Guideline on Antibiotic Prophylaxis (AP) for Dental Patients at Risk for Infection

Resident: J. Hencler
Date: 03/30/2011

Article title: Guideline on Antibiotic Prophylaxis (AP) for Dental Patients at Risk for Infection

Author(s): AAPD Council on Clinical Affairs
Journal: Reference Manual V32/NO6 10/11

Major topic: Antibiotic Prophylaxis

Type of Article: Guidelines/Reference

Main Purpose: Help practitioners make appropriate decisions regarding AP for at risk dental patients.

Key points in the article discussion:
Numerous med conditions predispose patients to bacteremia-induced infections. Bacteremia is anticipated following invasive dental tx. Prophylactic antibiotics are recommended for such at risk patients and should be determined on an individual basis. In 2007 the AHA revised and released new guidelines 1) IE is more likely to result from frequent bacterial exposure associated with daily activities then from dental tx, 2) prophylaxis may only prevent a very small number of IE cases if any of individuals that undergo dental tx, 3) the risk of antibiotic-associated adverse events exceeds benefit if any from prophylactic antibiotic therapy, and 4) maintenance of optimal oral health and hygiene may reduce incidence of bacteremia and is more important than prophylactic antibiotics to reduce risk b/f dental tx. Major changes from 1997 guidelines include: 1) the AHA concluded that only a small number of cases of IE might be prevented by AP for dental tx even if such AP were 100% effective, 2) IE AP for dental procedures is reasonable only for patients w/ cardiac conditions associated w/ the HIGHEST risk of IE, 3) AP is required for all dental procedures that involve manipulation of gingival, PA region, or perforation of mucosa, and 4) AP not recommended on increased lifetime risk of acquiring IE.

Recommendations: The conservative use of antibiotics is indicated to minimize the development of resistance to current antibiotic regimens.

Cardiac:
AHA recommends AP for conditions including prosthetic heart valves, hx of IE, unrepaired cyanotic CHD, repaired congenital heart defect w/ prosthetic material or device during the first 6 months, repaired CHD w/ residual defects at the site or adjacent to the site of a prosthetic patch or device, and cardiac transplantation recipients who develop valvulopathy. In addition, patients with a history of IV drug abuse may be at risk for developing bacterial endocarditis due to cardiac anomalies.

Immunocompromised:
These patients may not be able to tolerate a transient bacteria following dental tx and include conditions such as: HIV, severe combined immunodeficiency, neutropenia, immunosuppression, sickle cell anemia, status post splenectomy, chronic steroid usage, lupus, diabetes, and status post organ transplantation.

Shunts, indwelling vascular catheters, or medical devices:
AP for nonvalvular devices, including indwelling vascular catheters (central lines) is indicated only at time of placement. The AHA found no evidence that dental procedures cause infection of nonvalvular devices any time after implantation. Immunocompromised patients w/ nonvalvular devices should receive AP. Ventriculoatrial (VA) or ventriculovenus (VV) shunts for hydrocephalus are at risk for bacteremia-induced infections due to their vascular access require AP. Ventriculoperitoneal (VP) shunts don’t involve any vascular structure and do not require AP. AP is not indicated for patients w/ pins, plates, and screws, nor is it indicated routinely for most dental patients w/ total joint replacements. AP may be considered when high-risk dental procedures are performed for patients w/ in 2 yrs following implant surgery or for patients who have had previous joint infections. ALWAYS consult w/ PCP or specialist!

Assessment of article: Know it, Love it, Use it!