Andersons pediatric cardiology 1499

NICE 2008 recommendations are the most far reaching and recommend cessation of prophylaxis solely to prevent IE for dental and nondental procedures.216 NICE 2016 updated recommendations

NICE 2008 recommendations are the most far reaching and recommend cessation of prophylaxis solely to prevent IE for dental and nondental

procedures.216 NICE 2016 updated recommendations added the possibility for individual decision.5 The ESC 2009 and AHA 2007 guidelines still required that

a small group of high-risk patients have prophylaxis for dental procedures, with manipulation of the gingival or periapical region of the teeth or perforation of the oral mucosa (see earlier for recommendations extrapolated to piercing of the oral mucosa) The ESC 2015 recommendations discard the indication for

transplanted heart valvulopathy

The current ESC 2015 recommendations for antibiotic prophylaxis are

summarized in Box 56.6

Box 56.6

Recommendations on the European Society of Cardiology 2015 Guidelines for Antibiotic

Prophylaxis Around Dental Procedures

Antibiotic Prophylaxis Should Be Considered for

Patients at Highest Risk for IE:

1 Patients with any prosthetic valve, including a transcatheter valve, or those in whom any prosthetic material was used for cardiac valve repair

2 Patients with a previous episode of IE

3 Patients with CHD:

■ Any type of cyanotic CHD

■ Any type of CHD repaired with a prosthetic material, whether placed surgically or by percutaneous techniques, up to 6 months after the procedure or lifelong if residual shunt or valvar

regurgitation remains

Antibiotic prophylaxis is not recommended in other forms of valvar or CHD

Recommended Prophylaxis for High-Risk Dental

Antibiotic single-dose 30–60 minutes before procedure

1 No allergy to penicillin or ampicillin: Amoxicillin 2 g orally or IV

(children 50 mg/kg orally or IV)

2 Allergy to penicillin or ampicillin: Clindamycin 600 mg orally or IV (children 20 mg/kg orally or IV)

Cephalosporins should not be used in patients with anaphylaxis, angioedema,

or urticaria after intake of penicillin or ampicillin due to cross-sensitivity

CHD, Congenital heart disease; IE, infective endocarditis.

Recommendations are largely in line with US AHA 2007 recommendations Prophylaxis has been downgraded in France since 2002

UK NICE 2008 (amended 2016): no prophylaxis recommended unless there

is individual decision

Modified from ESC 2009/2015 IE guidelines

The impression is that prosthetic valves, percutaneously implanted pulmonary valves, and surgically implanted bovine jugular vein conduits present higher risk for IE However, the data show that while the risk of IE in the listed conditions might be higher, there are little data to support the effectiveness of

prophylaxis.245 It has been ascertained that it is invasive heart procedures and not dental procedures that are more significantly associated with IE in children with CHD.246

Prophylaxis for Nondental Procedures.

Systematic antibiotic prophylaxis is not recommended for nondental procedures Antibiotic therapy is needed only when invasive procedures are performed in the context of infection

For PPM and ICD implantations, prophylaxis should be administered within 1 hour before the procedure.10 The current preference is for Teicoplanin, which is easy to administer as a bolus There is no evidence of a benefit of a repeat dose, although the prophylaxis should be continued for 48 hours after a prolonged procedure

Preoperative screening of the nasal carriage for S aureus is recommended

before elective cardiac surgery to treat carriers The use of local mupirocin or chlorhexidine is advocated.247,248 Systematic local treatment without screening

is not recommended

It is recommended that potential sources of dental sepsis should be eliminated

at least 2 weeks before implantation of a prosthetic valve or other intracardiac or intravascular foreign material, unless the latter procedure is urgent

Prophylaxis Recommendations of 2007–2008 Compliance.

There are few studies on compliance with the IE prophylaxis recommendations

A 2016 paper reports that more than half of the pediatric cardiologists in the United States were skeptical and up to 56% of pediatric cardiologists on the survey did not totally adhere to the AHA 2007 IE prophylaxis

recommendations.249 There is heterogeneity in the attitudes among cardiologists

in Canada and Australia.250 By 2015, there had been certain reduction in the prescriptions for IE prophylaxis among pediatric and adult congenital

cardiologists in Canada251; the prescriptions have decreased by more than 90%

in the United Kingdom.252

Prophylaxis Recommendations of 2007–2008 (for France 2002)

Impact.

There are currently controversial data on the impact of the reduction in IE

prophylaxis.253

No change in incidence.

The majority of papers report no change of IE incidence in adult or mixed

cohorts254–256 and VGS incidence.256,257 The results for pure pediatric IE

cohorts also have shown no increase in overall pediatric IE incidence,20,16,258,259 with some increase in VGS pediatric IE in the older children259 or without VGS increase.16

Increase in incidence.

There are two papers mostly on adult cases published in 2015 reporting

minimally increased IE incidence in the United States260 and the United

Kingdom261 but without increase of the rate of hospitalization or valve

surgery.260 However, the authors stopped short of making a causal link between that IE incidence increase and the cessation of IE prophylaxis