Endocarditis prophylaxis Z29.21

Endocarditis is a serious life-threatening disease, the development of which can be minimized by prophylactic medication (Pinger 2019).

The bacteremia frequency depends on the type of intervention and is therefore subject to strong fluctuations. Overall, however, endocarditis is a rare disease (Pinger 2019).

The individual post-procedural bacteremia frequency is:

• after tooth extractions in gingivitis is up to 90%.
• in urological surgery up to 86 %
• septic abortion, interruptio up to 85
• ERCP for bile duct obstruction up to 50
• Varicosclerotherapy or varicosity injection between 30 % and 50
• Prostate resection between 10 % and 50
• Curettage of the uterus between 10 % and 50
• for tonsillectomy at approx. 35
• Pacemaker revision at 20
• Intubation between 0 and 16
• nasotracheal aspiration between 15 % and 20
• rigid bronchoscopy at approx. 15
• Haemodialysis at 8
• flexible bronchoscopy between 0 and 6
• Gastroscopy less than 5
• Colonoscopy less than 5
• ERCP less than 5
• normal birth between 1 % and 5
• Cardiac catheter at 1

With the above figures, it should be noted that after brushing the teeth, bacteremia with endocarditis-relevant pathogens is detectable in 23%. Thus, the risk of iatrogenic endocarditis can be classified as very low compared to the daily risk in everyday life.

(Pinger 2019)

A prerequisite for the development of endocarditis is bacteremia (Pinger 2019).

In 2007, the AHA (American Heart Association) brought about a paradigm shift in the previously common practice of endocarditis prophylaxis, as it was now questionable to what extent prophylaxis with antibiotics could influence the duration, intensity and frequency of a bacteremia, e.g. by a dental intervention (which has the highest bacteremia frequency). Patients who had received prophylactic medication nevertheless developed endocarditis. Additionally, it was shown that the reduction of bacteremia after tooth extraction could be reduced from 60% without prophylaxis to only 33% under prophylaxis with amoxicillin (Pinger 2019).

As there are no prospective, randomized and placebo-controlled studies on the benefit of prophylaxis with antibiotics, it was ultimately agreed that drug prophylaxis should only be performed in patients with the highest risk of endocarditis and only in interventions with the highest risk of developing endocarditis (Pinger 2019).

However, the changes to the guideline did not meet with general approval either nationally or internationally. It is therefore ultimately the responsibility of the treating physician, after weighing up the pros and cons and in consultation with the patient, to decide on possible endocarditis prophylaxis (Herold 2018).

In 2015, the guidelines prepared by the ESC (European Society of Cardiology) were largely aligned with those of the AHA Guidelines (Herold 2018).

The high-risk patients of the class II a recommendation include patients with:

• Valve reconstruction with implantation of prosthetic materials within the first 6 months postoperatively
• For example, after implantation of a mechanical and/or biological valve or TAVI (transcatheter aortic valve implantation) within the first 6 months after surgery
• Post-operative endocarditis
• in the case of congenital heart defects, the following groups are included:
  • Patients with a cyanotic heart defect that has not been operated on or has been treated palliatively with a systemic pulmonary shunt
  • Patients with operated heart defects in whom conduits have been implanted with or without a valve
  • Patients with operated heart defects where there is a residual shunt or persistent valve insufficiency
• Patients with currently surgically or interventionally treated vitium using prosthetic material that results in a residual shunt or persistent valve failure should receive lifelong prophylaxis

(Herald 2018).

Class II a indications include dental procedures with:

• manipulation of the gingiva
• Manipulations of the periapical region
• Injuries of the oral mucosa

(pinger 2019).

In 2014, AHA / ACC (American Heart Association / American College of Cardiology) recommended additional endocarditis prophylaxis in patients after heart transplantation with valve failure in patients with structurally abnormal valves. A recommendation for patients with mitral clip, anuloplasty ring or amplatzer devices was not given because the data available were insufficient (Pinger 2019).

In patients without current manifest infections, prophylaxis is expressly NOT recommended for procedures such as colonoscopy, gastroscopy, TEE, bronchoscopy, caesarean section, vaginal delivery, intubation, endocarditis prophylaxis (Pinger 2019). Prophylactic hygiene measures should be carried out in this group of patients (Herold 2018). These include regular dental checks twice a year and strict oral and skin hygiene. For prevention, these are more important than prophylaxis with antibiotics (Habib 2015).

The situation is different in this group of patients as soon as manifest infections exist. In this case, endocarditis prophylaxis is recommended for the above-mentioned interventions. When choosing antibiotics, one should take care to detect possible endocarditis pathogens (Herold 2018).

For interventions

• on the respiratory tract:

The antibiotic should be effective against S. aureus and against streptococci; e.g. aminopenicillin plus beta-lactamase inhibitor, cefazolin or clindamycin and, for MRSA, vancomycin

• on the gastrointestinal or urogenital tract:

Antibiotics effective against enterococci, such as ampicillin, piperacillin or vancomycin, should be administered

• on musculoskeletal tissue, skin and skin appendages:

The antibiotic should be effective against staphylococci and beta-haemolysing streptococci, such as penicillin or cephalosporin; if the allergy is known, the administration of clindamycin is recommended, and vancomycin for MRSA

(Herald 2018)

• during cardiac surgery:

Prophylaxis should take place immediately before the operation and be stopped after 48 hours at the latest. If the operation is to last longer, it may be necessary to repeat the administration of antibiotics (Pinger 2019).

Recommendation for therapy:

For the above mentioned high-risk patients of class II a recommendation there is the indication for dental interventions of class II a:

• antibiotic prophylaxis 30 - 60 minutes before the intervention as a single dose;
• if oral administration is possible, amoxicillin or ampicillin 2 g p. o. may be administered
• if oral administration is not possible, ampicillin or cefalexin 2 g i.v. is recommended
• for ampicillin or penicillin allergy, clindamycin 600 mg should be given orally
• with necessary i.v. administration Clindamycin 600 mg i.v.

(Herald 2018)

It should be noted that cephalosporins must not be used in patients who have reacted with anaphylaxis, angioedema or urticaria after ampicillin or penicillin due to cross-allergy (Herold 2018).

A study carried out in the Netherlands in 2017 investigated whether the paradigm shift in endocarditis prophylaxis has changed the number of people suffering from endocarditis. A total of 5,213 patients with endocarditis from three clinics were examined in the period 2005- 2011. The results showed a significant increase in the number of myocarditis cases. In 2005, there were 30.2 new cases per 1 million. And in 2011 there were 62.9 cases per 1 million (van den Brink 2017).

The mortality rate of the sick was 36.1 %. It was found that women (49.3 % vs. 28.2 %) and patients with valve implantation (66.2 % vs. 37 %) were affected more frequently (van den Brink 2017).

At the same time, however, the authors point out that they had no data on the prescription of antibiotics for endocarditis prophylaxis and that the results cannot prove causality.

Thus, it can only be stated that case-control studies or randomized studies are required to clarify the necessity of antibiotic prophylaxis. As long as these are not available, a degree of uncertainty remains (van den Brink 2017).

Addendum:

Knebel (2019) reports that antibiotic endocarditis prophylaxis for medical procedures is now restrictively managed. Acquired valvular vitiation is now no longer seen as an indication.

1. Habib G et al. (2015) ESC Pocket- Guidelines: Infective Endocarditis. Deutsche Gesellschaft für Kardiologie - Herz- und Kreislaufforschung e. V. (DGK) and European Society of Cardiology (ESC)Börm Bruckmeier Verlag GmbH 6- 9.
2. Herold G et al (2018) Internal medicine. Herold Publishers 159- 161

3. Knebel F, Frumkin D, Flachskampf F A (2019) Infective endocarditis. Hospital Hygiene up2date 14 (4) 411 - 425.

4. Pinger S (2019) Repetitorium cardiology: for clinic, practice, specialist examination. Deutscher Ärzteverlag. 374- 378
5. van den Brink F S et al (2017) Increased incidence of infective endocarditis after the 2009 European Society of Cardiology guideline update: a nationwide study in the Netherlands. PubMed. U.S. National Library of Medicine NLM. (2) 141- 147