine, Magee Women's Research Institute, Pittsburgh, Pennsylvania, USA
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6
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Lean SSH, Jou E, Ho JSY, Jou EGL. Prophylactic antibiotic use for infective endocarditis: a systematic review and meta-analysis. BMJ Open 2023; 13:e077026. [PMID: 37607797 PMCID: PMC10445353 DOI: 10.1136/bmjopen-2023-077026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 08/10/2023] [Indexed: 08/24/2023] Open
Abstract
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.
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Affiliation(s)
- Sue S H Lean
- Department of Dental Medicine, Wei Gong Memorial Hospital, Miaoli, Taiwan
| | - Eric Jou
- Queens' College, University of Cambridge, Cambridge, UK
| | - Jamie Sin Ying Ho
- Department of Medicine, National University Health System, Singapore
| | - Ernest G L Jou
- Department of Dental Medicine, Wei Gong Memorial Hospital, Miaoli, Taiwan
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Ravishankar R, Hussain A, Loubani M, Chaudhry M. Acute endocarditis in a pregnant patient requiring post-partum emergency mitral valve repair: a case report. J Surg Case Rep 2023; 2023:rjad441. [PMID: 37560607 PMCID: PMC10409567 DOI: 10.1093/jscr/rjad441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 07/15/2023] [Indexed: 08/11/2023] Open
Abstract
A 37-year-old pregnant patient presented with symptoms of shortness of breath, cough and malaise at 36 weeks' gestation. Antibiotics were started because of suspected bilateral pneumonia. A lower segment caesarean section was undertaken and significant desaturation lead to intubation of the patient. A CTPA confirmed bilateral pneumonia but also elements of heart failure with a 32 mm dilated pulmonary artery. Severe mitral regurgitation was confirmed with trans-thoracic and trans-oesophageal echocardiogram on Day 5 and emergency mitral valve repair was undertaken for possible infective endocarditis (IE) as per the modified Duke criteria, which was confirmed intra-operatively. The patient completed 4 weeks of antibiotics and suffered mild memory impairment post-operatively. She was discharged from complex rehabilitation after 6 weeks of hospital stay at her baseline state. This case presents IE in a pregnant patient with no significant risk factors with successful recovery because of prompt diagnosis and management.
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Affiliation(s)
- Ramanish Ravishankar
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Azar Hussain
- Department of Cardiothoracic Surgery, Castle Hill Hospital, Hull, UK
| | - Mahmoud Loubani
- Department of Cardiothoracic Surgery, Castle Hill Hospital, Hull, UK
| | - Mubarak Chaudhry
- Department of Cardiothoracic Surgery, Castle Hill Hospital, Hull, UK
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8
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Thornhill MH, Crum A, Rex S, Campbell R, Stone T, Bradburn M, Fibisan V, Dayer MJ, Prendergast BD, Lockhart PB, Baddour LM, Nicholl J. Infective endocarditis following invasive dental procedures: IDEA case-crossover study. Health Technol Assess 2022; 26:1-86. [PMID: 35642966 DOI: 10.3310/nezw6709] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Infective endocarditis is a heart infection with a first-year mortality rate of ≈ 30%. It has long been thought that infective endocarditis is causally associated with bloodstream seeding with oral bacteria in ≈ 40-45% of cases. This theorem led guideline committees to recommend that individuals at increased risk of infective endocarditis should receive antibiotic prophylaxis before undergoing invasive dental procedures. However, to the best of our knowledge, there has never been a clinical trial to prove the efficacy of antibiotic prophylaxis and there is no good-quality evidence to link invasive dental procedures with infective endocarditis. Many contend that oral bacteria-related infective endocarditis is more likely to result from daily activities (e.g. tooth brushing, flossing and chewing), particularly in those with poor oral hygiene. OBJECTIVE The aim of this study was to determine if there is a temporal association between invasive dental procedures and subsequent infective endocarditis, particularly in those at high risk of infective endocarditis. DESIGN This was a self-controlled, case-crossover design study comparing the number of invasive dental procedures in the 3 months immediately before an infective endocarditis-related hospital admission with that in the preceding 12-month control period. SETTING The study took place in the English NHS. PARTICIPANTS All individuals admitted to hospital with infective endocarditis between 1 April 2010 and 31 March 2016 were eligible to participate. INTERVENTIONS This was an observational study; therefore, there was no intervention. MAIN OUTCOME MEASURE The outcome measure was the number of invasive and non-invasive dental procedures in the months before infective endocarditis-related hospital admission. DATA SOURCES NHS Digital provided infective endocarditis-related hospital admissions data and dental procedure data were obtained from the NHS Business Services Authority. RESULTS The incidence rate of invasive dental procedures decreased in the 3 months before infective endocarditis-related hospital admission (incidence rate ratio 1.34, 95% confidence interval 1.13 to 1.58). Further analysis showed that this was due to loss of dental procedure data in the 2-3 weeks before any infective endocarditis-related hospital admission. LIMITATIONS We found that urgent hospital admissions were a common cause of incomplete courses of dental treatment and, because there is no requirement to record dental procedure data for incomplete courses, this resulted in a significant loss of dental procedure data in the 2-3 weeks before infective endocarditis-related hospital admissions. The data set was also reduced because of the NHS Business Services Authority's 10-year data destruction policy, reducing the power of the study. The main consequence was a loss of dental procedure data in the critical 3-month case period of the case-crossover analysis (immediately before infective endocarditis-related hospital admission), which did not occur in earlier control periods. Part of the decline in the rate of invasive dental procedures may also be the result of the onset of illness prior to infective endocarditis-related hospital admission, and part may be due to other undefined causes. CONCLUSIONS The loss of dental procedure data in the critical case period immediately before infective endocarditis-related hospital admission makes interpretation of the data difficult and raises uncertainty over any conclusions that can be drawn from this study. FUTURE WORK We suggest repeating this study elsewhere using data that are unafflicted by loss of dental procedure data in the critical case period. TRIAL REGISTRATION This trial is registered as ISRCTN11684416. FUNDING This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 28. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Martin H Thornhill
- Academic Unit of Oral and Maxillofacial Medicine, Surgery and Pathology, School of Clinical Dentistry, University of Sheffield, Sheffield, UK.,Department of Oral Medicine, Atrium Health, Carolinas Medical Center, Charlotte, NC, USA
| | - Annabel Crum
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Saleema Rex
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Richard Campbell
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Tony Stone
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Mike Bradburn
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Veronica Fibisan
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Mark J Dayer
- Department of Cardiology, Taunton and Somerset NHS Foundation Trust, Taunton, UK
| | | | - Peter B Lockhart
- Department of Oral Medicine, Atrium Health, Carolinas Medical Center, Charlotte, NC, USA
| | - Larry M Baddour
- Division of Infectious Diseases, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Jon Nicholl
- School of Health and Related Research, University of Sheffield, Sheffield, UK
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9
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Gholami R, Khan R, Ramkissoon A, Alabdulqader A, Gimpaya N, Bansal R, Scaffidi MA, Prasad V, Detsky AS, Baker JP, Grover SC. Recommendation Reversals in Gastroenterology Clinical Practice Guidelines. J Can Assoc Gastroenterol 2022; 5:98-99. [PMID: 35368318 PMCID: PMC8972276 DOI: 10.1093/jcag/gwab040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 09/28/2021] [Indexed: 11/23/2022] Open
Abstract
Background Recommendations in clinical practice guidelines (CPGs) may be reversed when evidence emerges to show they are futile or unsafe. In this study, we identified and characterized recommendation reversals in gastroenterology CPGs. Methods We searched CPGs published by 20 gastroenterology societies from January 1990 to December 2019. We included guidelines which had at least two iterations of the same topic. We defined reversals as when (a) the more recent iteration of a CPG recommends against a specific practice that was previously recommend in an earlier iteration of a CPG from the same body, and (b) the recommendation in the previous iteration of the CPG is not replaced by a new diagnostic or therapeutic recommendation in the more recent iteration of the CPG. The primary outcome was the number of recommendation reversals. Secondary outcomes included the strength of recommendations and quality of evidence cited for reversals. Results Twenty societies published 1022 CPGs from 1990 to 2019. Our sample for analysis included 129 unique CPGs. There were 11 recommendation reversals from 10 guidelines. New evidence was presented for 10 recommendation reversals. Meta-analyses were cited for two reversals, and randomized controlled trials (RCTs) for seven reversals. Recommendations were stronger after the reversal for three cases, weaker in two cases, and of similar strength in three cases. We were unable to compare recommendation strengths for three reversals. Conclusion Recommendation reversals in gastroenterology CPGs are uncommon but highlight low value or harmful practices.
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Affiliation(s)
- Reza Gholami
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Rishad Khan
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Anushka Ramkissoon
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Ontario, Canada
| | | | - Nikko Gimpaya
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Rishi Bansal
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Michael A Scaffidi
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Vinay Prasad
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California,USA
| | - Allan S Detsky
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Mount Sinai Hospital and University Health Network, Toronto, Ontario, Canada
| | - Jeffrey P Baker
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Samir C Grover
- Division of Gastroenterology, St. Michael’s Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
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10
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Luchian I, Goriuc A, Martu MA, Covasa M. Clindamycin as an Alternative Option in Optimizing Periodontal Therapy. Antibiotics (Basel) 2021; 10:antibiotics10070814. [PMID: 34356735 PMCID: PMC8300806 DOI: 10.3390/antibiotics10070814] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 06/24/2021] [Accepted: 07/02/2021] [Indexed: 11/29/2022] Open
Abstract
Periodontal disease is an oral infectious and inflammatory disease caused by microorganisms that determine the host-mediated destruction of soft and hard periodontal tissues, which ultimately leads to tooth loss. Periodontitis affects a large part of the population, with various degrees of severity. Treatment consists of etiologic therapy: the removal of biofilm through mechanical debridement plus microbial elimination by supplementary measures. Antibiotic administration, either systemically or through local delivery, has been shown to improve clinical outcomes after mechanical periodontal treatment. Clindamycin is a lincosamide with a broad spectrum, being active against aerobic, anaerobic, and β-lactamase-producing bacteria. This antibiotic offers several advantages and some disadvantages and has been used in periodontal treatment both systemically and locally with various degrees of success. Among the properties that recommend it for periodontal treatment is the bacteriostatic effect, the inhibition of bacterial proteins synthesis, the enhancement of neutrophil chemotaxis, phagocytosis and the oxidative burst–oxidative stress storm. Furthermore, it is easily absorbed at the level of oral tissues in a considerable amount. This substantial tissue penetration, especially inside the bone, is synergistic with a stimulating effect on the host immune system. The aim of this review is to explore the applicability of this antibiotic agent and to evaluate its antimicrobial potential and limitations at the level of the oral biofilm associated with periodontal disease.
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Affiliation(s)
- Ionut Luchian
- Department of Periodontology, Faculty of Dental Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16 Universității Street, 700115 Iași, Romania;
| | - Ancuta Goriuc
- Department of Biochemistry, Faculty of Dental Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16 Universității Street, 700115 Iași, Romania
- Correspondence: (A.G.); (M.A.M.); Tel.: +40-723-438-089 (A.G.); +40-742-189-178 (M.A.M.)
| | - Maria Alexandra Martu
- Department of Periodontology, Faculty of Dental Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16 Universității Street, 700115 Iași, Romania;
- Correspondence: (A.G.); (M.A.M.); Tel.: +40-723-438-089 (A.G.); +40-742-189-178 (M.A.M.)
| | - Mihai Covasa
- Department of Health and Human Development, University “Stefan cel Mare” Suceava, 13 Universității Street, 720229 Suceava, Romania;
- Department of Basic Medical Sciences, College of Osteopathic Medicine, Western University of Health Sciences, 309E Second Street, Pomona, CA 91766, USA
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11
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Williams ML, Doyle MP, McNamara N, Tardo D, Mathew M, Robinson B. Epidemiology of infective endocarditis before versus after change of international guidelines: a systematic review. Ther Adv Cardiovasc Dis 2021; 15:17539447211002687. [PMID: 33784909 PMCID: PMC8020745 DOI: 10.1177/17539447211002687] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Introduction: All major international guidelines for the management of infective endocarditis (IE) have undergone major revisions, recommending antibiotic prophylaxis (AP) restriction to high-risk patients or foregoing AP completely. We performed a systematic review to investigate the effect of these guideline changes on the global incidence of IE. Methods: Electronic database searches were performed using Ovid Medline, EMBASE and Web of Science. Studies were included if they compared the incidence of IE prior to and following any change in international guideline recommendations. Relevant studies fulfilling the predefined search criteria were categorized according to their inclusion of either adult or pediatric patients. Incidence of IE, causative microorganisms and AP prescription rates were compared following international guideline updates. Results: Sixteen studies were included, reporting over 1.3 million cases of IE. The crude incidence of IE following guideline updates has increased globally. Adjusted incidence increased in one study after European guideline updates, while North American rates did not increase. Cases of IE with a causative pathogen identified ranged from 62% to 91%. Rates of streptococcal IE varied across adult and pediatric populations, while the relative proportion of staphylococcal IE increased (range pre-guidelines 16–24.8%, range post-guidelines 26–43%). AP prescription trends were reduced in both moderate and high-risk patients following guideline updates. Discussion: The restriction of AP to only high-risk patients has not resulted in an increase in the incidence of streptococcal IE in North American populations. The evidence of the impact of AP restriction on IE incidence is still unclear for other populations. Future population-based studies with adjusted incidence of IE, AP prescription rates and accurate pathogen identification are required to delineate findings further in these other regions.
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Affiliation(s)
- Michael L Williams
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, 50 Missenden Road, Camperdown, NSW 2050, Australia
| | - Mathew P Doyle
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Centre for Human and Applied Physiology, School of Medicine, University of Wollongong, Keiraville, Australia
| | - Nicholas McNamara
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - Daniel Tardo
- Department of Medicine, St Vincents Hospital, Sydney, NSW, Australia.,School of Medicine, University of Notre Dame, Sydney, NSW, Australia
| | - Manish Mathew
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - Benjamin Robinson
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia
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12
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Young JR, Bannon AL, Anoushiravani AA, Posner AD, Adams CT, DiCaprio MR. Oral health implications in total hip and knee arthroplasty patients: A review. J Orthop 2021; 24:126-130. [PMID: 33679037 PMCID: PMC7930502 DOI: 10.1016/j.jor.2021.02.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 02/14/2021] [Indexed: 12/19/2022] Open
Abstract
Over the past two decades, oral health has emerged as a health care priority. Historically, patients greater than 65 years of age, the economically disadvantaged, members of racial or ethnic minority groups, or the disabled or home bound have experienced significant barriers to routine dental care. The connection between oral health care and periprosthetic joint infections (PJI) continues to be of importance to the orthopedic surgeon, as such infections are significantly morbid and costly. This review aims to introduce the importance of oral health as a small but crucial portion of an arthroplasty patient's overall perioperative management.
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Affiliation(s)
- Joseph R. Young
- Division of Orthopaedic Surgery, Albany Medical Center, Albany, NY, USA
| | - Annika L. Bannon
- Department of Family Medicine, Albany Medical Center, Albany, NY, USA
| | | | - Andrew D. Posner
- Division of Orthopaedic Surgery, Albany Medical Center, Albany, NY, USA
| | - Curtis T. Adams
- Division of Orthopaedic Surgery, Albany Medical Center, Albany, NY, USA
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Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O’Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary. J Am Coll Cardiol 2021; 77:450-500. [DOI: 10.1016/j.jacc.2020.11.035] [Citation(s) in RCA: 272] [Impact Index Per Article: 90.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Kahn F, Resman F, Bergmark S, Filiptsev P, Nilson B, Gilje P, Rasmussen M. Time to blood culture positivity in Staphylococcus aureus bacteraemia to determine risk of infective endocarditis. Clin Microbiol Infect 2020; 27:1345.e7-1345.e12. [PMID: 33197608 DOI: 10.1016/j.cmi.2020.11.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 10/30/2020] [Accepted: 11/08/2020] [Indexed: 01/04/2023]
Abstract
OBJECTIVES Patients with Staphylococcus aureus bacteraemia (SAB) at risk for infective endocarditis (IE) need to be identified because they should undergo echocardiography. We validated previous scoring systems for IE risk determination and evaluated whether time to blood culture positivity (TTP) could improve scoring systems. METHODS This retrospective population-based study included adults with SAB in 2016 in a derivation cohort and those from 2017 in a validation cohort. TTP was compared between patients with and without IE. A new score including TTP was constructed using a least absolute shrinkage selection operator. The new POSITIVE score was compared to the previously described PREDICT and VIRSTA scores. RESULTS A total of 465 episodes with SAB were included in the derivation cohort, of which 38 (8.2%) represented IE. Median (interquartile range) TTP was significantly shorter in episodes with IE, at 8.7 (7.7-10.6) hours compared to those without, at 13.3 (10.5-16.5) hours. When using a cutoff at 13 hours, TTP had a sensitivity of 100% (95% confidence interval (CI), 91-100) and specificity of 52% (95% CI, 47-57) for IE. The POSITIVE score included TTP, intravenous drug use, embolizations and presence of preexisting heart conditions. It had a sensitivity of 93% (95% CI, 76-99) and a specificity of 70% (95% CI, 66-74) in the validation cohort. The performance of POSITIVE was superior to PREDICT, and the specificity was higher than that of VIRSTA. CONCLUSIONS TTP, either by itself or as part of the POSITIVE score, can be used to identify patients with SAB at low risk for IE. Further validation is needed because TTP is sensitive to several external factors.
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Affiliation(s)
- Fredrik Kahn
- Skåne University Hospital, Sweden; Division of Infection Medicine, Department of Clinical Sciences Lund, Sweden
| | - Fredrik Resman
- Skåne University Hospital, Sweden; Division of Infectious Diseases, Department of Translational Medicine, Lund University, Malmö, Sweden
| | | | | | - Bo Nilson
- Clinical Microbiology, Labmedicine, Region Skåne, Lund, Sweden; Division of Medical Microbiology, Department of Laboratory Medicine, Sweden
| | - Patrik Gilje
- Skåne University Hospital, Sweden; Division of Cardiology, Department of Clinical Sciences, Lund University, Sweden
| | - Magnus Rasmussen
- Skåne University Hospital, Sweden; Division of Infection Medicine, Department of Clinical Sciences Lund, Sweden.
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Thornhill MH, Gibson TB, Durkin MJ, Dayer MJ, Lockhart PB, O'Gara PT, Baddour LM. Prescribing of antibiotic prophylaxis to prevent infective endocarditis. J Am Dent Assoc 2020; 151:835-845.e31. [PMID: 33121605 DOI: 10.1016/j.adaj.2020.07.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 07/22/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND In 2007, the American Heart Association recommended that antibiotic prophylaxis (AP) be restricted to those at high risk of developing complications due to infective endocarditis (IE) undergoing invasive dental procedures. The authors aimed to estimate the appropriateness of AP prescribing according to type of dental procedure performed in patients at high risk, moderate risk, or low or unknown risk of developing IE complications. METHODS Eighty patients at high risk, 40 patients at moderate risk, and 40 patients at low or unknown risk of developing IE complications were randomly selected from patients with linked dental care, health care, and prescription benefits data in the IBM MarketScan Databases, one of the largest US health care convenience data samples. Two clinicians independently analyzed prescription and dental procedure data to determine whether AP prescribing was likely, possible, or unlikely for each dental visit. RESULTS In patients at high risk of developing IE complications, 64% were unlikely to have received AP for invasive dental procedures, and in 32 of 80 high-risk patients (40%) there was no evidence of AP for any dental visit. When AP was prescribed, several different strategies were used to provide coverage for multiple dental visits, including multiday courses, multidose prescriptions, and refills, which sometimes led to an oversupply of antibiotics. CONCLUSIONS AP prescribing practices were inconsistent, did not always meet the highest antibiotic stewardship standards, and made retrospective evaluation difficult. For those at high risk of developing IE complications, there appears to be a concerning level of underprescribing of AP for invasive dental procedures. PRACTICAL IMPLICATIONS Some dentists might be failing to fully comply with American Heart Association recommendations to provide AP cover for all invasive dental procedures in those at high risk of developing IE complications.
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Abstract
Patient and procedural factors can increase the risk of infectious adverse events during endoscopy. Prophylactic antibiotic use must be judicious and individualized in the era of antibiotic resistance. New and emerging procedures require high-quality studies to elucidate appropriate risk profiles.
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Affiliation(s)
- Brian P H Chan
- Division of Gastroenterology, Center for Advanced Endoscopy, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA
| | - Tyler M Berzin
- Division of Gastroenterology, Center for Advanced Endoscopy, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA.
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17
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Adesomo A, Gonzalez-Brown V, Rood KM. Infective Endocarditis as a Complication of Intravenous Drug Use in Pregnancy: A Retrospective Case Series and Literature Review. AJP Rep 2020; 10:e288-e293. [PMID: 33274121 PMCID: PMC7704245 DOI: 10.1055/s-0040-1716732] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 06/04/2020] [Indexed: 01/04/2023] Open
Abstract
Objective An increase in opioid use disorder and subsequent intravenous drug use has led to an increase in sequalae that may complicate pregnancy, such as infective endocarditis. Infective endocarditis has the potential for significant maternal and neonatal morbidity and mortality. We sought to examine the management considerations and clinical implications of intravenous drug use-related infective endocarditis in pregnancy from our center's experience. Study Design Retrospective study of management of pregnancies complicated by infective endocarditis as a result of active intravenous drug use at an academic tertiary care hospital from January 2012 through December 2019. Results Twelve women with active intravenous drug use histories were identified as having clinical and echocardiographic features consistent with infective endocarditis. Six women were discharged against medical advice and did not complete the full course of recommended antibiotic regimen. Eight women were started or continued on opioid agonist therapy during their hospitalization. Four neonates required neonatal intensive care unit admission for pharmacologic treatment for neonatal abstinence syndrome. Conclusion Management of intravenous drug use-associated infective endocarditis in pregnancy involves more than treating the acute condition. In pregnant women with opioid use disorder and infective endocarditis, addiction and chronic psychosocial conditions need to be addressed to optimize care.
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Affiliation(s)
- Adebayo Adesomo
- Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio
| | - Veronica Gonzalez-Brown
- Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio
| | - Kara M Rood
- Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio
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DelMauro MA, Kalberer DC, Rodgers IR. Infection prophylaxis in periorbital Mohs surgery and reconstruction: a review and update to recommendations. Surv Ophthalmol 2020; 65:323-347. [DOI: 10.1016/j.survophthal.2019.12.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 11/27/2019] [Accepted: 12/02/2019] [Indexed: 01/04/2023]
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Loyola-Rodriguez JP, Franco-Miranda A, Loyola-Leyva A, Perez-Elizalde B, Contreras-Palma G, Sanchez-Adame O. Prevention of infective endocarditis and bacterial resistance to antibiotics: A brief review. SPECIAL CARE IN DENTISTRY 2019; 39:603-609. [PMID: 31464005 DOI: 10.1111/scd.12415] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 07/31/2019] [Accepted: 08/03/2019] [Indexed: 12/26/2022]
Abstract
The purpose of this statement is to debate the recommendations of the American Heart Association (AHA) for the prevention of infective endocarditis through an antibiotic prophylaxis protocol and its relation with bacterial resistance to antibiotics. Since dental infections involve biofilms that include several bacterial species (Gram-negative and Gram-positive), it is essential, from the dental point of view, to consider the frequency, magnitude, and duration of bacteremia associated with active dental infections before applying antibiotic prophylaxis. The actual guidelines for antibiotic prophylaxis should be revised according to recent evidence of bacterial resistance. Amoxicillin/clavulanic acid and moxifloxacin should be considered due to their effectiveness against bacteria associated with oral, GU, and GI infections and the low rates of antibiotic resistance associated with these antibiotics, instead of the actual protocol, which includes amoxicillin (2 g) or clindamycin (600 mg) administered an hour before the dental procedures. The breaking point to test the antibiotic bacterial resistance (ABR) had a wide range in the different studies that were analyzed, which could explain the widely varied ABR percentages reported for the various antibiotics used for antibiotic prophylaxis.
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Affiliation(s)
- Juan Pablo Loyola-Rodriguez
- Laboratorio de Biomateriales y Bionanotecnología, Maestría en Ciencias de la Salud, Facultad de Medicina, Universidad Autónoma de Guerrero, Acapulco, México
| | | | - Alejandra Loyola-Leyva
- Doctorado en Ciencias Biomedicas Básicas, Universidad Autónoma de San Luis Potosí, México
| | - Bulfrano Perez-Elizalde
- Medicina Translacional, Maestría en Ciencias de la Salud, Facultad de Medicina, Universidad Autónoma de Guerrero, Acapulco, México
| | - Guillermo Contreras-Palma
- Laboratorio de Biomateriales y Bionanotecnología, Maestría en Ciencias de la Salud, Facultad de Medicina, Universidad Autónoma de Guerrero, Acapulco, México
| | - Oscar Sanchez-Adame
- Medicina Translacional, Maestría en Ciencias de la Salud, Facultad de Medicina, Universidad Autónoma de Guerrero, Acapulco, México
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Streptococcus gordonii: A Rare Cause of Infective Endocarditis. Case Rep Infect Dis 2019; 2019:7127848. [PMID: 31281690 PMCID: PMC6594294 DOI: 10.1155/2019/7127848] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 05/14/2019] [Accepted: 05/30/2019] [Indexed: 12/05/2022] Open
Abstract
Infective endocarditis is a rare but life-threatening disease seen across the globe. Organisms from the oral cavity still represent a large proportion of pathogens seen in endocarditis and can be from either daily dental routines or invasive procedures. With the recent changes to antibiotic prophylaxis for infective endocarditis prior to dental procedures, the physician must have a heightened degree of suspicion when presented with a patient with undifferenced sepsis following dental procedures. The authors present a case of infective endocarditis caused by Streptococcus gordonii after the drainage of a dental abscess.
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21
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Thornhill MH, Gibson TB, Cutler E, Dayer MJ, Chu VH, Lockhart PB, O'Gara PT, Baddour LM. Antibiotic Prophylaxis and Incidence of Endocarditis Before and After the 2007 AHA Recommendations. J Am Coll Cardiol 2018; 72:2443-2454. [PMID: 30409564 DOI: 10.1016/j.jacc.2018.08.2178] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 08/06/2018] [Accepted: 08/20/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND The American Heart Association updated its recommendations for antibiotic prophylaxis (AP) to prevent infective endocarditis (IE) in 2007, advising that AP cease for those at moderate risk of IE, but continue for those at high risk. OBJECTIVES The authors sought to quantify any change in AP prescribing and IE incidence. METHODS High-risk, moderate-risk, and unknown/low-risk individuals with linked prescription and Medicare or commercial health care data were identified in the Truven Health MarketScan databases from May 2003 through August 2015 (198,522,665 enrollee-years of data). AP prescribing and IE incidence were evaluated by Poisson model analysis. RESULTS By August 2015, the 2007 recommendation change was associated with a significant 64% (95% confidence interval [CI]: 59% to 68%) estimated fall in AP prescribing for moderate-risk individuals and a 20% (95% CI: 4% to 32%) estimated fall for those at high risk. Over the same period, there was a barely significant 75% (95% CI: 3% to 200%) estimated increase in IE incidence among moderate-risk individuals and a significant 177% estimated increase (95% CI: 66% to 361%) among those at high risk. In unknown/low-risk individuals, there was a significant 52% (95% CI: 46% to 58%) estimated fall in AP prescribing, but no significant increase in IE incidence. CONCLUSIONS AP prescribing fell among all IE risk groups, particularly those at moderate risk. Concurrently, there was a significant increase in IE incidence among high-risk individuals, a borderline significant increase in moderate-risk individuals, and no change for those at low/unknown risk. Although these data do not establish a cause-effect relationship between AP reduction and IE increase, the fall in AP prescribing in those at high risk is of concern and, coupled with the borderline increase in IE incidence among those at moderate risk, warrants further investigation.
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Affiliation(s)
- Martin H Thornhill
- Unit of Oral & Maxillofacial Medicine Surgery and Pathology, School of Clinical Dentistry, University of Sheffield, Sheffield, United Kingdom; Department of Oral Medicine, Carolinas Medical Center, Charlotte, North Carolina.
| | - Teresa B Gibson
- Truven Health Analytics/IBM Watson Health, Ann Arbor, Michigan
| | - Eli Cutler
- Truven Health Analytics/IBM Watson Health, Ann Arbor, Michigan
| | - Mark J Dayer
- Department of Cardiology, Taunton and Somerset NHS Trust, Taunton, Somerset, United Kingdom
| | - Vivian H Chu
- Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina
| | - Peter B Lockhart
- Department of Oral Medicine, Carolinas Medical Center, Charlotte, North Carolina
| | - Patrick T O'Gara
- Cardiovascular Medicine Division, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts
| | - Larry M Baddour
- Division of Infectious Diseases, Mayo Clinic College of Medicine, Rochester, Minnesota
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Østergaard L, Valeur N, Wang A, Bundgaard H, Aslam M, Gislason G, Torp-Pedersen C, Bruun NE, Søndergaard L, Køber L, Fosbøl EL. Incidence of infective endocarditis in patients considered at moderate risk. Eur Heart J 2018; 40:1355-1361. [DOI: 10.1093/eurheartj/ehy629] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 05/01/2018] [Accepted: 09/18/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Lauge Østergaard
- Heart Center, University Hospital of Copenhagen, Rigshospitalet, Blegdamsvej 8, KBH N, Denmark
| | - Nana Valeur
- Department of Cardiology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Andrew Wang
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Henning Bundgaard
- Heart Center, University Hospital of Copenhagen, Rigshospitalet, Blegdamsvej 8, KBH N, Denmark
| | - Mohsin Aslam
- Heart Center, University Hospital of Copenhagen, Rigshospitalet, Blegdamsvej 8, KBH N, Denmark
| | - Gunnar Gislason
- Department of Cardiology, Roskilde University Hospital, Roskilde, Denmark
- Department of Cardiovascular Epidemiology and Research, The Danish Heart Foundation, Copenhagen, Denmark
| | | | - Niels Eske Bruun
- Department of Cardiology, Roskilde University Hospital, Roskilde, Denmark
- Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Denmark
- Clinical Institute, Aalborg University, Aalborg, Denmark
| | - Lars Søndergaard
- Heart Center, University Hospital of Copenhagen, Rigshospitalet, Blegdamsvej 8, KBH N, Denmark
| | - Lars Køber
- Heart Center, University Hospital of Copenhagen, Rigshospitalet, Blegdamsvej 8, KBH N, Denmark
| | - Emil Loldrup Fosbøl
- Heart Center, University Hospital of Copenhagen, Rigshospitalet, Blegdamsvej 8, KBH N, Denmark
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Mechanical Genomic Studies Reveal the Role of d-Alanine Metabolism in Pseudomonas aeruginosa Cell Stiffness. mBio 2018; 9:mBio.01340-18. [PMID: 30206169 PMCID: PMC6134093 DOI: 10.1128/mbio.01340-18] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The mechanical properties of bacteria are important for protecting cells against physical stress. The cell wall is the best-characterized cellular element contributing to bacterial cell mechanics; however, the biochemistry underlying its regulation and assembly is still not completely understood. Using a unique high-throughput biophysical assay, we identified genes coding proteins that modulate cell stiffness in the opportunistic human pathogen Pseudomonas aeruginosa. This approach enabled us to discover proteins with roles in a diverse range of biochemical pathways that influence the stiffness of P. aeruginosa cells. We demonstrate that d-Ala—a component of the peptidoglycan—is tightly regulated in cells and that its accumulation reduces expression of machinery that cross-links this material and decreases cell stiffness. This research demonstrates that there is much to learn about mechanical regulation in bacteria, and these studies revealed new nonessential P. aeruginosa targets that may enhance antibacterial chemotherapies or lead to new approaches. The stiffness of bacteria prevents cells from bursting due to the large osmotic pressure across the cell wall. Many successful antibiotic chemotherapies target elements that alter mechanical properties of bacteria, and yet a global view of the biochemistry underlying the regulation of bacterial cell stiffness is still emerging. This connection is particularly interesting in opportunistic human pathogens such as Pseudomonas aeruginosa that have a large (80%) proportion of genes of unknown function and low susceptibility to different families of antibiotics, including beta-lactams, aminoglycosides, and quinolones. We used a high-throughput technique to study a library of 5,790 loss-of-function mutants covering ~80% of the nonessential genes and correlated P. aeruginosa individual genes with cell stiffness. We identified 42 genes coding for proteins with diverse functions that, when deleted individually, decreased cell stiffness by >20%. This approach enabled us to construct a “mechanical genome” for P. aeruginosa. d-Alanine dehydrogenase (DadA) is an enzyme that converts d-Ala to pyruvate that was included among the hits; when DadA was deleted, cell stiffness decreased by 18% (using multiple assays to measure mechanics). An increase in the concentration of d-Ala in cells downregulated the expression of genes in peptidoglycan (PG) biosynthesis, including the peptidoglycan-cross-linking transpeptidase genes ponA and dacC. Consistent with this observation, ultraperformance liquid chromatography-mass spectrometry analysis of murein from P. aeruginosa cells revealed that dadA deletion mutants contained PG with reduced cross-linking and altered composition compared to wild-type cells.
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Pascall E, Tulloh RMR. Pulmonary hypertension in congenital heart disease. Future Cardiol 2018; 14:343-353. [PMID: 29792339 PMCID: PMC6136120 DOI: 10.2217/fca-2017-0065] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 02/22/2018] [Indexed: 12/27/2022] Open
Abstract
Pulmonary hypertension is defined as a mean pulmonary arterial pressure ≥25 mmHg. We focus on its relevance in congenital heart disease, reviewing pathophysiology, diagnosis and management. Pulmonary hypertension is a relatively common complication of congenital heart disease, with adult prevalence between 5 and 10%. A multifactorial cause is recognized, relating to the size and nature of cardiac defect as well as environmental and genetic factors. More complex disease is increasingly recognized rather than pure Eisenmenger complex. Remodeling of the pulmonary vascular bed causes increased pulmonary vascular resistance diagnosed by a collection of investigations including echocardiography, exercise testing, cardiac catheterization, MRI and CT scanning. Management employs disease-modifying medications which are now used with increasing benefit.
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Affiliation(s)
- Emma Pascall
- Department of Congenital Heart Disease, Bristol Heart Institute, Upper Maudlin Street, Bristol, BS2 8BJ, UK
| | - Robert MR Tulloh
- Department of Congenital Heart Disease, Bristol Heart Institute, Upper Maudlin Street, Bristol, BS2 8BJ, UK
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25
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Akbulut Y, Goymen M, Zer Y, Buyuktas Manay A. Investigation of bacteremia after debonding procedures. Acta Odontol Scand 2018; 76:314-319. [PMID: 29566581 DOI: 10.1080/00016357.2018.1451654] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE The purpose of this study is to investigate the effect of debonding procedures after completion of orthodontic treatments on bacteremia. MATERIALS AND METHODS Twenty-eight patients who were treated with fixed orthodontic treatment at the Faculty of Dentistry's Department of Orthodontics at Gaziantep University and who had an indication of debonding were selected for this study, and blood samples were taken from these patients at different times and examined for bacteremia. Blood culture samples were taken from the antecubital veins of the patients prior to debonding (T0), immediately after removing the bracket (T1), and immediately after cleaning the composite residues and plaque deposits on the enamel surface (T2). The blood samples were then inoculated in blood culture bottles and investigated for bacterial growth. RESULTS The results showed that there was no bacterial growth in the blood samples taken at T0 and T1, whereas 10 of the blood culture samples taken at T2 showed bacterial growth including the following bacteria; Streptococcus viridans, Streptococcus mitis, Streptococcus parasanguinis, Streptococcus salivarius, Streptococcus oralis, Staphylococcus aureus, Actinomyces oris, Actinomyces naeslundii and Klebsiella pneumoniae. CONCLUSION It was concluded that patients in the risk group could develop bacteremia during debonding procedures. The presence of these bacteria in sterile blood suggested the possibility of bacterial endocarditis.
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Affiliation(s)
- Yasin Akbulut
- Diyarbakır Education and Research Hospital, Ministry of Health, Health Sciences University, Diyarbakır, Turkey
| | - Merve Goymen
- Department of Orthodontics, Gaziantep University, Gaziantep, Turkey
| | - Yasemin Zer
- Department of Microbiology, Gaziantep University, Gaziantep, Turkey
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Infective Endocarditis After Invasive Medical and Surgical Procedures. J Am Coll Cardiol 2018; 71:2753-2755. [PMID: 29903349 DOI: 10.1016/j.jacc.2018.03.533] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 03/21/2018] [Indexed: 11/22/2022]
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27
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Loyola-Rodriguez JP, Ponce-Diaz ME, Loyola-Leyva A, Garcia-Cortes JO, Medina-Solis CE, Contreras-Ramire AA, Serena-Gomez E. Determination and identification of antibiotic-resistant oral streptococci isolated from active dental infections in adults. Acta Odontol Scand 2018; 76:229-235. [PMID: 29160117 DOI: 10.1080/00016357.2017.1405463] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To determine and identify antibiotic-resistant bacteria (ARB) of oral streptococci from active dental infections in adults and its association with age and gender. MATERIAL AND METHODS This cross-sectional study included 59 subjects from 18 to 62 years old. Ninety-eighth samples obtained from the subjects were cultivated in agar plates containing antibiotics amoxicillin/clavulanic acid (A-CA), clindamycin, and moxifloxacin (concentrations of 16, 32 or 64 µg/ml). PCR assay was performed to identify bacterial species. RESULTS The bacterial species that showed more antibiotic-resistance (AR) was S. mutans (45.9%), followed by S. gordonii (21.6%), S. oralis (17.6%), S. sanguinis (9.5%), S. salivarius (5.4%) and S. sobrinus (0%). Moreover, clindamycin (59.4%) showed the highest frequency of AR. Moxifloxacin and A-CA showed an susceptibility >99.1%, while clindamycin showed the lowest efficacy (93.3%); there was a significant statistically difference (p < .01). The age group between 26 and 50 years old (32.2%) and females (28.8%) showed more multiresistance. Clindamycin showed a statistical difference (p < .05) when comparing groups by gender. CONCLUSIONS Clindamycin was the antibiotic with the highest frequency of ARB and lower bactericidal effect. Moxifloxacin and A-CA showed the highest efficacy and the lowest ARB frequency. Streptococcus mutans was the bacterial specie that showed an increased frequency of AR.
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Affiliation(s)
| | - Maria Elena Ponce-Diaz
- Area of Dentistry of the Institute of Health´s Sciences, Autonomous University of the State of Hidalgo, Pachuca, Mexico
| | - Alejandra Loyola-Leyva
- Doctorado en Ciencias Biomédicas Básicas, Facultad de Medicina, Universidad Autónoma de San Luis Potosí, San Luis Potosí, México
| | - Jose O. Garcia-Cortes
- Facultad de Estomatología, Universidad Autónoma de San Luis Potosí, San Luis Potosí, México
| | - Carlo E. Medina-Solis
- Area of Dentistry of the Institute of Health´s Sciences, Autonomous University of the State of Hidalgo, Pachuca, Mexico
| | - Azael A. Contreras-Ramire
- Area of Dentistry of the Institute of Health´s Sciences, Autonomous University of the State of Hidalgo, Pachuca, Mexico
| | - Eduardo Serena-Gomez
- CISALUD Valle de las Palmas, Universidad Autónoma de Baja California, Tijuana, México
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28
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Anesthesia for Congenital Heart Diseases in Adults. Anesthesiology 2018. [DOI: 10.1007/978-3-319-74766-8_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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29
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Thom K, Hanslik A, Russell JL, Williams S, Sivaprakasam P, Allen U, Male C, Brandão LR. Incidence of infective endocarditis and its thromboembolic complications in a pediatric population over 30years. Int J Cardiol 2017; 252:74-79. [PMID: 29126655 DOI: 10.1016/j.ijcard.2017.10.085] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 10/13/2017] [Accepted: 10/23/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pediatric infective endocarditis (IE) has been associated with high morbidity and mortality, mostly related to thromboembolic complications (TEC). The objective of our study was to describe the experience in children with IE and to review the changes over a thirty-year period, regarding origin of IE, incidence of vegetations, TEC and their respective morbidity and mortality rates. METHODS A retrospective chart review of children aged 0-18years with IE defined by the Duke Criteria and admitted to The Hospital for Sick Children, was conducted. Data were divided into three periods (P); P1 (1979-1988); P2 (1989-1998); and P3 (1999-2008). RESULTS The study included 113 patients, median age 7yrs.; females: 46 (41%), congenital heart defects 95 (84%), comparable in all periods. Overall, cardiac vegetations were found in 68/113 patients (60%); large vegetations (≥1cm) in 32 patients (28%). Fourty-five (45/133 [40%]) TEC were documented, 22 patients (20%) developed cerebrovascular events (CVE) and 23 patients (20%) had non-CVE. Patients diagnosed during P3 were older, had more vegetations (p<0.05), and a higher incidence of community acquired-IE (p<0.05). Overall, mortality was 15%, comparable in all periods. Significant risk factors for mortality were vegetations (HR 6.44; 95% CI: 2.07-20.01, p=0.002) and heart failure (HR 28.39; 95% CI: 10.49-76.85, p<0.001). CONCLUSIONS Over the study period, we report a growing incidence of community acquired pediatric IE in older children accompanied by an increasing rate of TEC. Heart failure and vegetations were associated with an increased mortality. These preliminary data need to be confirmed by prospective data.
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Affiliation(s)
- K Thom
- Pediatric Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada; Division of Pediatric Cardiology, Department of Children and Adolescent Medicine, Medical University Vienna, Austria
| | - A Hanslik
- Division of Pediatric Cardiology, Department of Children and Adolescent Medicine, Medical University Vienna, Austria
| | - J L Russell
- Pediatric Cardiology, Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Canada
| | - S Williams
- Pediatric Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
| | - P Sivaprakasam
- Pediatric Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
| | - U Allen
- Infectious Disease, The Hospital for Sick Children, Toronto, Canada
| | - C Male
- Division of Pediatric Cardiology, Department of Children and Adolescent Medicine, Medical University Vienna, Austria
| | - L R Brandão
- Pediatric Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada.
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Luo L, Sun Q, Chen L, Ying D, Wu X, Chen Z. Survival of the fetus during maternal thoracotomy under cardiopulmonary bypass for infective endocarditis. J Obstet Gynaecol Res 2017; 43:1634-1638. [PMID: 28707745 DOI: 10.1111/jog.13414] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 04/21/2017] [Accepted: 05/03/2017] [Indexed: 11/30/2022]
Abstract
Infective endocarditis (IE) during pregnancy is a rare but serious condition. Cardiopulmonary bypass during pregnancy has a high rate of fetal morbidity and mortality. We here report the case of a 22-year-old pregnant woman with confirmed IE. Multiple large cardiac valve vegetations, severe aortic valve regurgitation, and hemodynamic compromise were observed. With full implementation of fetal monitoring and protection strategies, open heart surgery was performed at 31.4 weeks' gestation to aid survival, followed by an elective cesarean delivery at 34.4 weeks. As of the 3-month follow-up, both the mother and infant were in good health. This shows that a fetus can survive maternal thoracotomy under cardiopulmonary bypass with proper perioperative management, which means that this technique does not need to be excluded from consideration in the treatment of IE complicating pregnancy.
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Affiliation(s)
- Li Luo
- Department of Obstetrics and Gynecology, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Qiulei Sun
- Department of Obstetrics and Gynecology, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Liping Chen
- Department of Obstetrics and Gynecology, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Demei Ying
- Department of Obstetrics and Gynecology, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Xiaohua Wu
- Department of Obstetrics and Gynecology, Xinqiao Hospital, Third Military Medical University, Chongqing, China
| | - Zhengqiong Chen
- Department of Obstetrics and Gynecology, Xinqiao Hospital, Third Military Medical University, Chongqing, China
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DeSimone DC, El Rafei A, Challener DW, Carr AB, Kelly JA, Rocca WA, St Sauver JL, Bock-Goodner CM, Lahr BD, Steckelberg JM, Wilson WR, Baddour LM. Effect of the American Heart Association 2007 Guidelines on the Practice of Dental Prophylaxis for the Prevention of Infective Endocarditis in Olmsted County, Minnesota. Mayo Clin Proc 2017; 92:S0025-6196(17)30238-0. [PMID: 28549764 PMCID: PMC5681438 DOI: 10.1016/j.mayocp.2017.03.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 03/06/2017] [Accepted: 03/08/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To determine the adherence of dental providers to the 2007 American Heart Association (AHA) infective endocarditis prevention guidelines regarding antibiotic drug administration before invasive dental procedures. PATIENTS AND METHODS The study included all adults (≥18 years old) with a moderate-risk (MR) or high-risk (HR) cardiac condition who received dental care at participating dental offices from January 1, 2005, through June 1, 2015, in Olmsted County, Minnesota. Data collected included the date and type of dental procedure performed and receipt of antibiotic prophylaxis (AP). RESULTS A total of 1351 patients underwent 8854 dental visits at participating dental offices during the study period; 1236 patients had an MR cardiac condition and 115 had an HR condition. The percentage of visits in which antibiotic drugs were used for indicated dental procedures in the MR group declined from 64.6% before to 8.6% after publication of the 2007 AHA guidelines (P<.001); for the HR group, AP declined from 96.9% before to 81.3% after publication of the guidelines (P=.02). CONCLUSION In this historical cohort in Olmsted County there was a statistically significant reduction in AP in the MR group before invasive dental procedures. In addition, there was an unanticipated significant reduction in AP in the HR group after publication of the 2007 AHA guidelines. These findings can be used to provide feedback and education to medical and dental professionals who are involved in decision making regarding the use of dental prophylaxis for their patients.
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Affiliation(s)
- Daniel C DeSimone
- Division of Infectious Diseases, Department of Health Sciences Research, Mayo Clinic, Rochester, MN.
| | - Abdelghani El Rafei
- Division of Infectious Diseases, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Douglas W Challener
- Division of Internal Medicine, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Alan B Carr
- Division of Dental Specialties, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - James A Kelly
- Division of Dental Specialties, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Walter A Rocca
- Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Department of Neurology, Mayo Clinic, Rochester, MN
| | - Jennifer L St Sauver
- Division of Epidemiology, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | | | - Brian D Lahr
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - James M Steckelberg
- Division of Infectious Diseases, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Walter R Wilson
- Division of Infectious Diseases, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Larry M Baddour
- Division of Infectious Diseases, Department of Health Sciences Research, Mayo Clinic, Rochester, MN; Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
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Bierens JJLM, Lunetta P, Tipton M, Warner DS. Physiology Of Drowning: A Review. Physiology (Bethesda) 2017; 31:147-66. [PMID: 26889019 DOI: 10.1152/physiol.00002.2015] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Drowning physiology relates to two different events: immersion (upper airway above water) and submersion (upper airway under water). Immersion involves integrated cardiorespiratory responses to skin and deep body temperature, including cold shock, physical incapacitation, and hypovolemia, as precursors of collapse and submersion. The physiology of submersion includes fear of drowning, diving response, autonomic conflict, upper airway reflexes, water aspiration and swallowing, emesis, and electrolyte disorders. Submersion outcome is determined by cardiac, pulmonary, and neurological injury. Knowledge of drowning physiology is scarce. Better understanding may identify methods to improve survival, particularly related to hot-water immersion, cold shock, cold-induced physical incapacitation, and fear of drowning.
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Affiliation(s)
| | - Philippe Lunetta
- Department of Pathology and Forensic Medicine, University of Turku, Turku, Finland
| | - Mike Tipton
- Department of Sport and Exercise Science, Extreme Environments Laboratory, University of Portsmouth, Portsmouth, United Kingdom; and
| | - David S Warner
- Departments of Anesthesiology, Neurobiology and Surgery, Duke University Medical Center, Durham, North Carolina
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Abstract
Links between infective endocarditis (IE) and dental and other invasive procedures were first identified in the 1920s, and the use of antibiotic prophylaxis (AP) to prevent IE was first recommended by the American Heart Association in 1955. Recognising the weak evidence to support this practice and the wider risks of anaphylaxis and antibiotic resistance, guidelines in the USA and Europe have been rationalised in the last decade with restriction of AP to those patients perceived to be at the highest risk. In the UK, the National Institute for Health and Care Excellence controversially recommended the complete cessation of AP for all invasive procedures in 2008 and subsequent epidemiological studies have suggested a significant increase in cases above the baseline trend. AP appears to be safe and is likely to be cost-effective. Until further data are available, we recommend continued adherence to US and European guidelines.
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Affiliation(s)
- Martin H Thornhill
- Department of Oral & Maxillofacial Medicine and Surgery, University of Sheffield School of Clinical Dentistry, Claremont Crescent, Sheffield, S10 2TA, UK.
- Department of Oral Medicine, Carolinas Medical Center, Charlotte, NC, USA.
| | - Mark Dayer
- Taunton and Somerset NHS Trust, Taunton, UK
| | - Peter B Lockhart
- Department of Oral Medicine, Carolinas Medical Center, Charlotte, NC, USA
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Kyo S, Imanaka K, Masuda M, Miyata T, Morita K, Morota T, Nomura M, Saiki Y, Sawa Y, Sueda T, Ueda Y, Yamazaki K, Yozu R, Iwamoto M, Kawamoto S, Koyama I, Kudo M, Matsumiya G, Orihashi K, Oshima H, Saito S, Sakamoto Y, Shigematsu K, Taketani T, Komuro I, Takamoto S, Tei C, Yamamoto F. Guidelines for Perioperative Cardiovascular Evaluation and Management for Noncardiac Surgery (JCS 2014) ― Digest Version ―. Circ J 2017; 81:245-267. [DOI: 10.1253/circj.cj-66-0135] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Yumul R, Emdadi A, Moradi N. Anesthesia for Noncardiac Surgery in Children with Congenital Heart Disease. Semin Cardiothorac Vasc Anesth 2016. [DOI: 10.1177/108925320300700204] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This review covers the classification of congenital heart diseases, and the preoperative assessment, monitoring, anesthetic considerations, and management in the pediatric population with congenital heart disease. It does not present “recipes” for individual cardiac defects. The pathophysiology is presented as it relates to principles of management, patient assessment, selection, and application of an anesthetic regimen to specific cardiac lesions and procedures. Familiarity with the child's pathophysiology, preoperative preparation, choice of monitors, induction, maintenance, emergence from anesthesia, and plans for the postoperative period should avoid major problems in anesthetic management.
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Affiliation(s)
| | | | - Nassim Moradi
- Department of Anesthesiology, Charles R. Drew University of Medicine, Martin Luther King Jr. Medical Center, Los Angeles, California
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36
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Affiliation(s)
- Ali Ataya
- Pulmonary Vascular Disease Program, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of Florida, Gainesville, Florida
| | - Sheylan Patel
- Pulmonary Vascular Disease Program, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of Florida, Gainesville, Florida
| | - Jessica Cope
- Pulmonary Vascular Disease Program, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of Florida, Gainesville, Florida
| | - Hassan Alnuaimat
- Pulmonary Vascular Disease Program, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of Florida, Gainesville, Florida
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Abstract
Extraordinary technological advances have greatly accelerated our ability to identify bacteria, at the species level, present in clinical samples taken from the human mouth. In addition, technologies are evolving such that the oral samples can be analyzed for their protein and metabolic products. As a result, pictures are the advent of personalized dental medicine is becoming closer to reality.
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Kanagalingam J, Feliciano R, Hah JH, Labib H, Le TA, Lin JC. Practical use of povidone-iodine antiseptic in the maintenance of oral health and in the prevention and treatment of common oropharyngeal infections. Int J Clin Pract 2015; 69:1247-56. [PMID: 26249761 PMCID: PMC6767541 DOI: 10.1111/ijcp.12707] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 07/23/2015] [Indexed: 12/14/2022] Open
Abstract
AIMS To better inform medical practitioners on the role of antiseptics in oropharyngeal health and disease, this article focuses on povidone-iodine (PVP-I), an established and widely-available antiseptic agent. METHODOLOGY Review of the anti-infective profile, efficacy and safety of PVP-I in managing common upper respiratory tract infections such as the common cold, influenza and tonsillo-pharyngitis, as well as oral complications resulting from cancer treatment (oral mucositis), and dental conditions (periodontitis, caries). RESULTS Antiseptics with broad-spectrum anti-infective activity and low resistance potential offer an attractive option in both infection control and prevention. While there is some evidence of benefit of antiseptics in a variety of clinical settings that include dental and oral hygiene, dermatology, oncology, and pulmonology, there appears to be discordance between the evidence-base and practice. This is especially apparent in the management and prevention of oropharyngeal infections, for which the use of antiseptics varies considerably between clinical practices, and is in marked contrast to their dermal application, where they are extensively used as both a prophylaxis and a treatment of skin and wound infections, thus minimising the use of antibiotics. CONCLUSION The link between oral and oropharyngeal health status and susceptibility to infection has long been recognised. The high rates of antibiotic misuse and subsequent development of bacterial resistance (e.g. increasing vancomycin-resistant enterococci (VRE) and methicillin-resistant Staphylococcus aureus (MRSA)) in large parts of the world, especially across Asia Pacific, highlight the need for identifying alternative antimicrobials that would minimise the use of these medications. This, together with recent large-scale outbreaks of, for example, avian and swine influenza virus, further underline the importance of an increasing armamentarium for infection prevention and control.
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Affiliation(s)
- J Kanagalingam
- Lee Kong Chian School of Medicine, NTU-Imperial College, Singapore
| | - R Feliciano
- Department of Otolaryngology, St Luke's Medical Center, Global City, Philippines
| | - J H Hah
- Department of Otolaryngology-Head and Neck Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul, South Korea
| | - H Labib
- Dr. Hussein Labib Dental Clinic, Dubai, United Arab Emirates
| | - T A Le
- Department of Oncology, Cho Ray hospital, Ho Chi Minh City, Vietnam
| | - J-C Lin
- Department of Radiation Oncology, Taichung Veterans General Hospital, Taichung, Taiwan
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Chen PC, Tung YC, Wu PW, Wu LS, Lin YS, Chang CJ, Kung S, Chu PH. Dental Procedures and the Risk of Infective Endocarditis. Medicine (Baltimore) 2015; 94:e1826. [PMID: 26512586 PMCID: PMC4985400 DOI: 10.1097/md.0000000000001826] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Infective endocarditis (IE) is an uncommon but potentially devastating disease. Recently published data have revealed a significant increase in the incidence of IE following the restriction on indications for antibiotic prophylaxis as recommended by the revised guidelines. This study aims to reexamine the basic assumption behind the rationale of prophylaxis that dental procedures increase the risk of IE.Using the Longitudinal Health Insurance Database of Taiwan, we retrospectively analyzed a total of 739 patients hospitalized for IE between 1999 and 2012. A case-crossover design was conducted to compare the odds of exposure to dental procedures within 3 months preceding hospitalization with that during matched control periods when no IE developed.In the unadjusted model, the odds ratio (OR) was 0.93 for tooth extraction (95% confidence interval [CI] 0.54-1.59), 1.64 for surgery (95% CI 0.61-4.42), 0.92 for dental scaling (95% CI 0.59-1.42), 1.69 for periodontal treatment (95% CI 0.88-3.21), and 1.29 for endodontic treatment (95% CI 0.72-2.31). The association between dental procedures and the risk of IE remained insignificant after adjustment for antibiotic use, indicating that dental procedures did not increase the risk of IE.Therefore, this result may argue against the conventional assumption on which the recommended prophylaxis for IE is based.
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Affiliation(s)
- Pei-Chun Chen
- From the Clinical Informatics and Medical Statistics Research Center (PCC, CJC); Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taipei (YCT, LSW, YSL, PHC); Department of Radiology, Chang Gung Memorial Hospital, Linkou (PWW); Department of Orthodontics and Craniofacial Dentistry, Division of Periodontology, Chang Gung Memorial Hospital, Taipei, Taiwan; and Cheers Dental Clinic, New Taipei, Taiwan (SK); Healthcare Center (PHC); and Heart Failure Center, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taipei, Taiwan (PHC)
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Acceptance among and impact on dental practitioners and patients of American Heart Association recommendations for antibiotic prophylaxis. J Am Dent Assoc 2015; 144:1030-5. [PMID: 23989842 DOI: 10.14219/jada.archive.2013.0230] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The 2007 American Heart Association (AHA) guidelines for the prevention of infective endocarditis (IE) called for a major reduction in the number of patients recommended for antibiotic prophylaxis (AP) and redefined the dental procedures considered to put these patients at risk of acquiring the infection. The purpose of the authors' study was to determine the acceptance of these changes among and the impact of the changes on dentists and their patients. METHODS The authors sent a survey to a random sample of 5,500 dentists in the United States. RESULTS Ninety-five percent of the 878 respondents indicated that they saw patients who receive AP. More than 75 percent were either satisfied or very satisfied with the AHA guidelines, and the respondents indicated that they believed almost three-quarters of their patients also were pleased. Seventy percent of dentists, however, had patients who took antibiotics before a dental procedure even though the guidelines no longer recommend it. CONCLUSIONS Acceptance of the 2007 guidelines appears to be high, but controversy remains. Additional scientific data are needed to resolve these issues. PRACTICAL IMPLICATIONS The 2007 AHA guidelines have greatly simplified the identification of patients who need AP for dental procedures, given that, in general, far fewer people with cardiac abnormalities are considered to be at risk as a result of invasive procedures. Some physicians, however, continue to prescribe antibiotics for some patients whom the AHA no longer considers to need them. Patients also may choose to continue this practice themselves. There is ongoing controversy surrounding this common clinical question in dental practice, and the next guidelines from the AHA may change on the basis of data from future clinical studies.
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The Efficacy of Long-Term Post-Operative Antibiotic Therapy Versus Placebo on Dental Implants. ACTA ACUST UNITED AC 2015. [DOI: 10.5812/thrita.30678] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Habib G, Lancellotti P, Antunes MJ, Bongiorni MG, Casalta JP, Del Zotti F, Dulgheru R, El Khoury G, Erba PA, Iung B, Miro JM, Mulder BJ, Plonska-Gosciniak E, Price S, Roos-Hesselink J, Snygg-Martin U, Thuny F, Tornos Mas P, Vilacosta I, Zamorano JL. 2015 ESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J 2015; 36:3075-3128. [PMID: 26320109 DOI: 10.1093/eurheartj/ehv319] [Citation(s) in RCA: 3046] [Impact Index Per Article: 338.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
MESH Headings
- Acute Kidney Injury/diagnosis
- Acute Kidney Injury/therapy
- Ambulatory Care
- Aneurysm, Infected/diagnosis
- Aneurysm, Infected/therapy
- Anti-Bacterial Agents/therapeutic use
- Antibiotic Prophylaxis
- Arrhythmias, Cardiac/diagnosis
- Arrhythmias, Cardiac/therapy
- Clinical Laboratory Techniques
- Critical Care
- Cross Infection/etiology
- Dentistry, Operative
- Diagnostic Imaging/methods
- Embolism/diagnosis
- Embolism/therapy
- Endocarditis/diagnosis
- Endocarditis/therapy
- Endocarditis, Non-Infective/diagnosis
- Endocarditis, Non-Infective/therapy
- Female
- Fibrinolytic Agents/therapeutic use
- Heart Defects, Congenital
- Heart Failure/diagnosis
- Heart Failure/therapy
- Heart Valve Diseases/diagnosis
- Heart Valve Diseases/therapy
- Humans
- Long-Term Care
- Microbiological Techniques
- Musculoskeletal Diseases/diagnosis
- Musculoskeletal Diseases/microbiology
- Musculoskeletal Diseases/therapy
- Myocarditis/diagnosis
- Myocarditis/therapy
- Neoplasms/complications
- Nervous System Diseases/diagnosis
- Nervous System Diseases/microbiology
- Nervous System Diseases/therapy
- Patient Care Team
- Pericarditis/diagnosis
- Pericarditis/therapy
- Postoperative Complications/etiology
- Postoperative Complications/prevention & control
- Pregnancy
- Pregnancy Complications, Cardiovascular/diagnosis
- Pregnancy Complications, Cardiovascular/therapy
- Prognosis
- Prosthesis-Related Infections/diagnosis
- Prosthesis-Related Infections/therapy
- Recurrence
- Risk Assessment
- Risk Factors
- Splenic Diseases/diagnosis
- Splenic Diseases/therapy
- Thoracic Surgical Procedures
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Feuerstein JD, Sethi S, Tapper EB, Belkin E, Lewandowski JJ, Singla A, Sheth SG, Sawhney M. Current knowledge of antibiotic prophylaxis guidelines regarding GI open-access endoscopic procedures is inadequate. Gastrointest Endosc 2015; 82:268-275.e7. [PMID: 25841581 DOI: 10.1016/j.gie.2015.01.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 01/04/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND The American Heart Association (AHA) guidelines from 2007 and the American Society for Gastrointestinal Endoscopy (ASGE) guidelines from 2008 recommended against antibiotic prophylaxis before GI endoscopic procedures to prevent bacterial endocarditis. OBJECTIVE To determine physician knowledge regarding these guidelines and to identify physician subgroups for which knowledge was suboptimal. DESIGN A survey questionnaire was developed based on AHA and ASGE guidelines regarding antibiotics before endoscopy. Physicians were queried about 10 theoretical scenarios as to whether or not they would recommend before-procedure antibiotics. SETTING The survey was administered at 3 academic medical centers. PARTICIPANTS Attending physicians and trainees in primary care and subspecialties. INTERVENTIONS Survey. MAIN OUTCOME MEASUREMENTS Percentage of the survey questions answered correctly and predictors of correct response. RESULTS The survey was administered to 941 participants of whom 12 declined to participate. Eighty percent (n=740/929) of participants completed the survey. The median number of correct answers was 70% (interquartile range [IQR] 50%-90%) and was similar at each institution (P=.6). A total of 7.3% (n=54) of respondents answered all questions correctly. There was no significant difference in correct responses between attending physicians and trainees or between study centers (median 7, IQR 5-9; P=.75). Gastroenterologists were more likely to answer questions correctly than other subspecialists or primary care physicians (P<.0001). On multivariate analysis, physician knowledge correlated directly with self-reported familiarity with guidelines (0.21; 95% confidence interval [CI], 0.08-0.34; P=.002) and specialty (0.56; 95% CI, 0.30-0.82; P<.001) and inversely with year of medical school graduation (0.22; 95% CI, 0.07-0.37; P=.005). LIMITATIONS Survey study that used theoretical scenarios. CONCLUSION Physician knowledge of guidelines regarding antibiotic use before endoscopy is suboptimal. Further interventions are needed to improve the knowledge of before-procedure guidelines.
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Affiliation(s)
- Joseph David Feuerstein
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Saurabh Sethi
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Elliot B Tapper
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Edward Belkin
- Department of Medicine, University of Massachusetts Memorial Medical Center, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Jeffrey J Lewandowski
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Anand Singla
- Department of Medicine and Division of Gastroenterology, University of Washington, University of Washington School of Medicine, Seattle, Washington, USA
| | - Sunil G Sheth
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Mandeep Sawhney
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Santos-Paul MAD, Neves ILI, Neves RS, Ramires JAF. Local anesthesia with epinephrine is safe and effective for oral surgery in patients with type 2 diabetes mellitus and coronary disease: a prospective randomized study. Clinics (Sao Paulo) 2015; 70:185-9. [PMID: 26017649 PMCID: PMC4449474 DOI: 10.6061/clinics/2015(03)06] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 01/05/2015] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE To investigate the variations in blood glucose levels, hemodynamic effects and patient anxiety scores during tooth extraction in patients with type 2 diabetes mellitus T2DM and coronary disease under local anesthesia with 2% lidocaine with or without epinephrine. STUDY DESIGN This is a prospective randomized study of 70 patients with T2DM with coronary disease who underwent oral surgery. The study was double blind with respect to the glycemia measurements. Blood glucose levels were continuously monitored for 24 hours using the MiniMed Continuous Glucose Monitoring System. Patients were randomized into two groups: 35 patients received 5.4 mL of 2% lidocaine, and 35 patients received 5.4 mL of 2% lidocaine with 1:100,000 epinephrine. Hemodynamic parameters (blood pressure and heart rate) and anxiety levels were also evaluated. RESULTS There was no difference in blood glucose levels between the groups at each time point evaluated. Surprisingly, both groups demonstrated a significant decrease in blood glucose levels over time. The groups showed no significant differences in hemodynamic and anxiety status parameters. CONCLUSION The administration of 5.4 mL of 2% lidocaine with epinephrine neither caused hyperglycemia nor had any significant impact on hemodynamic or anxiety parameters. However, lower blood glucose levels were observed. This is the first report using continuous blood glucose monitoring to show the benefits and lack of side effects of local anesthesia with epinephrine in patients with type 2 diabetes mellitus and coronary disease.
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Affiliation(s)
| | | | - Ricardo Simões Neves
- Heart Institute, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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Infective endocarditis epidemiology and consequences of prophylaxis guidelines modifications: the dialectical evolution. Curr Infect Dis Rep 2014; 16:440. [PMID: 25233804 DOI: 10.1007/s11908-014-0440-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Historically, infective endocarditis (IE) affected patients with predisposing cardiac conditions and community-acquired bacteremia. Over the past 30 years, significant changes have occurred, regarding microorganisms, underlying valvular heart diseases, portals of entry, and patients' comorbidities. Given these epidemiological changes and unproven prophylaxis efficacy, experts in most countries currently limit antibiotic indications to patients with high-risk cardiac conditions having oral procedures and, in the UK, recommend discontinuing their use altogether. To date, no epidemiological impact on streptococcal IE incidence has been observed. Policy must now address these epidemiological modifications, focus on community-acquired and health care-associated staphylococcal bacteremia prevention, and prompt the adoption of broader and nonexclusively antibiotic-based strategies.
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Loyola-Rodriguez JP, Garcia-Cortes JO, Martinez-Martinez RE, Patiño-Marin N, Martinez-Castañon GA, Zavala-Alonso NV, Amano A. Molecular identification and antibiotic resistant bacteria isolated from primary dentition infections. Aust Dent J 2014; 59:497-503. [PMID: 25091293 DOI: 10.1111/adj.12213] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Bacterial resistance to antibiotics is a health problem in many parts of the world. The aim of this study was to identify bacteria from dental infections and determine bacterial resistance to antibiotics used in dental care in the primary dentition. METHODS This cross-sectional study comprised 60 children who presented for dental treatment for active dental infections in the primary dentition. Samples from dental infections were collected and bacteria were identified by polymerase chain reaction (PCR) assay. Bacterial resistance to antibiotics was determined by colony forming units on agar plates containing amoxicillin, clindamycin and amoxillicin-clavulanic acid (A-CA) tested at 8 μg/ml or 16 μg/ml. RESULTS Clindamycin in both concentrations tested (8 μg/ml and 16 μg/ml) showed the highest bacterial resistance (85.9%), followed by amoxicillin (43.7%) and A-CA (12.0%). All comparisons among the three antibiotics used in the study exhibited statistical significance (p = <0.05) in both concentrations tested (8 μg/ml and 16 μg/ml), and under aerobic and anaerobic conditions. The most prevalent resistant species identified by PCR in primary dentition infections were: Streptococcus oralis and Prevotella intermedia (75.0%); Treponema denticola and Porphyromonas gingivalis (48.3%); Streptococcus mutans (45.0%); Campylobacter rectus; and Streptococcus salivarius (40%). CONCLUSIONS This study demonstrated that A-CA exhibited the lowest bacterial resistance for clinical isolates in primary dentition infections.
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Affiliation(s)
- J P Loyola-Rodriguez
- Master's Degree in Dental Science Program with specialization in Advanced Education in General Dentistry, San Luis Potosi University, Mexico
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Abstract
Maternal cardiac disease is a major cause of non-obstetric morbidity and accounts for 10-25% of maternal mortality. Valvular heart disease may result from congenital abnormalities or acquired lesions, some of which may involve more than one valve. Maternal and fetal risks in pregnant patients with valve disease vary according to the type and severity of the valve lesion along with resulting abnormalities of functional capacity, left ventricular function, and pulmonary artery pressure. Certain high-risk conditions are considered contraindications to pregnancy, while others may be successfully managed with observation, medications, and, in refractory cases, surgical intervention. Communication between the patient׳s obstetrician, maternal-fetal medicine specialist, obstetrical anesthesiologist, and cardiologist is critical in managing a pregnancy with underlying maternal cardiac disease. The management of the various types of valve diseases in pregnancy will be reviewed here, along with a discussion of related complications including mechanical prosthetic valves and infective endocarditis.
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Affiliation(s)
- Cara Pessel
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Medical Center, 622 W. 168th St, PH-16, New York, NY 10032..
| | - Clarissa Bonanno
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Medical Center, 622 W. 168th St, PH-16, New York, NY 10032
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Veloso TR, Que YA, Chaouch A, Giddey M, Vouillamoz J, Rousson V, Moreillon P, Entenza JM. Prophylaxis of Experimental Endocarditis With Antiplatelet and Antithrombin Agents: A Role for Long-term Prevention of Infective Endocarditis in Humans? J Infect Dis 2014; 211:72-9. [DOI: 10.1093/infdis/jiu426] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA, O’Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt TM, Thomas JD, Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Creager MA, Curtis LH, DeMets D, Guyton RA, Hochman JS, Kovacs RJ, Ohman EM, Pressler SJ, Sellke FW, Shen WK, Stevenson WG, Yancy CW. 2014 AHA/ACC guideline for the management of patients with valvular heart disease. J Thorac Cardiovasc Surg 2014; 148:e1-e132. [DOI: 10.1016/j.jtcvs.2014.05.014] [Citation(s) in RCA: 631] [Impact Index Per Article: 63.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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50
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Fernández-Esparrach G, Sendino O, Araujo I, Pellisé M, Almela M, González-Suárez B, López-Cerón M, Córdova H, Sanabria E, Uchima H, Llach J, Ginès À. Incidence of bacteremia in cirrhotic patients undergoing upper endoscopic ultrasonography. GASTROENTEROLOGIA Y HEPATOLOGIA 2014; 37:327-33. [DOI: 10.1016/j.gastrohep.2014.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Revised: 02/06/2014] [Accepted: 02/18/2014] [Indexed: 01/16/2023]
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