O Cavezzi Junior
O Cavezzi Junior. Antimicrobial prophylaxis against infective endocarditis for dental procedure. - A brief commentary. The Internet Journal of Dental Science. 2008 Volume 7 Number 2.
For over a half century, guidelines for the prevention of infective endocarditis (IE) have recommended antibiotic prophylaxis for certain patients receiving dental care. Much emphasis has been attributed historically on the baseless concept that dental procedures are main cause of cases of IE and dentistry carried the blame for induce endocarditis without much supporting evidence.
In 2007, the American Heart Association (AHA) and British Society for Antimicrobial Chemotherapy (BSAC) updated the recommendations for IE prophylaxis before dental procedures and those recommendations are clearly evidence-based 9 . The dental treatment is a very rarely cause of IE and antibiotic prophylaxis do not give assurances as preventive. So, the value of antibiotic prophylaxis in prevention of IE has been questioned for over 20 years 3 .
In reviewing the literature 2 , we did not find support that antibiotic prophylaxis actually prevents endocarditis from dental procedure only an extremely small number of cases of IE might be prevented by antibiotic prophylaxis for dental procedure. There is increasing evidence that spontaneous bacteremia are more likely to cause IE in at risk patients than specific episodes of dental treatment 568 . The majority of infective endocarditis cases caused by oral bacteria result from chewing, flossing, tooth brushing and others daily activities, and the presence of dental disease may increase the risk of bacteremia associated with these daily events 8 . Anyway the role of dental procedures in the production of infective endocarditis has probably been overestimated in relation to oral health condition thus more attention should be given to the importance of good oral hygiene and control of dental biofilm in the prevention of IE. In short, the care of the oral health must be the first step in the prevention of infective endocarditis from dental origin than antibiotic prophylaxis.
Almost a year after the issued of new recommendations for prevention of IE, we still seeing most patients and health care professionals resistant to adopt this new recommendations and persisting to prescribe antibiotic prophylaxis when the need no longer exists. Only a few patients will be elected to receive antibiotic prophylaxis according to the AHA and BSAC, thus only employ in the very highest risk patients 8 . (Tables 1, 2, 3)
The prescription of antibiotics carries the risk for both, patient and community, through the undesirable effects and the fact of introducing microorganisms mutants or genetically transfer the microbial resistance, respectively.
The scientific community has focused the link between the overuse of antibiotics and the increasing prevalence of the drug resistant organisms 14710 .
This concern is overt when evaluating ambulatory patients wich receiving short courses of antibiotics and they became an important reservoir of resistant microorganisms 7 . Antibiotic resistance is a serious incident and capable to be prevented through common sense and clinical judgment. Health care professionals have misused antibiotics for too long and carry the blame of antibiotic resistance. The risks associated with widespread antibiotic use and lack of efficacy data take us back to rethink our practice
The new guidelines should be seen as great progress based on evidence that currently exists and must be followed until more evidence arise. We need further debate, especially as there are increasing environmental concerns over the misuse of antibiotics. We are now experiencing a shift thus we need time to change this scenario.
* Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD.
† Prophylaxis is recommended because endothelialization of prosphetic material occurs within 6 months after the procedure.
* IM indicates intramuscular; IV, intravenous.
** Or other fi rst-or second-generation oral cephalosporin in equivalent adult or pediatric dosage.
† Cephalosporings should not be used in an individual with a history of anaphylaxis, angioedema, or urticaria with
penicillins or ampicillin.