03 October 2023

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Updated guidelines for infective endocarditis

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Infective endocarditis is an infection of the endocardium, usually of bacterial origin (frequently due to streptococci or staphylococci) and sometimes fungal. It is an uncommon, but not rare, disease which can cause fever, heart murmurs, petechiae, anemia, embolic phenomena and endocardial vegetations, which can also lead to serious consequences. For this reason, the ESC guidelines on infective endocarditis were updated (after 8 years), presented in Amsterdam at the European Congress of Cardiology and published simultaneously in the European Heart Journal.

First of all, it is necessary to clarify which subjects are at greater risk of developing infective endocarditis.

These are patients who have already previously had infective endocarditis, patients with prosthetic valves implanted surgically or transcatheter or undergoing repair of a heart valve and patients with untreated congenital heart disease and with congenital heart disease corrected surgically.

One of the "entry gates" for the bacteria/fungi responsible for endocarditis is represented by the oral cavity, colonized by a significant commensal flora, including bacteria belonging to the Streptococci group. According to these latest guidelines, antibiotic prophylaxis is recommended in patients at high risk of infective endocarditis undergoing risky dental procedures and is currently not recommended in other situations.

Risky dental procedures include tooth extractions, oral surgery procedures (including periodontal surgery, implant surgery, and oral biopsies), and dental procedures that involve manipulation of the gingival or periapical region of the teeth (including scaling and root canal procedures).

The use of dental implants raises concerns about the potential risk due to foreign material at the interface between the buccal cavity and the blood, but available data remain very limited.

So far there is no evidence that implants are contraindicated in all at-risk patients and the indication should be discussed on an individual basis. Implant placement procedures and invasive dental procedures on osteointegrated implants, however, should be covered by antibiotic prophylaxis in individuals at high risk of developing infective endocarditis.

Once dental implants are placed in high-risk patients, professional dental hygiene and follow-up should be performed at least twice a year under antibiotic coverage. The main target of antibiotic prophylaxis is oral streptococci.

Single dose antibiotic situation before the procedure 30-60 minute

                                      Adults               |           Children

No allergies        Amoxicillin 2g orally | 50mg/kg or.

to penicillins      Ampicillin 2g i.m. or i.v. | 50mg/kg i.v. or i.m.                  

 

Allergy                Cefalexin 2g orally | 50mg/kg orally

to penicillins     Azithromycin or clarithromycin 500mg orally | 15mg/kg orally

                              Cefazolin or ceftriaxone 1g i.m. or i.v. | 50mg/kg i.v. or i.m.

Finally, it should not be forgotten that the prevention of infective endocarditis also depends on preventive measures other than antibiotic prophylaxis. People at risk should be instructed to maintain good dental and skin hygiene, to pay attention to signs of infection and, when they experience fever of unknown origin, to tell their doctor that they are at risk for this condition (and consequently doctors should consider screening for infective endocarditis before starting antibiotic therapy).