A Bionic *** !

[tobagotwo]

Delineated with excellence and exactitude, Kristy. Thank you.

The notion of the moon being made of cheese was not the result of scientific study, but rather from the printed fantasy from John Heywood's Proverbes (1546): "The moon is made of a greene cheese..."

Regarding the information used for the study that changed the rules, there is over 50 years of copious data regarding the efficacy of preventative antibiotics for the prevention of endocarditis. What was not in all that data was a shred of a link between the use of them and prevention of the disease.

Please note the repetitive inclusion of the phrase "if any" throughout the revised recommendation document, in reference to the antibiotics' possible benefits. This is in anticipation of further changes to the document that can reasonably be expected within the next five years or so.

Yes, it sounds a bit cruel, as we had felt protected before, but the prophylactic antibiotic model seems to be little more than a medical rabbit's foot for the vast majority of us. As with many other journeys in life, we must now put each foot forward in the faith that we will continue to move ahead, regardless of the loss of another small comfort on the way.

Best wishes,

 

[Lynlw]

Delineated with excellence and exactitude, Kristy. Thank you.

The notion of the moon being made of cheese was not the result of scientific study, but rather from the printed fantasy from John Heywood's Proverbes (1546): "The moon is made of a greene cheese."

Regarding the information used for the study that changed the rules, there is over 50 years of copious data regarding the efficacy of preventative antibiotics for the prevention of endocarditis. What was not in all that data was a shred of a link between the use of them and prevention of the disease.

Please note the repetitive inclusion of the phrase "if any" throughout the revised recommendation document, in reference to the antibiotics' possible benefits. This is in anticipation of further changes to the document that can reasonably be expected within the next five years or so.

Yes, it sounds a bit cruel, as we had felt protected before, but the prophylactic antibiotic model seems to be little more than a medical rabbit's foot for the vast majority of us. As with many other journeys in life, we must now put each foot forward in the faith that we will continue to move ahead, regardless of the loss of another small comfort on the way.

Best wishes,

This bold wording in the valve guidelines basically says the same thing

"The committee recognizes that decades of previous recommendations for patients with most forms of VHD and other conditions have been abruptly changed by the new AHA guidelines.4 Because this may cause consternation among patients, clinicians should be available to discuss the rationale for these new changes with their patients, including the lack of scientific evidence to demonstrate a proven benefit for infective endocarditis prophylaxis. In select circumstances, the committee also understands that some clinicians and some patients may still feel more comfortable continuing with prophylaxis for infective endocarditis, particularly for those with bicuspid aortic valve or coarctation of the aorta, severe mitral valve prolapse, or hypertrophic obstructive cardiomyopathy. In those settings, the clinician should determine that the risks associated with antibiotics are low before continuing a prophylaxis regimen. Over time, and with continuing education, the committee anticipates increasing acceptance of the new guidelines among both provider and patient communities."

 

[TXWildflower]

Boy, lots of reading in there. I went to periodontist today who for a simple cleaning and even a deep scaling doesn't require that I take antibiotics and my cardio agrees. Seems studies have shown it isn't necessary. When I mentioned my sometime who knows when OHS he said that after that happened then we'd have to start using the prohylactics (sp) again, even for a cleaning. He wants to do surgery on a couple of gum areas though and for that one he wants me to pre-medicate - even before having the valve replaced. Times are a changing and I am all for not having to take an anti biotic if I don't have too.

Rhena

 

[LonMel]

I'm going for dental work this month and I find it propitious that this thread is being discussed. I asked my cardiologist if I need prophylaxis and he agrees that I should be on either amoxilillin/penicillin.

 

[catwoman]

Woodbutcher...it's not about massive bleeding...it's about releasing subgingival (below the gumline) bacteria into the bloodstream. A cleaning is the dirtiest thing the dentist/hygienist does in a patient's mouth. It stirs up all sorts of bacteria. However a filling in the top of the tooth stirs up no bacteria, plus the anesthetic injection is placed away from any tissue that harbors bacteria. The injection is not an issue.

The studies are showing that having antibiotics on board doesn't prevent endocarditis, and it may impact antibiotic use in the future (antibiotic resistance, allergic reaction). That's why the new guidelines. However...IF you have a non-native valve (not your own equipment) then you should have antibiotic cover for cleanings, crown preparations, extractions, (anything where the dentist's instruments go below the gumline.)

Hope this helps.

Kristy:
Thanks for pointing this out. Many people here don't know that you work for a dentist.

 

[deano89]

dotors test for endocarditis by doing simple blood cultures, i was also told by my dentists it is the scale and polish which carries the greatest risk because the bacteria live just below the gum line and when the cleaning takes place these can easily get into the blood stream

 

[KristyW]

Delineated with excellence and exactitude, Kristy. Thank you.

,

Thanks for pointing this out. Many people here don't know that you work for a dentist.

Awww shucks...thanks both of you. Just trying to pass on a little bit of what I've learned

 

[Adrienne]

Woodbutcher...it's not about massive bleeding...it's about releasing subgingival (below the gumline) bacteria into the bloodstream. A cleaning is the dirtiest thing the dentist/hygienist does in a patient's mouth. It stirs up all sorts of bacteria. However a filling in the top of the tooth stirs up no bacteria, plus the anesthetic injection is placed away from any tissue that harbors bacteria. The injection is not an issue.

The studies are showing that having antibiotics on board doesn't prevent endocarditis, and it may impact antibiotic use in the future (antibiotic resistance, allergic reaction). That's why the new guidelines. However...IF you have a non-native valve (not your own equipment) then you should have antibiotic cover for cleanings, crown preparations, extractions, (anything where the dentist's instruments go below the gumline.)

Hope this helps.

Kristy, I may have asked you this before but isn't it also true that if one has already had endocarditis that it leaves little lesions where bacteria can latch onto and that even if a person has had a repair rather than a replacement but has also had previous endocarditis (before the surgery) that it makes sense to premedicate?

 

[Woodbutcher]

Thanks Kristy for your clear reply. "The studies are showing that having antibiotics on board doesn't prevent endocarditis" So then, why would antibiotic cover be of any use if having any work below the gumline if one has a non native valve?
I saw my GP today about my relentless virus that's had me floored for over a week now and quizzed him about this whole antibiotic cover thing (He's a GP now but has been a heart specialist), to my surprise he agreed with the findings and thought it better NOT to take antibiotic cover before dental procedures !? This is all so confusing ?

 

[KristyW]

Kristy, I may have asked you this before but isn't it also true that if one has already had endocarditis that it leaves little lesions where bacteria can latch onto and that even if a person has had a repair rather than a replacement but has also had previous endocarditis (before the surgery) that it makes sense to premedicate?

Adrienne,

I don't know about B.E. & lesions. I do know that the new protocols do mention previous incidence of BE as a reason to premedicate. So you could be right about premedicating with valve repair and previous B.E.

 

[KristyW]

Thanks Kristy for your clear reply. "The studies are showing that having antibiotics on board doesn't prevent endocarditis" So then, why would antibiotic cover be of any use if having any work below the gumline if one has a non native valve?

Well Woodbutcher,

If you look at Bob's research...it seems that the experts are moving towards not premedicating even the "non-native" valve patients, but that it was just too big of a change to advocate at that time. Many patients and Doctors would revolt at that thought. I look at the new protocols as a stepping stone as they move towards not premedicating any of us.

Hope that helps clear up some of the confusion.

 

[Woodbutcher]

Thanks Kristy,
Well, it would seem that that stepping stone has already been stepped here in the UK and nobody now, valve or otherwise can have cover without really kicking up a fuss for it.
Now I'll be in two minds next time I visit the dentist ?

 

[Lynlw]

I often find it interesting that most people That I know of that got BE a few weeks after going to a dentist did not know they had heart conditions and did not premedicate. Most people I know that knew of their heart problems and got BE (Like Justin) got it some ohter way (not in a time frame close to dental visit) So Maybe it did help? it would be an interesting (and yes non scientific) poll

 

[Lynlw]

Kristy, I may have asked you this before but isn't it also true that if one has already had endocarditis that it leaves little lesions where bacteria can latch onto and that even if a person has had a repair rather than a replacement but has also had previous endocarditis (before the surgery) that it makes sense to premedicate?

I'm not Kristy, but actually the newest guidelines (updated 2008 Valve guidelines) also include repairs (not just replacements) IF they use a ring or something. hopefully this will take you to Table 2. Updates to Section 2.3.1. Endocarditis Prophylaxis
http://circ.ahajournals.org/cgi/content/full/118/8/887/TBL2190377
in the column for "Prophylaxis against infective endocarditis is reasonable for the following patients at highest risk for adverse outcomes from infective endocarditis who undergo dental procedures that involve manipulation of either gingival tissue or the periapical region of teeth or perforation of the oral mucosa4:"
the first group of patients is
"Patients with prosthetic cardiac valves or prosthetic material used for cardiac valve repair."

 

[Adrienne]

Thanks KristyW and Lynlw. In any case, I always premedicate before dental cleanings. When I had my endocarditis in 2004, it was NOT after a dental appointment or any other procedure (I always premedicated then too). I still think (and I have said this before) that I think the reason they are now saying only the people most at risk should premedicate is because they are thinking of the population as a whole and the risk of antibiotics becoming ineffective. Although I can understand this from their point of view, from mine, as one particular patient that does not ever want to contract endocarditis ever again, I will premedicate. I have a hard time believing that it does not help at all. The very fact that antibiotics can clear up an infection that is already there would tend to say to me that flooding the system with antibiotics just before a procedure that would tend to let bacteria into the bloodstream would help kill those bacteria before they get a chance to latch onto a heart valve.

 

[Lynlw]

Thanks KristyW and Lynlw. In any case, I always premedicate before dental cleanings. When I had my endocarditis in 2004, it was NOT after a dental appointment or any other procedure (I always premedicated then too). I still think (and I have said this before) that I think the reason they are now saying only the people most at risk should premedicate is because they are thinking of the population as a whole and the risk of antibiotics becoming ineffective. Although I can understand this from their point of view, from mine, as one particular patient that does not ever want to contract endocarditis ever again, I will premedicate. I have a hard time believing that it does not help at all. The very fact that antibiotics can clear up an infection that is already there would tend to say to me that flooding the system with antibiotics just before a procedure that would tend to let bacteria into the bloodstream would help kill those bacteria before they get a chance to latch onto a heart valve.

I agree and I Believe the fact that Justin's Strep was reistant to everything but vanco and gento had something to do with all the antibiotics he already had taken and he was only 11.
I can't see how it is cost effective not to give antibiotics to people at the most risk tho, because treating BE is VERY expenisve just the 6 weeks of IV antibiotics alone is tens of thousands, and Justin didn't even have any damage needing a valve replacement (Thank God). Imagine the cost of that on top it. Just the money paying for treating 1 person's BE would problably cover a huge amount of peoples premedications.

 

[tobagotwo]

The bulk of the confusion is in the fact that the AHA/ACC is trying to carefully back out of what they have been telling people they must do for over 50 years.

There never was any evidence that prophylactic antibiotics prevented infective endocarditis. It just seemed like it might, and doctors started doing it and encouraged each other to do it. It became a standard of treatment, and was never very harshly questioned.

The concern of general issues around using antibiotics too freely and losing their ability to fight bacteria, specific loss of antibiotic usefulness in people who have taken too many, and the concerns of people having allergic reactions to antibiotic doses caused the organizations to agree to a large-scale study of whether the dosing of patients to prevent infective endocarditis (IE) was actually effective. The study came back resoundingly saying it was not effective at all.

This leaves them in a quandary. The use of prophylactic antibiotics (PAs) is entrenched. Many people believe in PAs no matter what facts are presented. If patients get IE when they are not taking PAs, they are apt to sue, saying that dropping the PAs was the cause. While it's defensible that this is not the cause, this could be very expensive for doctors and insurance companies in both time and money. Not to mention the fact that there is a percentage of doctors who also still believe in PAs, regardless of what contrary facts are presented to them. It's complicated.

So, the new recommendations back out only halfway, to give the industry and the patient population time to adjust to the new information. It will also provide data over time to illustrate the lack of added danger to the reluctant.

Does it make sense to keep any groups in the recommended for PA list? Medically, it would certainly seem not. After all, it's not how much risk the person is in, it's whether the treatment would reduce the risk (it doesn't).

However, the recommendations are a political, financial, and insurance document as well as a medical statement. It's a compromise of many issues. Thus, it's a contradictory mess from some viewpoints.

The review of the 50+ years of data is unequivocal. The use of prophylactic antibiotics as it occurs today is ineffective in preventing infective endocarditis. It's like taking aspirin for birth control. It may make you feel better on some level, but it won't prevent you from becoming pregnant.

However, it will take years to remove it from the list of standard treatments, and there are many patients who will never accept the loss of it, as it's an emotional safety net in a scary world of heart disease: it made people feel safe.

Best wishes,

 

[Lynlw]

I'm not arguing with what you wrote Bob, That's what I've been reading too, but
I'm not quite sure how they know it does NOT work. They didn't set up any studies as far as I know giving 1/2 the at risk patients PA and the other 1/2 no PA (or placebos) and the end results were the same. I know this isn't scientific at all, but just what I've noticed after being on heart groups since just about computers were getting pretty common in homes MOST people I know (children and adults) that knew they had Heart conditions and still got BE, did not get it close to dental visits (during which they PA) but some other time (and Justin and another girl I am friends with the Mom, both got it shrtly after loosing a larger baby tooth and both grew a form of Strep common in the mouth. actually the one girl had what I thought were symptons of BE (she was 5 or 6) for a whle and her mom kept taking her to the doc, I remeberred her knocking her tooth out a weird way a couple weeks earlier, and told the Mom to ask the doc for Blood cultures since they couldn't figure out what was wrong and it turned out they were positive.
Alot of people I know that got BE and never knew they had heart conditions, so never PA were DXD with BE shortly after going to the dentist. It could all be just coincidences, but will be interesting to see what happens to the rate of people getting BE in the next few years. Especially in the UK were they don't advise PA for dental for any one.

 

[Woodbutcher]

I've been reading Bobs post with interest and Lyns views too. It just seems remarkable to me that such firmly held views can change overnight? I've only had my valve 9 months but have been to the dentist several times over those months. I of course leant all about the importance of Antibiotic cover from them. There was absolutely no way they'd treat me, be it a filling or cleaning without cover, insisting it really wouldn't be worth the risk. Then I go in a couple of days ago and the very same dentist is saying, "no don't worry about it, we can no longer prescribe it and you're better off not risking taking it anyway" !? I just cant get my head around this massive shift of the goal posts ! It would be like me going to the nurse for my inr test and her casually saying "Oh no we've stopped the Warfarin thing now, it would seem it never did anything anyway".
It seems too black and white all round for my head to deal with .

 

[Lynlw]

WARNING may be long and boring

WARNING may be long and boring

I've been reading Bobs post with interest and Lyns views too. It just seems remarkable to me that such firmly held views can change overnight? I've only had my valve 9 months but have been to the dentist several times over those months. I of course leant all about the importance of Antibiotic cover from them. There was absolutely no way they'd treat me, be it a filling or cleaning without cover, insisting it really wouldn't be worth the risk. Then I go in a couple of days ago and the very same dentist is saying, "no don't worry about it, we can no longer prescribe it and you're better off not risking taking it anyway" !? I just cant get my head around this massive shift of the goal posts ! It would be like me going to the nurse for my inr test and her casually saying "Oh no we've stopped the Warfarin thing now, it would seem it never did anything anyway".
It seems too black and white all round for my head to deal with .

That's pretty interesting, because when you first got your valve, the new recomendations (March 2008) had already been in place. I wonder why he changed his mind now

NOT that this means much but I thought it was interesting and it is just UK not elsewhere.
SO I was confused because I was pretty sure when the US changed their guidelines(2006) the UK did the same ones. Basically they didn't think PA prevented BE but to play it safe or make people more comfortable they would give them to the most at risk (previous BE, valves, some CHDs ect) but When this thread was started I went and read most (but not all it's 107 pages) of the NICE and saw they didn't recomend them at all. http://www.nice.org.uk/nicemedia/pdf/CG64NICEguidance.pdf

SO it still bothered me, because I remember lots of discusions in 2006 on all my groups that have members all over. So I checked the NICE guideline and they started March 2008. SO I (since I never sleep and have no life) searched for the 2006 UK info and they DID origonally recomend it for the high risk (even tho they said it might not help)http://jac.oxfordjournals.org/cgi/content/full/57/6/1035 from April 2006
High-risk cardiac factors requiring antibiotic prophylaxis
Previous infective endocarditis
Cardiac valve replacement surgery, i.e. mechanical or biological prosthetic valves
Surgically constructed systemic or pulmonary shunt or conduit

Dental procedures requiring antibiotic prophylaxis
All dental procedures involving dento-gingival manipulation

So I haven't read all of both guidelines, BUT the one thing that the 2008 NICE guidelines say they take into effect that all the other orgs don't is COST.
(bottom of page 11-12 of 107) http://www.nice.org.uk/nicemedia/pdf/CG64NICEguidance.pdf

"Four clinical guidelines on the prevention of IE are discussed in subsequent sections: American Heart Association (AHA) 2007 (Wilson et al. 2007), British Society for Antimicrobial Chemotherapy (BSAC)
2006 (Gould et al. 2006), European Society of Cardiology (ESC) 2004 (Horstkotte et al. 2004) and British Cardiac Society (BCS)/Royal College of Physicians (RCP) 2004 (Advisory Group of the British Cardiac Society Clinical Practice Committee 2004).
The recommendations of these four guidelines, and where reported the rationale for their recommendations, have been considered by the GDG in the development of this guideline. However, it should be emphasised that the GDG has based its recommendations on an independent consideration of the available clinical and cost-effectiveness evidence and, where appropriate, expert opinion."


right before that on page 10 it says
Infective endocarditis (IE) is an inflammation of the endocardium, particularly affecting the heart valves, caused mainly by bacteria but occasionally by other infectious agents. It is a rare condition, with an annual incidence of fewer than 10 per 100,000 cases in the normal population. Despite advances in diagnosis and treatment, IE remains a life-threatening disease with significant mortality (approximately 20%) and morbidity.
The predisposing factors for the development of IE have changed in the past 50 years, mainly with the decreasing incidence of rheumatic heart disease and the increasing impact of prosthetic heart valves, nosocomial infection and intravenous drug misuse. However, the potentially serious impact of IE on the individual has not changed (Prendergast 2006).

Published medical literature contains many case reports of IE being preceded by an interventional procedure, most frequently dentistry. IE can be caused by several different organisms, many of which could be transferred into the blood during an interventional procedure. Streptococci, Staphylococcus aureus and enterococci are important causative organisms.

It is accepted that many cases of IE are not caused by interventional procedures (Brincat et al. 2006), but with such a serious condition it is reasonable to consider that any cases of IE that can be prevented should be prevented. Consequently, since 1955, antibiotic prophylaxis that aims to prevent endocarditis has been used in at-risk patients. However, the evidence base for the use of antibiotic prophylaxis has relied heavily on extrapolation from animal models of the disease (Pallasch 2003) and the applicability of these models to people has been questioned. With a rare but serious condition such as IE it is difficult to plan and execute research using experimental study designs. Consequently, the evidence available in this area is limited, being drawn chiefly from observational (case–control) studies