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Viridans Group Streptococcal Infective Endocarditis Prevention
Quick Takes
- 2007 AHA guideline recommendations limited the use of periprocedural antibiotic prophylaxis to patients who are felt to be at the highest risk of an adverse outcome from infective endocarditis (IE), rather than including all patients at increased lifetime risk of developing IE.
- This writing group of experts performed a MEDLINE search for articles on compliance with the 2007 guideline recommendations, and the frequency of and morbidity or mortality from VGS IE after publication of the 2007 guidelines.
- The writing group found no convincing evidence that the 2007 change in guideline recommendations resulted in a change in the frequency of or morbidity or mortality associated with VGS IE, and recommended no changes to the 2007 antibiotic prophylaxis guidelines.
Study Questions:
How well accepted are the 2007 American Heart Association (AHA) updated guidelines on the recommended use of periprocedural antibiotic prophylaxis to prevent infective endocarditis (IE); and is there evidence that the guideline change has been associated with a change in viridans group streptococcal (VGS) IE frequency, morbidity, or mortality?
Methods:
A writing group of experts in the prevention and treatment of IE was formed, including members of the American Dental Association, Infectious Diseases Society of America, American Academy of Pediatrics, and AHA. MEDLINE database searches were done for English language articles on compliance with the 2007 guideline recommendations, and the frequency of and morbidity or mortality from VGS IE after publication of the 2007 guidelines.
Results:
Surveys and clinical studies suggested good general awareness of the 2007 guidelines, but variable compliance. Specifically, 70% of dentists surveyed in the United States (US) reported that they had patients who continued to take antibiotic prophylaxis that was no longer recommended by the 2007 guidelines; and multiple published studies documented a decline in the rate of (guideline-suggested) antibiotic prophylaxis among high-risk groups, as well as in lower-risk groups.
A review of published studies to determine whether there was an increased incidence of or mortality from VGS IE since the 2007 guideline publication found only retrospective, population, or health system-based studies that relied on claims data, registries, or epidemiological observations; and used nonstandardized methods for the identification of IE. With these limitations, the writing group found no high-quality data suggesting an increased frequency of or mortality from native valve VGS IE. Among the four groups felt to be at high risk for adverse outcomes associated with IE (prosthetic heart valve or prosthetic material used with valve repair, previous or recurrent IE, congenital heart disease, and prior heart transplant with valvuloplasty), the writing group found no convincing evidence from retrospective and observational studies that there was an increase in frequency of and mortality or morbidity from VGS IE since 2007.
The writing group concluded that evidence does not support expanding antibiotic prophylaxis to other patient groups, including patients with rheumatic valve disease, bicuspid aortic valve, aortic stenosis, or mitral valve prolapse. The writing group found no high-quality analyses that examined the cost-effectiveness of antibiotic prophylaxis in the US; one study in the United Kingdom concluded that antibiotic prophylaxis for all patients at risk of IE would be less costly and more effective than no antibiotic prophylaxis for all patients at risk of IE, but the writing group felt that methodological limitations led to an overestimation of the cost-effectiveness of antibiotic prophylaxis in that study.
Conclusions:
Based on their review of available evidence, the writing group recommended no changes to the 2007 VGS IE prevention guidelines, with a continued recommendation for IE antibiotic prophylaxis only for categories of patients felt to be at highest risk for adverse outcomes from IE, and emphasizing the role of good oral health and regular access to dental care for all patients. The writing group concluded that randomized controlled studies to determine whether antibiotic prophylaxis is effective against VGS IE are needed to further refine recommendations.
Perspective:
The 2007 AHA guideline recommendations limited the use of periprocedural antibiotic prophylaxis to patients who are felt to be at the highest risk of an adverse outcome from IE, rather than including all patients at increased lifetime risk of developing IE. The present AHA scientific statement notes the variable adoption of those guideline recommendations, and summarizes existing data on VGS IE (predominantly from retrospective, population, or health system-based studies relying on claims data, registries, or epidemiological observations; and using nonstandardized methods for the identification of IE), with the conclusion that existing data do not convincingly demonstrate a change in the frequency of or morbidity or mortality associated with VGS IE after the guideline change. In the absence of randomized, prospective trials, some practitioners—guided by the ethical principles of beneficence, autonomy, and truthfulness and honesty—have opted to educate patients and allow them to make an informed choice regarding the use of antibiotic prophylaxis. This might in part explain the observed variable adoption of the 2007 guidelines, and also might be a factor contributing to the absence of a detectable increase in IE frequency, morbidity, and mortality.
Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Congenital Heart Disease and Pediatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Prevention, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and CHD and Pediatrics, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Interventions, Heart Transplant, Interventions and Structural Heart Disease
Keywords: Antibiotic Prophylaxis, Aortic Valve Stenosis, Bicuspid, Communicable Diseases, Cost-Benefit Analysis, Dental Care, Endocarditis, Heart Defects, Congenital, Heart Transplantation, Heart Valve Diseases, Mitral Valve Prolapse, Oral Health, Rheumatic Diseases, Secondary Prevention, Viridans Streptococci
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