Dental and cardiac risk factors for infective endocarditis. A population-based, case-control study

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

OBJECTIVE

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

SUBJECTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Candida Infectious Endocarditis and Implantable Cardiac Device Infections

Intravascular diseases due to Candida species, including endocarditis and cardiac device-associated infections, are rare yet devastating manifestations of invasive candidiasis affecting an already vulnerable population. Despite their significant associated morbidity and mortality, limited prospective data exist to inform the optimal diagnostic and therapeutic approaches to these entities. Herein, we review the existing literature pertaining to the epidemiology, diagnosis, and management of infectious endocarditis, rhythm management device infections, and circulatory support device infections caused by Candida species and suggest areas for future research.

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

Background

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

Methods

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

Findings

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

Interpretation

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

Funding

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

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

OBJECTIVES

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

DESIGN

Prospectively registered systematic review and meta-analysis.

DATA SOURCES

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

ELIGIBILITY CRITERIA

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

DATA EXTRACTION AND SYNTHESIS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION NUMBER

CRD42022326664.

Streptococcus anginosus: a stealthy villain in deep odontogenic abscesses

Odontogenic infections (OIs) occasionally spread to deep facial and neck tissues. Our study aimed to explore the role of Streptococcus anginous group (SAG) in these severe OIs. A retrospective study of patients aged ≥ 18 years who required hospital care for acute OI was conducted. We analysed data of OI microbial samples and recorded findings of SAG and other pathogens. These findings were compared with data regarding patients' prehospital status and variables of infection severity. In total, 290 patients were included in the analyses. The most common (49%) bacterial finding was SAG. Other common findings were Streptococcus viridans and Prevotella species, Parvimonas micra, and Fusobacterium nucleatum. Infection severity variables were strongly associated with SAG occurrence. Treatment in an intensive care unit was significantly more common in patients with SAG than in patients without SAG (p < 0.001). In addition, SAG patients expressed higher levels of C-reactive protein (p = 0.001) and white blood cell counts (p < 0.001), and their hospital stays were longer than those of non-SAG patients (p = 0.001). SAG is a typical finding in severe OIs. Clinical features of SAG-related OIs are more challenging than in other OIs. Early detection of SAG, followed by comprehensive infection care with prompt and careful surgical treatment, is necessary due to the aggressive behaviour of this dangerous pathogen.

Antibiotic prophylaxis before dental procedures to prevent infective endocarditis: a systematic review

PURPOSE

Infective endocarditis (IE) is a severe bacterial infection. As a measure of prevention, the administration of antibiotic prophylaxis (AP) prior to dental procedures was recommended in the past. However, between 2007 and 2009, guidelines for IE prophylaxis changed all around the word, limiting or supporting the complete cessation of AP. It remains unclear whether AP is effective or not against IE.

METHODS

We conducted a systematic review whether the administration of AP in adults before any dental procedure, compared to the non-administration of such drugs, has an effect on the risk of developing IE. We searched for studies in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE via OVID, and EMBASE. Two different authors filtered articles independently and data extraction was performed based on a pre-defined protocol.

RESULTS

The only cohort study meeting our criteria included patients at high-risk of IE. Analysis of the extracted data showed a non-significant decrease in the risk of IE when high-risk patients take AP prior to invasive dental procedures (RR 0.39, p-value 0.11). We did not find other studies including patients at low or moderate risk of IE. Qualitative evaluation of the excluded articles reveals diversity of results and suggests that most of the state-of-the-art articles are underpowered.

CONCLUSIONS

Evidence to support or discourage the use of AP prior to dental procedures as a prevention for IE is very low. New high-quality studies are needed, even though such studies would require big settings and might not be immediately feasible.

Mitral Valve Endocarditis in Patient Awaiting TAVI: A Case Report

Background

The current literature focuses on the risk of infective endocarditis (IE) following transcatheter aortic valve implantation (TAVI). However, the risk of IE in patients waiting for TAVI is not well-studied. We present a unique case of a patient waiting for TAVI with decompensated heart failure who was found to have a large mitral vegetation, and consider risk factors for the development of IE in this population.

Case description

We report the case of an 85-year-old male with severe aortic stenosis and recurrent small bowel angiodysplasias, requiring frequent blood transfusions and intravenous iron. He presented to a peripheral hospital in decompensated heart failure. Transfer was arranged to our center to expedite TAVI, under the premise that worsening aortic stenosis precipitated his decompensated state. Prior to TAVI, an echocardiogram was done, and demonstrated a 30 × 18 mm mass on the mitral valve with anterior leaflet perforation and severe mitral regurgitation. The findings were consistent with IE, and the TAVI was cancelled. Despite antibiotic therapy, the patient unfortunately deteriorated and palliative care was provided.

Conclusions

This case highlights the need for further research regarding the risk of IE in patients waiting for TAVI. Current literature focuses on the development and management of IE following TAVI. Clinicians must understand that TAVI candidates have multiple risk factors for IE, including valvular disease, age, and comorbidities. IE should be considered as a possible cause for decompensated heart failure in patients awaiting TAVI.

Quantifying the risk of prosthetic joint infections after invasive dental procedures and the effect of antibiotic prophylaxis

BACKGROUND

Dentists face the expectations of orthopedic surgeons and patients with prosthetic joints to provide antibiotic prophylaxis (AP) before invasive dental procedures (IDPs) to reduce the risk of late periprosthetic joint infections (LPJIs), despite the lack of evidence associating IDPs with LPJIs, lack of evidence of AP efficacy, risk of AP-related adverse reactions, and potential for promoting antibiotic resistance. The authors aimed to identify any association between IDPs and LPJIs and whether AP reduces LPJI incidence after IDPs.

METHOD

The authors performed a case-crossover analysis comparing IDP incidence in the 3 months immediately before LPJI hospital admission (case period) with the preceding 12-month control period for all LPJI hospital admissions with commercial or Medicare supplemental or Medicaid health care coverage and linked dental and prescription benefits data.

RESULTS

Overall, 2,344 LPJI hospital admissions with dental and prescription records (n = 1,160 commercial or Medicare supplemental and n = 1,184 Medicaid) were identified. Patients underwent 4,614 dental procedures in the 15 months before LPJI admission, including 1,821 IDPs (of which 18.3% had AP). Our analysis identified no significant positive association between IDPs and subsequent development of LPJIs and no significant effect of AP in reducing LPJIs.

CONCLUSIONS

The authors identified no significant association between IDPs and LPJIs and no effect of AP cover of IDPs in reducing the risk of LPJIs.

PRACTICAL IMPLICATIONS

In the absence of benefit, the continued use of AP poses an unnecessary risk to patients from adverse drug reactions and to society from the potential of AP to promote development of antibiotic resistance. Dental AP use to prevent LPJIs should, therefore, cease.

Increasing clinical impact and microbiological difficulties in diagnosing coagulase-negative staphylococci in infective endocarditis - a review starting from a series of cases

Coagulase-negative staphylococci (CoNS) are an emergent aetiology of infective endocarditis (IE) on native valves in previously healthy individuals, its presence is associated with prosthetic valves or with other cardiac implants. The identification of CoNS in cultures was customarily seen as contamination, but more recent epidemiological studies have revealed an increasing number of causative and virulent new CoNS species. Starting from two clinical cases of community-acquired CoNS IE on native valves, the review debates the difficulties in identifying CoNS as the causal pathogens, comprising differentiation of contamination from infection in IE, alongside the challenges raised by antibiotic resistance. Even if the risk of CoNS IE is more increased in subjects with prosthetic materials or other foreign devices and immunodeficiencies, native valve infections with these staphylococci are increasing and should be considered important pathogens in IE. Despite the lack of sensitive and specific tools to correctly differentiate contamination from infection in CoNS endocarditis, a comprehensive evaluation with clinical and paraclinical data accurately succeeds in establishing the diagnosis. The genetic profile of CoNS predisposes to antibiotic multi-resistance, making the treatment of IE challenging; the rapid identification of antibiotic susceptibility is essential to prescribe the appropriate therapy and improve outcomes.

Clinical characteristics of children and guardians possessing CBP-positive Streptococcus mutans strains: a cross-sectional study

Streptococcus mutans is a major etiological agent for dental caries. We previously demonstrated that S. mutans strains expressing collagen-binding proteins (CBPs) were related to the pathogenesis of systemic diseases. However, their acquisition and colonization remain unknown. Here, we investigated the detection rates of CBP-positive S. mutans strains in children and their guardians to clarify the background for the acquisition and colonization in children. Saliva samples were collected from children and their mothers, and detection of S. mutans and collagen-binding genes (cnm, cbm) was performed by PCR after DNA extraction. The oral status of each child was examined, and their mothers were asked to complete a questionnaire. The isolation rate of Cnm-positive S. mutans was significantly higher in mothers than in children. Notably, the possession rates of CBP-positive strains in children were significantly higher in children whose mothers had CBP-positive strains than in children whose mothers did not have these strains. Furthermore, children with CBP-positive strains had a significantly shorter breastfeeding period than children without these strains. The present results suggest that nutritional feeding habits in infancy are one of the factors involved in the acquisition and colonization of CBP-positive S. mutans strains.

Antibiotic Prophylaxis Against Infective Endocarditis Before Invasive Dental Procedures

BACKGROUND

Antibiotic prophylaxis (AP) before invasive dental procedures (IDPs) is recommended to prevent infective endocarditis (IE) in those at high IE risk, but there are sparse data supporting a link between IDPs and IE or AP efficacy in IE prevention.

OBJECTIVES

The purpose of this study was to investigate any association between IDPs and IE, and the effectiveness of AP in reducing this.

METHODS

We performed a case-crossover analysis and cohort study of the association between IDPs and IE, and AP efficacy, in 7,951,972 U.S. subjects with employer-provided Commercial/Medicare-Supplemental coverage.

RESULTS

Time course studies showed that IE was most likely to occur within 4 weeks of an IDP. For those at high IE risk, case-crossover analysis demonstrated a significant temporal association between IE and IDPs in the preceding 4 weeks (OR: 2.00; 95% CI: 1.59-2.52; P = 0.002). This relationship was strongest for dental extractions (OR: 11.08; 95% CI: 7.34-16.74; P < 0.0001) and oral-surgical procedures (OR: 50.77; 95% CI: 20.79-123.98; P < 0.0001). AP was associated with a significant reduction in IE incidence following IDP (OR: 0.49; 95% CI: 0.29-0.85; P = 0.01). The cohort study confirmed the associations between IE and extractions or oral surgical procedures in those at high IE risk and the effect of AP in reducing these associations (extractions: OR: 0.13; 95% CI: 0.03-0.34; P < 0.0001; oral surgical procedures: OR: 0.09; 95% CI: 0.01-0.35; P = 0.002).

CONCLUSIONS

We demonstrated a significant temporal association between IDPs (particularly extractions and oral-surgical procedures) and subsequent IE in high-IE-risk individuals, and a significant association between AP use and reduced IE incidence following these procedures. These data support the American Heart Association, and other, recommendations that those at high IE risk should receive AP before IDP.

Antibiotic Prophylaxis for Prosthetic Joint Patients Undergoing Invasive Dental Procedures: Time for a Rethink?

BACKGROUND

In the United States, it has been common practice to recommend that dentists provide antibiotic prophylaxis (AP) before invasive dental procedures (IDPs) to prevent late periprosthetic joint infections (LPJIs) in patients who have prosthetic arthroplasties despite lack of evidence for a causal relationship between IDP and LPJI and a lack of evidence for AP efficacy.

METHODS

A recent study quantified the IDP incidence over the 15-month period prior to LPJI hospital admissions in the United Kingdom for which dental records were available. A case-crossover analysis compared IDP incidence in the 3 months before LPJI admission with the preceding 12 months. The English population was used because guidelines do not recommend AP and any relationship between IDPs and LPJI should be fully exposed.

RESULTS

No significant positive association was identified between IDPs and LPJI. Indeed, the incidence of IDPs was lower in the 3 months before LPJI hospital admission than that in the preceding 12 months.

CONCLUSION

In the absence of a significant positive association between IDPs and LPJI, there is no rationale to administer AP before IDPs in patients with prosthetic joints, particularly given the cost and inconvenience of AP, the risk of adverse drug reactions, and the potential for unnecessary AP use that promotes antibiotic resistance. These results should reassure orthopedic surgeons and their patients that dental care of patients who have prosthetic joints should focus on maintaining good oral hygiene rather than on recommending AP for IDPs. Moreover, it should also reassure those in other countries where AP is not recommended that such guidance is sufficient.

Infective endocarditis following invasive dental procedures: IDEA case-crossover study

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.

Antibiotic prophylaxis for preventing bacterial endocarditis following dental procedures

BACKGROUND

Infective endocarditis is a severe infection arising in the lining of the chambers of the heart. It can be caused by fungi, but most often is caused by bacteria. Many dental procedures cause bacteraemia, which could lead to bacterial endocarditis in a small proportion of people. The incidence of bacterial endocarditis is low, but it has a high mortality rate.  Guidelines in many countries have recommended that antibiotics be administered to people at high risk of endocarditis prior to invasive dental procedures. However, guidance by the National Institute for Health and Care Excellence (NICE) in England and Wales states that antibiotic prophylaxis against infective endocarditis is not recommended routinely for people undergoing dental procedures. This is an update of a review that we first conducted in 2004 and last updated in 2013.

OBJECTIVES

Primary objective To determine whether prophylactic antibiotic administration, compared to no antibiotic administration or placebo, before invasive dental procedures in people at risk or at high risk of bacterial endocarditis, influences mortality, serious illness or the incidence of endocarditis. Secondary objectives To determine whether the effect of dental antibiotic prophylaxis differs in people with different cardiac conditions predisposing them to increased risk of endocarditis, and in people undergoing different high risk dental procedures. Harms Had we foundno evidence from randomised controlled trials or cohort studies on whether prophylactic antibiotics affected mortality or serious illness, and we had found evidence from these or case-control studies suggesting that prophylaxis with antibiotics reduced the incidence of endocarditis, then we would also have assessed whether the harms of prophylaxis with single antibiotic doses, such as with penicillin (amoxicillin 2 g or 3 g) before invasive dental procedures, compared with no antibiotic or placebo, equalled the benefits in prevention of endocarditis in people at high risk of this disease.

SEARCH METHODS

An information specialist searched four bibliographic databases up to 10 May 2021 and used additional search methods to identify published, unpublished and ongoing studies SELECTION CRITERIA: Due to the low incidence of bacterial endocarditis, we anticipated that few if any trials would be located. For this reason, we included cohort and case-control studies with suitably matched control or comparison groups. The intervention was antibiotic prophylaxis, compared to no antibiotic prophylaxis or placebo, before a dental procedure in people with an increased risk of bacterial endocarditis. Cohort studies would need to follow at-risk individuals and assess outcomes following any invasive dental procedures, grouping participants according to whether or not they had received prophylaxis. Case-control studies would need to match people who had developed endocarditis after undergoing an invasive dental procedure (and who were known to be at increased risk before undergoing the procedure) with those at similar risk who had not developed endocarditis.  Our outcomes of interest were mortality or serious adverse events requiring hospital admission; development of endocarditis following any dental procedure in a defined time period; development of endocarditis due to other non-dental causes; any recorded adverse effects of the antibiotics; and the cost of antibiotic provision compared to that of caring for patients who developed endocarditis.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened search records, selected studies for inclusion, assessed the risk of bias in the included study and extracted data from the included study. As an author team, we judged the certainty of the evidence identified for the main comparison and key outcomes using GRADE criteria. We presented the main results in a summary of findings table.

MAIN RESULTS

Our new search did not find any new studies for inclusion since the last version of the review in 2013. No randomised controlled trials (RCTs), controlled clinical trials (CCTs) or cohort studies were included in the previous versions of the review, but one case-control study met the inclusion criteria. The trial authors collected information on 48 people who had contracted bacterial endocarditis over a specific two-year period and had undergone a medical or dental procedure with an indication for prophylaxis within the past 180 days. These people were matched to a similar group of people who had not contracted bacterial endocarditis. All study participants had undergone an invasive medical or dental procedure. The two groups were compared to establish whether those who had received preventive antibiotics (penicillin) were less likely to have developed endocarditis. The authors found no significant effect of penicillin prophylaxis on the incidence of endocarditis. No data on other outcomes were reported. The level of certainty we have about the evidence is very low.

AUTHORS' CONCLUSIONS

There remains no clear evidence about whether antibiotic prophylaxis is effective or ineffective against bacterial endocarditis in at-risk people who are about to undergo an invasive dental procedure. We cannot determine whether the potential harms and costs of antibiotic administration outweigh any beneficial effect. Ethically, practitioners should discuss the potential benefits and harms of antibiotic prophylaxis with their patients before a decision is made about administration.

Analysis of Prosthetic Joint Infections Following Invasive Dental Procedures in England

Importance

Dentists in the United States are under pressure from orthopedic surgeons and their patients with prosthetic joints to provide antibiotic prophylaxis before invasive dental procedures (IDP) to reduce the risk of late prosthetic joint infection (LPJI). This has been a common practice for decades, despite a lack of evidence for an association between IDP and LPJI, a lack of evidence of antibiotic prophylaxis efficacy, cost of providing antibiotic prophylaxis, and risk of both adverse drug reactions and the potential for promoting antibiotic resistance.

Objective

To quantify any temporal association between IDP and subsequent LPJI.

Design, Setting, and Participants

This cohort study used a case-crossover and time trend design to examine any potential association between IDP and LPJI. The population of England (55 million) was chosen because antibiotic prophylaxis has never been recommended to prevent LPJI in England, and any association between IDP and LPJI would therefore be fully exposed. All patients admitted to hospitals in England for LPJI from December 25, 2011, through March 31, 2017, and for whom dental records were available were included. Analyses were performed between May 2018 and June 2021.

Exposures

Exposure to IDP.

Main Outcomes and Measures

The main outcome was the incidence of IDP in the 3 months before LPJI hospital admission (case period) compared with the incidence in the 12 months before that (control period).

Results

A total of 9427 LPJI hospital admissions with dental records (mean [SD] patient age, 67.8 [13.1] years) were identified, including 4897 (52.0%) men and 4529 (48.0%) women. Of these, 2385 (25.3%) had hip prosthetic joints, 3168 (33.6%) had knee prosthetic joints, 259 (2.8%) had other prosthetic joints, and 3615 (38.4%) had unknown prosthetic joint types. There was no significant temporal association between IDP and subsequent LPJI. Indeed, there was a lower incidence of IDP in the 3 months prior to LPJI (incidence rate ratio, 0.89; 95% CI, 0.82-0.96; P = .002).

Conclusions and Relevance

These findings suggest that there is no rationale to administer antibiotic prophylaxis before IDP in patients with prosthetic joints.

Clinical and echocardiographic characteristics associated with the development of infective endocarditis in patients with significant mitral stenosis

BACKGROUND

Infective endocarditis (IE) confers significant mortality and morbidity in patients with underlying mitral stenosis (MS), with both diseased native valves and after valvular procedures.

PURPOSE

We examined the clinical and echocardiographic parameters in association with the development of IE on patients with significant MS.

METHODS

A total of 478 consecutive patients with index echocardiographic diagnosis of significant mitral stenosis (mitral valve area <1.5 cm² ) were included. Patients were grouped into those with or without IE on at least 5 years of follow-up. Baseline clinical, echocardiographic profile and clinical outcomes were compared.

RESULTS

IE was observed in 4.4% (n = 21) of the cohort. These patients were younger (45.3 ± 14.6 vs. 53.2 ± 15.5 years, p = 0.022) at the time of MS diagnosis. NT-proBNP was higher in patients who developed IE (13529 ± 12230 vs. 4381 ± 5875 pg/ml, p < 0.001), with larger left atrial diameter (54.4 ± 10.1 vs. 49.9 ± 9.5 mm, p = 0.040) and elevated pulmonary artery systolic pressure (PASP, 62.3 ± 17.2 vs. 47.2 ± 16.5 mmHg, p = 0.026). There was no significant difference in terms of MS severity, other concomitant valvulopathies, or etiology (rheumatic or degenerative) of MS. Patients who smoked had higher incidence of IE (33.3% vs. 14.2%, log-rank 7.27, p = 0.007). After adjusting for age, valve procedure and PASP, patients who smoked remained at elevated risk of IE (adjusted hazards ratio 2.99, 95% confidence interval 1.18-7.56, p = 0.021).

CONCLUSION

IE occurs in a proportion of patients with MS. Smoking, younger age of diagnosis of MS as well as dilated left atria with elevated PASP may be associated with an elevated risk of this complication.

The role of antiaggregant agents and anticoagulants in the prevention of aortic valve endocarditis: A double-cohort retrospective study

Objective

Antiaggregants (Ag) could prevent infective endocarditis (IE) in preclinical studies. In this study we investigated whether Ag or anticoagulants (Ac) were also protective in humans.

Methods

In part I we determined the incidence of IE of bioprosthetic aortic valves (PVE) in 333 consecutive patients who underwent aortic valve replacement for noninfective aortic insufficiency between 2009 and 2019. In part II we retrospectively analyzed data of 137 patients who had developed IE of the native aortic valve (NVE) between 2007 and 2015. Multivariable Fine–Gray and logistic regression models were used to investigate associations between Ag and Ac therapy and IE.

Results

Sixteen of 333 (4.8%) aortic valve replacement recipients developed PVE after a median of 3.72 years. There was no association between Ag and PVE, whereas Ac was associated with a higher IE occurrence (no association for vitamin K antagonists but significant for fondaparinux or low molecular-weight heparins; hazard ratio, 4.61; 95% CI, 1.01-21.9). In contrast, among the 137 patients in part II, vitamin K antagonists (odds ratio [OR], 7.52; 95% CI, 2.51-22.6), double antiplatelet therapy (OR, 44.3; 95% CI, 4.83-407), novel oral Ac (OR, 4.17; 95% CI, 1.15-15.1), and fondaparinux or low molecular-weight heparins (OR, 9.87; 95% CI, 1.81-53.9), but not acetylsalicylic acid, were associated with NVE.

Conclusions

Ac were associated with IE in both cohorts, whereas Ag were not associated with PVE. This might reflect differences in the studied populations, with Ag and Ac being prescribed for conditions associated with long-term IE risk in the NVE cohort. Therefore, determining the potential protective effect of Ag and Ac will necessitate further well–controlled studies.

Health status in patients hospitalised for severe odontogenic infections

OBJECTIVE

Previous findings refer to certain predisposing medical conditions that compound the risk of developing severe and potentially lethal acute odontogenic infections (OI). The objective of this study was to clarify this rationale and infection severity in general.

MATERIAL AND METHODS

Records of patients aged ≥18 years requiring hospital care for deep OI were retrospectively investigated. The main outcome variable was need for intensive care unit (ICU) treatment. Additional outcome variable was occurrence of infection complications and/or distant infections. Several parameters describing patients' prior health and recent dental treatment were set as independent variables.

RESULTS

Of the 303 acute OI patients included, 71 patients (23%) required treatment in the ICU, with no significant difference between previously healthy and patients with disease history. OIs originating from teeth in the mandible compared with maxilla had 7.8-fold risk (p = .007) for ICU treatment in binary logistic regression analyses. Elevated levels of infection parameters at hospital admission predicted further ICU stay. Infection complications and/or distant infections occurred in 7.6% of patients, of which septicaemia and pneumonia were the most common. The mortality rate was 0.3%. Infection complications and/or distant infections occurred significantly more often in smokers (p = .001) and in patients with excessive consumption of alcohol or drugs (p = .025), however smoking showed 3.5-folded independent risk for infection complications and/or distant infections (p = .008) in logistic regression.

CONCLUSIONS

Severe OIs often occur in previously healthy patients. Smokers in particular are prone to the most serious OIs.

Involvement of Tunisian General Practitioners in the Management of Patients at Risk of Infective Endocarditis: A Cross-Sectional Study

Objectives

This work aimed to estimate the knowledge and practice of general dentists in the governorate of Manouba regarding the management of patients at risk of infective endocarditis.

Materials and Methods

A survey involving private sector general dentists in the governorate of Manouba was performed. It contained 21 questions, and it was addressed to 111 dentists. Only 82 dentists responded. To carry out the descriptive study, we used the SPSS software version 21.0.

Results

Our results proved the lack of knowledge among dentists in the governorate of Manouba with regard to the management of patients at risk of infective endocarditis. An overestimation of the risk and an overprescription of antibiotic were found in order to ensure an over-protection for the patients as well as the dentist. In fact, 85.4% of these dentists prescribed antibiotic prophylaxis for the two groups of patients (high risk and moderate risk). Only 9.8% followed the right modality of antibiotic prophylaxis prescription; 4.9% of the dentists prescribed antibiotic only 1 hour before the act and 4.9% of them prescribed antibiotic 1 hour before the act and continued the treatment in case of the presence of an infectious site.

Conclusion

A discrepancy towards an over-estimation of risk and overprescription of antibiotic was found between the recommendations and real practice. Similar studies in the other governorates of Tunisia are recommended in order to better understand the problem.

2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

This executive summary of the valvular heart disease guideline provides recommendations for clinicians to diagnose and manage valvular heart disease as well as supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from January 1, 2010, to March 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, Cochrane, Agency for Healthcare Research and Quality Reports, and other selected database relevant to this guideline. Structure: Many recommendations from the earlier valvular heart disease guidelines have been updated with new evidence and provides newer options for diagnosis and treatment of valvular heart disease. This summary includes only the recommendations from the full guideline which focus on diagnostic work-up, the timing and choice of surgical and catheter interventions, and recommendations for medical therapy. The reader is referred to the full guideline for graphical flow charts, text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in developing these guidelines.

Cranberry extract-based formulations for preventing bacterial biofilms

Generating formulations for the delivery of a mixture of natural compounds extracted from natural sources is a challenge because of unknown active and inactive ingredients and possible interactions between them. As one example, natural cranberry extracts have been proposed for the prevention of biofilm formation on dental pellicle or teeth. However, such extracts may contain phenolic acids, flavonol glycosides along with other constituents like coumaroyl iridoid glycosides, flavonoids, alpha-linolenic acid, n-6 (or n-3) fatty acids, and crude fiber. Due to the presence of a variety of compounds, determining which molecules (and how many molecules) are essential for preventing biofilm growth is nontrivial to ascertain. Therefore, a formulation that could contain natural, unrefined, cranberry extract (with all its constituent compounds) at high loading would be ideal. Accordingly, we have generated several candidate formulations including poly(lactic-co-glycolic) acid (PLGA)-based microencapsulation of cranberry extract (CE15) as well as formulations including stearic acid along with polyvinylpyrrolidone (PVP) or Ethyl lauroyl arginate (LAE) complexed with cranberry extracts (CE15). We found that stearic acid in combination with PVP or LAE as excipients led to higher loading of the active and inactive compounds in CE15 as compared with a PLGA microencapsulation and also sustained release of CE15 in a tunable manner. Using this method, we have been able to generate two successful formulations (one preventative based, one treatment based) that effectively inhibit biofilm growth when incubated with saliva. In addition to cranberry extract, this technique could also be a promising candidate for other natural extracts to form controlled release systems.Graphical abstract.

Relationship of periodontitis and edentulism to angiographically diagnosed coronary artery disease: A cross-sectional study

OBJECTIVE

The objective of the study is to examine the connection between oral status and the extent of coronary artery disease (CAD), which is diagnosed by angiography.

BACKGROUND

Periodontitis and tooth loss have been linked to atherosclerosis and CAD in previous studies. However, no distinct connection was revealed due to the diversity of the results and the variety of diagnostic methods. To provide a more consistent data pool and stronger evidence, there is a need for studies with standard measurements and diagnostic criteria.

METHODS

309 patients, who consulted to Ankara University, Faculty of Medicine, Department of Cardiology and had coronary angiography, were enrolled to this study. Individuals were grouped based on their coronary angiography results, as CAD (+) (n = 233) and CAD (-) (n = 76). Studied parameters included cardiovascular risk factors, plaque index (PI), remaining teeth count, bleeding on probing (BOP), and probing pocket depth (PPD). Periapical radiographs were taken from teeth with ≥4 mm PPD. Oral status was categorized as periodontally healthy subjects/patients with gingivitis (Group 1), patients with periodontitis (Group 2), and edentulous subjects (Group 3).

RESULTS

PI (P < 0.001), PPD (P = 0.001), BOP (P = 0.004), the number of patients with less than 10 teeth (P = 0.014), and edentulism (P = 0.009) were significantly higher in CAD (+) patients, who were mostly older (P < 0.001) and male (P < 0.001). Multivariate logistic regression analysis revealed that Group 2 (odds ratio = 2.48, 95% confidence interval = 1.24-4.95, P = 0.010) and Group 3 (odds ratio = 2.01, 95% confidence interval = 1.14-5.17, P = 0.040) were highly associated with CAD. Two and three stenosed vessels were significantly higher in Groups 2 and 3 compared to Group 1 (P = 0.003).

CONCLUSIONS

It was found that both edentulism and periodontitis were related to CAD.

Invasive Procedures Associated With the Development of Infective Endocarditis

BACKGROUND

Various invasive medical procedures might induce bacteremia and, hence, act as triggers for infective endocarditis. However, empirical data in humans on the potential dangers of invasive medical procedures in this regard are very sparse. Due to lack of sufficient data, it is currently debated whether the risk for endocarditis with medical procedures is substantial or rather negligible.

OBJECTIVES

The purpose of this nationwide case-crossover study was to quantify the excess risk for infective endocarditis in association with invasive medical and surgical procedures.

METHODS

The authors identified all adult patients treated for endocarditis in hospitals in Sweden between January 1, 1998, and December 31, 2011. The authors applied a case-crossover design and compared the occurrence of invasive medical procedures 12 weeks before endocarditis with a corresponding 12-week time period exactly 1 year earlier. The authors considered all invasive nondental medical procedures except for those that are likely to be undertaken due to endocarditis or sepsis or due to infections that could possibly lead to endocarditis.

RESULTS

The authors identified 7,013 cases of infective endocarditis during the study period. Among others, several cardiovascular procedures, especially coronary artery bypass grafting; procedures of the skin and management of wounds; transfusion; dialysis; bone marrow puncture; and some endoscopies, particularly bronchoscopy, were strongly associated with an increased risk for infective endocarditis.

CONCLUSIONS

This study suggests that several invasive nondental medical procedures are associated with a markedly increased risk for infective endocarditis.

Genomic, Phenotypic, and Virulence Analysis of Streptococcus sanguinis Oral and Infective-Endocarditis Isolates

Streptococcus sanguinis, an abundant and benign inhabitant of the oral cavity, is an important etiologic agent of infective endocarditis (IE), particularly in people with predisposing cardiac valvular damage. Although commonly isolated from patients with IE, little is known about the factors that make any particular S. sanguinis isolate more virulent than another or, indeed, whether significant differences in virulence exist among isolates. In this study, we compared the genomes of a collection of S. sanguinis strains comprised of both oral isolates and bloodstream isolates from patients diagnosed with IE. Oral and IE isolates could not be distinguished by phylogenetic analyses, and we did not succeed in identifying virulence genes unique to the IE strains. We then investigated the virulence of these strains in a rabbit model of IE using a variation of the Bar-seq (barcode sequencing) method wherein we pooled the strains and used Illumina sequencing to count unique barcodes that had been inserted into each isolate at a conserved intergenic region. After we determined that several of the genome sequences were misidentified in GenBank, our virulence results were used to inform our bioinformatic analyses, identifying genes that may explain the heterogeneity in virulence. We further characterized these strains by assaying for phenotypes potentially contributing to virulence. Neither strain competition via bacteriocin production nor biofilm formation showed any apparent relationship with virulence. Increased cell-associated manganese was, however, correlated with blood isolates. These results, combined with additional phenotypic assays, suggest that S. sanguinis virulence is highly variable and results from multiple genetic factors.

Infectious Endocarditis Prophylaxis in Children

Infectious endocarditis (IE) is a rare illness with high morbidity and mortality. Incidence of IE is on the rise in industrialized countries, particularly as those with congenital heart defects are living longer and the use of indwelling central catheters increases. With the 2007 American Heart Association guidelines, there has been a shift in recommending antibiotic prophylaxis only to high-risk patient populations. This clinical review will highlight the changing epidemiology and etiology of IE, followed by an emphasis on the appropriate indications for antibiotic prophylaxis in high-risk populations undergoing specific procedures.

Increased incidence of infective endocarditis in patients with ventricular septal defect

BACKGROUND

Ventricular septal defect (VSD) is one of the most common congenital heart anomalies in childhood and there is an increasing prevalence of VSDs in the adult population. The long-term risk of infective endocarditis (IE) is of concern. The aim of this study was to clarify and compare the incidence of IE in adults with repaired and unrepaired VSDs.

METHODS

Patients with VSDs were identified using the Adult Congenital Heart Disease registry at the National Heart Centre Singapore. Patients were divided into Group 1 (repaired VSD) and Group 2 (unrepaired VSDs). The electronic medical records were searched for hospitalization due to IE during a 10-year period (October 2, 2007-October 1, 2017).

RESULTS

Four hundred seventy-nine patients (53% male) were identified, with a mean age of 35.0 ± 13.7 years. There were 164 patients (34.2%) in Group 1 and 315 patients (65.8%) in Group 2. In total, there were eight episodes of IE from six patients (3 male, mean age of 42.2 ± 20.7 years). Two patients had recurrent IE. The overall incidence of IE was 1.67/1000 y, and this is 11-15-fold higher compared to general adult population. The incidence of IE in Group 2 was 1.90/1000 y. There were no IE cases in Group 1.

CONCLUSION

Patients with VSDs, especially if unrepaired, carry a substantially increased risk of IE compared to the general population.

Infective Endocarditis in Patients With Bicuspid Aortic Valve or Mitral Valve Prolapse

BACKGROUND

There is little information concerning infective endocarditis (IE) in patients with bicuspid aortic valve (BAV) or mitral valve prolapse (MVP). Currently, IE antibiotic prophylaxis (IEAP) is not recommended for these conditions.

OBJECTIVES

This study sought to describe the clinical and microbiological features of IE in patients with BAV and MVP and compare them with those of IE patients with and without IEAP indication, to determine the potential benefit of IEAP in these conditions.

METHODS

This analysis involved 3,208 consecutive IE patients prospectively included in the GAMES (Grupo de Apoyo al Manejo de la Endocarditis infecciosa en España) registry at 31 Spanish hospitals. Patients were classified as high-risk IE with IEAP indication (high-risk group; n = 1,226), low- and moderate-risk IE without IEAP indication (low/moderate-risk group; n = 1,839), and IE with BAV (n = 54) or MVP (n = 89).

RESULTS

BAV and MVP patients had a higher incidence of viridans group streptococci IE than did high-risk group and low/moderate-risk group patients (35.2% and 39.3% vs. 12.1% and 15.0%, respectively; all p < 0.01). A similar pattern was seen for IE from suspected odontologic origin (14.8% and 18.0% vs. 5.8% and 6.0%; all p < 0.01). BAV and MVP patients had more intracardiac complications than did low/moderate-risk group (50% and 47.2% vs. 30.6%, both p < 0.01) patients and were similar to high-risk group patients.

CONCLUSIONS

IE in patients with BAV and MVP have higher rates of viridans group streptococci IE and IE from suspected odontologic origin than in other IE patients, with a clinical profile similar to that of high-risk IE patients. Our findings suggest that BAV and MVP should be classified as high-risk IE conditions and the case for IEAP should be reconsidered.

Streptococcus sanguinis biofilm formation & interaction with oral pathogens

Caries and periodontitis are the two most common human dental diseases and are caused by dysbiosis of oral flora. Although commensal microorganisms have been demonstrated to protect against pathogens and promote oral health, most previous studies have addressed pathogenesis rather than commensalism. Streptococcus sanguinis is a commensal bacterium that is abundant in the oral biofilm and whose presence is correlated with health. Here, we focus on the mechanism of biofilm formation in S. sanguinis and the interaction of S. sanguinis with caries- and periodontitis-associated pathogens. In addition, since S. sanguinis is well known as a cause of infective endocarditis, we discuss the relationship between S. sanguinis biofilm formation and its pathogenicity in endocarditis.

Is antibiotic prophylaxis to prevent infective endocarditis worthwhile?

Infective endocarditis (IE) is a rare condition which is associated with considerable morbidity and mortality. Almost 100 years ago, the links between endocarditis and procedures, particularly dental procedures, were postulated. Over 50 years ago the first guidelines recommending antibiotic prophylaxis (AP), with the aim of preventing IE developing after procedures, were proposed. However, there has only ever been circumstantial evidence in humans that AP prevents IE. The rarity of IE has made a randomised controlled clinical trial impractical to date. This article outlines the history of AP and reviews the evidence base for the use of AP to prevent IE.

Dental procedures, antibiotic prophylaxis, and endocarditis among people with prosthetic heart valves: nationwide population based cohort and a case crossover study

Objective To assess the relation between invasive dental procedures and infective endocarditis associated with oral streptococci among people with prosthetic heart valves.Design Nationwide population based cohort and a case crossover study.Setting French national health insurance administrative data linked with the national hospital discharge database.Participants All adults aged more than 18 years, living in France, with medical procedure codes for positioning or replacement of prosthetic heart valves between July 2008 and July 2014.Main outcome measures Oral streptococcal infective endocarditis was identified using primary discharge diagnosis codes. In the cohort study, Poisson regression models were performed to estimate the rate of oral streptococcal infective endocarditis during the three month period after invasive dental procedures compared with non-exposure periods. In the case crossover study, conditional logistic regression models calculated the odds ratio and 95% confidence intervals comparing exposure to invasive dental procedures during the three month period preceding oral streptococcal infective endocarditis (case period) with three earlier control periods.Results The cohort included 138 876 adults with prosthetic heart valves (285 034 person years); 69 303 (49.9%) underwent at least one dental procedure. Among the 396 615 dental procedures performed, 103 463 (26.0%) were invasive and therefore presented an indication for antibiotic prophylaxis, which was performed in 52 280 (50.1%). With a median follow-up of 1.7 years, 267 people developed infective endocarditis associated with oral streptococci (incidence rate 93.7 per 100 000 person years, 95% confidence interval 82.4 to 104.9). Compared with non-exposure periods, no statistically significant increased rate of oral streptococcal infective endocarditis was observed during the three months after an invasive dental procedure (relative rate 1.25, 95% confidence interval 0.82 to 1.82; P=0.26) and after an invasive dental procedure without antibiotic prophylaxis (1.57, 0.90 to 2.53; P=0.08). In the case crossover analysis, exposure to invasive dental procedures was more frequent during case periods than during matched control periods (5.1% v 3.2%; odds ratio 1.66, 95% confidence interval 1.05 to 2.63; P=0.03).Conclusion Invasive dental procedures may contribute to the development of infective endocarditis in adults with prosthetic heart valves.

Current Concepts of Prophylactic Antibiotics for Dental Patients

Despite numerous guidelines, joint interprofessional collaboration, and years of data collection, the use of antibiotic prophylaxis before dental procedures remains controversial. There continues to be disagreement on indications, justification, and outcome of the use of various antibiotic prophylaxis regiments. This is complicated by the lack of data demonstrating any positive or negative impact on the care of patients. The dental community has distanced itself from a leadership role in this conversation, based on multiple concerns including fear of litigation, lack of clear pathophysiology, and unclear cause-effect relationship.

Challenges in Infective Endocarditis

Infective endocarditis is defined by a focus of infection within the heart and is a feared disease across the field of cardiology. It is frequently acquired in the health care setting, and more than one-half of cases now occur in patients without known heart disease. Despite optimal care, mortality approaches 30% at 1 year. The challenges posed by infective endocarditis are significant. It is heterogeneous in etiology, clinical manifestations, and course. Staphylococcus aureus, which has become the predominant causative organism in the developed world, leads to an aggressive form of the disease, often in vulnerable or elderly patient populations. There is a lack of research infrastructure and funding, with few randomized controlled trials to guide practice. Longstanding controversies such as the timing of surgery or the role of antibiotic prophylaxis have not been resolved. The present article reviews the challenges posed by infective endocarditis and outlines current and future strategies to limit its impact.

Impact of AHA's 2007 guideline change on incidence of infective endocarditis in infants and children

Use a nationally representative sample to assess impacts of new clinical guidelines issued by the American Heart Association (AHA) in 2007 for many types of invasive procedures, with recommendations for significant decreases in antimicrobial prophylaxis use.

STUDY DESIGN

Interrupted time series analyses of pediatric hospitalizations for Infective Endocarditis (IE), using the Nationwide Inpatient Sample (NIS) ICD-9-CM diagnostic codes, identified IE hospitalizations for patients <18 years old from 2001 to 2012. Changes in IE incidence before and after 2007 AHA guidelines were evaluated, with differences in IE clinical severity assessed using in-hospital mortality and length of stay. Analyses were stratified by pathogen type and age group (0-9 y/o and 10-17 y/o).

RESULTS

With 3,748 patients in the study, we observed rising trends in IE incidence, but no significant difference between pre- and post-guideline. There was a significant trend increase for IE due to viridans group streptococci (VGS) for ages >10 years old, comparing pre-guideline to post-guideline periods, but not in children 0-9 years of age. Neither in-hospital mortality nor length of stay changed significantly during study.

CONCLUSIONS

The data did not demonstrate an impact of the 2007 guideline changes on overall incidence of pediatric IE. However, a significant increase in disease incidence trend due to VGS was observed for the 10-17 year-old group, compared pre- and post-guideline.

Assessment of periodontitis and its role in viridans streptococcal bacteremia and infective endocarditis

OBJECTIVES

To evaluate the role of periodontitis in viridans group streptococci (VGS) bacteremia and infective endocarditis (IE).

METHODS

A total of 200 subjects including two groups. Group A- 34 subjects undergoing tooth extraction with periodontitis, 46 subjects undergoing tooth extraction without periodontitis and 40 healthy controls. Group B: 40 confirmed cases of IE (17 with and 23 without periodontitis) and 40 healthy controls. Subgingival plaque and blood samples were obtained and processed by standard procedures.

RESULTS

A total of 53 blood samples (66.25%) yielded positive cultures after tooth extraction. The relationship between the presence of periodontitis and a positive blood culture was significantly higher (p=0.05) for tooth extraction cases with periodontitis (79.40%) than tooth extraction cases without periodontitis (56.50%). Periodontitis was observed in 42.5% of IE cases. Out of the 40 patients of IE, the blood samples yielded 40 different isolates, majority were viridans streptococci 15 (37.5%) and staphylococci nine (22.5%). No statistically significant difference was observed between the subgingival plaque and blood isolates of periodontitis in both the groups, indicating similarity of biotypes of viridans streptococci isolated from the blood and the subgingival plaque. Similarity was also observed between the antibiogram profiles of viridans streptococci from both the groups.

CONCLUSIONS

Periodontitis enhances viridans streptococcal bacteremia and may be a potential risk factor for IE.

Oral Streptococcal Endocarditis, Oral Hygiene Habits, and Recent Dental Procedures: A Case-Control Study

BACKGROUND.

We aimed to compare oral hygiene habits, orodental status, and dental procedures in patients with infective endocarditis (IE) according to whether the IE-causing microorganism originated in the oral cavity.

METHODS.

We conducted an assessor-blinded case-control study in 6 French tertiary-care hospitals. Oral hygiene habits were recorded using a self-administered questionnaire. Orodental status was analyzed by trained dental practitioners blinded to the microorganism, using standardized clinical examination and dental panoramic tomography. History of dental procedures was obtained through patient and dentist interviews. Microorganisms were categorized as oral streptococci or nonoral pathogens using an expert-validated list kept confidential during the course of the study. Cases and controls had definite IE caused either by oral streptococci or nonoral pathogens, respectively. Participants were enrolled between May 2008 and January 2013.

RESULTS.

Cases (n = 73) were more likely than controls (n = 192) to be aged <65 years (odds ratio [OR], 2.85; 95% CI, 1.41-5.76), to be female (OR, 2.62; 95% CI, 1.20-5.74), to have native valve disease (OR, 2.44; 95% CI, 1.16-5.13), to use toothpicks, dental water jet, interdental brush, and/or dental floss (OR, 3.48; 95% CI, 1.30-9.32), and to have had dental procedures during the prior 3 months (OR, 3.31; 95% CI, 1.18-9.29), whereas they were less likely to brush teeth after meals. The presence of gingival inflammation, calculus, and infectious dental diseases did not significantly differ between groups.

CONCLUSIONS.

Patients with IE caused by oral streptococci differ from patients with IE caused by nonoral pathogens regarding background characteristics, oral hygiene habits, and recent dental procedures, but not current orodental status.

Orthodontic Treatment and Long-Term Management of a Patient with Marfan Syndrome

Marfan syndrome (MFS) is caused by abnormal systemic connective tissue. The main clinical manifestations include long limbs, long slender fingers, lens subluxation, abnormal cardiac valves, and aortic aneurysm. We report the case of an 11-year-old patient with MFS who underwent orthodontic treatment and was followed up until the age of 25 years. We found no significant differences in tooth movement between the patient with MFS and healthy subjects. However, because patients with MFS show characteristic facial growth and an increased risk of developing systemic comorbidities, their dental status requires careful observation over time.

Antibiotic prophylaxis for infective endocarditis: a systematic review and meta-analysis

OBJECTIVE

The use of antibiotic prophylaxis (AP) for prevention of infective endocarditis (IE) is controversial. In recent years, guidelines to cardiologists and dentists have advised restriction of AP to high-risk groups (in Europe and the USA) or against its use at all (in the UK). The objective of this systematic review was to appraise the evidence for use of AP for prevention of bacteraemia or IE in patients undergoing dental procedures.

METHODS

We conducted electronic searches in Medline, Embase, Cochrane Library and ISI Web of Science. We assessed the methodological characteristics of included studies using the Strengthening the Reporting of Observational Studies in Epidemiology criteria for observational studies and the Cochrane Risk of Bias Tool for trials. Two reviewers independently determined the eligibility of studies, assessed the methodology of included studies and extracted the data.

RESULTS

We identified 178 eligible studies, of which 36 were included in the review. This included 10 time-trend studies, 5 observational studies and 21 trials. All trials identified used bacteraemia as an endpoint rather than IE. One time-trend study suggests that total AP restriction may be associated with a rising incidence of IE, while data on the consequences of relative AP restriction are conflicting. Meta-analysis of trials indicates that AP is effective in reducing the incidence of bacteraemia (risk ratio 0.53, 95% CI 0.49 to 0.57, p<0.01), but case-control studies suggest this may not translate to a statistically significant protective effect against IE in patients at low risk of disease.

CONCLUSIONS

The evidence base for the use of AP is limited, heterogeneous and the methodological quality of many studies is poor. Postprocedural bacteraemia is not a good surrogate endpoint for IE. Given the logistical challenges of a randomised trial, high-quality case-control studies would help to evaluate the role of dental procedures in causing IE and the efficacy of AP in its prevention.