Do you agree with the new prophylatic guidelines?

[LUVMyBirman]

Most of us do not have concern about obtaining prophylactics. Mainly because we have had valve replacement. And it is approved for such.

As many of you may be aware, they have changed the guidelines for those that have valve issues other than replacmen. Let's use MVP with reguirg as an example.

This is what the AHA states.

"Changes in these guidelines do not change the fact that your cardiac condition puts you at increased risk for developing endocarditis. If you develop signs or symptoms of endocarditis – such as unexplained fever – see your doctor right away. If blood cultures are necessary (to determine if endocarditis is present), it is important for your doctor to obtain these cultures and other relevant tests BEFORE antibiotics are started"


Seems like a no brainer. Looks like a study to me. I am certain of it. Just like eggs are good for you this week and not the next. I am willing to bet that we will see a retraction.

Our dentist himself decided not to take the pre meds under the current "guidelines". He had a valve condition. Guess what he contracted? Enodocarditis.

I am really hot under the collar as this issue hits close to home. I was told the reason they do not want to prescribe for straight MVP with reguirg is that MRSA (Staph) is more prevalent and with the overuse of antibiotics, it would be untreatable if contracted.

Overprescribing? This may just have started with the millions of unnecessary rx's prescribed to uptight parents when their kid had the sniffles.

Just blowing off steam.

 

[LUVMyBirman]

For people who are in the waiting room.

 

[lilteach3234]

Before I have any procedure done, my cardio has to sign off on it....so whatever doc/dentist I see, has to fax over a request, he will look at it, and sign off on it......he will also give the go ahead on meds.

I've not had anything done yet as I am only 6 wks post op, but this is what I hear he does.

 

[Nupur]

I am very concerned about this. Voted 4. My cardio and PCP both refused to give me meds for dental work. Yet, the surgeon I consulted said that I should take meds, he doesn't like the new guidelines. So I am at a loss. I am having a lot of dental procedures lately (root canal gone bad, that's a long story) but finally last time the dentist prescribed me antibiotics which I filled and took hours after the procedure. Shouldn't it be my choice? I hate putting myself at risk.

 

[Trinityheart8891]

hey,

I guess I am a weird case, I have already had my aortic valve worked on, but I am in the waiting room for both my aortic and mitral repair/replacements. I took pre dental antibiotics for 21 years of my life, I am 22 years old

recently I was told to stop them. The bottom line here is that there is NO evidence that pre dental antibiotics reduce the incidence of endocarditis, this means that people who take pre dental antibiotics and those who dont have the same risk for endocarditis (for those in the waiting room, not those who have had replacements) (read, your cardio probably would have still contracted endocarditis if he had taken pre dental antibiotics) there is still a big chance of endocarditis whether or not you take pre dental antibiotics, not to mention you create bacteremia (bacteria in the blood, the same reason you talke pre dental antibiotics) which can cause endocarditis every day by brushing your teeth, eating sharp/crunchy foods, this is as risky if not risker than a dental appt. this coupled with the increasing numbers of resistant bacteria, which is caused by many many things, including overzealous pediatricians, as well as many adults taking antibiotics that arent needed, including predental antibiotics, and preemptive antibiotics for stuff like sore throats

the bottom line here is that the risk outweights the benefits, which are non existant according to the recent research, whether or not you take antibiotics you have the same risk of endocarditis, so why encourage antibiotic resistance? my GP said she would prescribe pre dental antibiotics if I wanted them but my cardiologist insisted that good dental hygeine and good care of skin and cuts.scrapes, etc was more important than antibiotic prophylaxis. I was freaked out at first, but this really makes sense to me.

 

[LUVMyBirman]

Nurpur,

I feel your frustration. Your situation was my point.

Have already had my MVR. My concern is for someone close to me. I tried to go through the proper channels to get protection. Will now have no choice but to take the matter into my own hands.

I have heard of cases of infection because of the change in guidelines. If we know this, I am sorry, they should reverse. Abuse of the prescribing system is not from patients like us going for dental work. It's much deeper issue. We are paying the price. Talk about giving someone with a heart condition more stress!

 

[pamela]

It shouldn't be stressful. True prophylactic antibiotic protection should mean that you take a daily dose of antibiotic. If you ever missed a dose you'd be opening the door for bacteria... If you're a woman you'll likely experience a die off of the beneficial bacteria we need to stay healthy and comfortable in a feminine way, imagine uncontrolled parasitic problems, simply because our bodies no longer host the predators that take care of the little blighters. Antibiotics interfere with estrogen absorbtion leading to unplanned pregnancy and many other difficulties. I'm pretty sure that we're not looking at this happening for people on the normal side of living.

Sometimes it's best to listen to reason about the statistics that have pointed the doctors, with the years of education behind them, to recommend the use of prophylactic antibiotics only in cases where the heart has already had an infection or when we have a non-native cardiac implant.

 

[deano89]

i have ticked the doctors /dentist wont help and i am concerned. which is the case with the dentist prctice i have had since childhood .
but i did search out a dentist who would prescribe them so have now changed to her ,interestingly her interpetation is if the pataient insists then she will precscribe.
before this i had treatment without for and extraction and two crowns but each time i felt like a lab rat and the anxiety level was very high and i did have a fever 1 week after a crown but thankully the cultures were ok thats when i decided to try other dentists
evrthing i have been told and even my doctor said the same this is not based on anything other than a group sitting down and deciding it wasnt neccessary
if that is the case then we are the study group !!!

 

[sue943]

In the UK the guidelines are from NICE. The following link shows that the medical profession are not happy nor agree with the new guidelines.

http://www.anticoagulationeurope.org/disagreeNICE.html

My own cardiologist thinks that if an 'at risk' patient wishes to have antibiotic cover they should be given it. My dental work is now done by the hospital here and the consultant (most senior doctors) prescribes Amoxil for me, 3 grams an hour before cleaning.

Quoting from this article...

Risk factors for PVE have been identified as previous endocarditis, diabetes, renal failure, poor functional class (i.e. very symptomatic patients or patients in heart failure), older age and double valve replacement.
.........

I have had endocarditis, I have diabetes, I have kidney stones and slightly impaired renal function, I am 61 and I have a double valve replacement so guess why my private dentist is scared of me and referred me to the hospital dental department! According to the hospital dental surgeon I am 'off the scale'.

 

[JeffM]

Poll questions.

Poll questions.

I didn't see a choice that applied to me. I have had concerns for years about the over prescribing of antibiotics on the non-cardiac patient population. Furthering the problem are the people who skip dosses or stop taking their antibiotics altogether when they feel well. I see this as a much bigger contributor to the creation of resistant bacteriae. I really don't know the facts about the effectiveness of prophylaxis before dental care but when I hear about so much disagreement among medical professionals about it, I feel the cardiac patient should have a choice.

By the way, what's the deal with some pharmacies giving away free antibiotics? I realize this is a new take on the "loss leader" concept, but how can this be good in light of pervasive overuse?

 

[catwoman]

Most of us do not have concern about obtaining prophylactics. Mainly because we have had valve replacement. And it is approved for such.

As many of you may be aware, they have changed the guidelines for those that have valve issues other than replacmen. Let's use MVP with reguirg as an example.

Are these truly new?

I know the AHA changed the guidelines in 2007, but I've examined the AHA website and don't see any date in 2009 given for the guidelines for antibiotics as prophylactics for predentals.
I checked Circulation's website and can't find anything for 2009.

 

[Jkm7]

I am very concerned about this. Voted 4. My cardio and PCP both refused to give me meds for dental work. Yet, the surgeon I consulted said that I should take meds, he doesn't like the new guidelines. So I am at a loss. I am having a lot of dental procedures lately (root canal gone bad, that's a long story) but finally last time the dentist prescribed me antibiotics which I filled and took hours after the procedure. Shouldn't it be my choice? I hate putting myself at risk.

How about asking your dentist for the Rx. Most are more than happy for their patients to pre-medicate. It is protection for them against your possibly getting an infection that might have been avoided.

Dentist might be very willing to do it for you.

 

[skeptic49]

hey,

The bottom line here is that there is NO evidence that pre dental antibiotics reduce the incidence of endocarditis, this means that people who take pre dental antibiotics and those who dont have the same risk for endocarditis (for those in the waiting room, not those who have had replacements) (read, your cardio probably would have still contracted endocarditis if he had taken pre dental antibiotics) there is still a big chance of endocarditis whether or not you take pre dental antibiotics, not to mention you create bacteremia (bacteria in the blood, the same reason you talke pre dental antibiotics) which can cause endocarditis every day by brushing your teeth, eating sharp/crunchy foods, this is as risky if not risker than a dental appt. this coupled with the increasing numbers of resistant bacteria, which is caused by many many things, including overzealous pediatricians, as well as many adults taking antibiotics that arent needed, including predental antibiotics, and preemptive antibiotics for stuff like sore throats

the bottom line here is that the risk outweights the benefits, which are non existant according to the recent research, whether or not you take antibiotics you have the same risk of endocarditis, so why encourage antibiotic resistance?

Thank you for this beautifully written analysis, which I totally agree with based on my reading of the "new" guidelines and my conversations with physicians and dentists.

I'm in the waiting room and I know that I am at risk for endocarditis from any number of sources (e.g. dental, prostate infections, etc..) and I'm also quite confident that antibiotic prophalaxis is of utterly no benefit to me in preventing it. I don't like it but I have to face reality. Taking amox pre-surgery is equivalent to taking a placebo: it may make you feel better but it does no real good.

Jim

 

[Tbone]

Taking them just gives me more piece of mind. I always have, and always will. You know it wasn't that long ago when they raised the dosage.

 

[COLLEEN S]

I dont really think its overprescribing it. If MRSA would appear, there are stronger strains of antibiotics to eradicate any problem.

 

[Adrienne]

I find it hard to believe that the benefits are non-existant. The very fact that oral antibiotics usually cure a bacterial infection if the bacteria have not yet latched onto a valve is enough of a reason to me to think that having the antibiotics in your bloodstream when the dentist does a procedure just has to have some effect. I am not a health professional, but it just seems logical to me.

 

[LUVMyBirman]

Adrienne,

Another great point.

If there was zero benefit. They would instated an order not to pre-med for everyone. Makes me think they are not certain..and testing the waters! Time will tell.

Colleen,

I agree, that was the 'brush off' response I received. Someone here once said "it's not your chest on the table".

JKM7,

Yes, the dentist should not have a problem with prescribing in most cases. That is IF you are established. One of our issues right now. We are in the middle of establishing and it has not been fun!

 

[Trinityheart8891]

the thing is they never did prove that antibiotics were effective as pre dental prophylaxis even from the beginning when they started prescribing them, they didnt have any evidence for prescribing them, they just did it. there are as many cases of endocarditis in those who take the antibiotics as those who dont, this is called evidence based medicine, now that they are proving that there are no difference in the numbers of endocarditis in those who do and dont take antibiotics except in those at the highest risk, there is no justification for prescribing antibiotics unless someone is considered "high risk"

the antibiotics that they prescribe arent necessarily the right ones for the bacteria that enter the bloodstream its just a guess, and amoxicillin and penicillin are the exact types of antibiotics that caused the surge of MRSA, the thing is is that MRSA isnt the only up and coming resistant bacteria, vancomycin used to be the strongest antibiotic we had, and now we have bacteria that are resistant to that. At the hospital I have clinical at we've seen at least 3 or 4 cases of endocarditis come through that were caused by bacteria that wouldnt have responded to "cillin" antibiotics, and probably didnt come from oropharyngeal bacteria anyways, plus there are tons of bacteria in the mouth that dont respond to cillin antibiotics, not only that we are running out of effective antibiotics, there isnt always a stronger antibiotic, we are burning through them faster than they are being developed, and that means if we keep abusing antibiotics the way we are at some point there wont be anything effective when we really need it

 

[LUVMyBirman]

Trinity,

Thank you for the explanation. It's obvious you are in touch as I see you have a medical background.

As you explain, I am starting to agree with some the obvious points.

I do know for a fact that amox is still widely prescribed to children with ear infections and respiratory illnesses such as the flu. They were to stop prescribing for the ear and let it work it's way out. Actually, on my own child, I use a homeopathic drop for the inner ear that works great. Have personally seen antibiotic resistance with the ear.

Examples of overprescribing. Where I feel most of the problem lies. Not for the occasional dental cleaning!

 

[tobagotwo]

Unfortunately, this poll doesn't allow for someone to agree with the new guidelines, or even to go the other way, saying they're still too strict, and antibiotics are still overprescribed. It only allows people to vote whether they've been told to take them, or the negative, that they feel they're at risk.

There was no science to the initial idea of "prophylactic antibiotics." It just sounded like it ought to work. So doctors just started doing it. And then they had to do it, so other doctors didn't accuse them of not taking care of their patients properly. No one ever checked.

The results of 50 years of data are quite clear that there is a greater risk from taking the antibiotics than not, and that prophylactic antibiotics do not prevent endocarditis. That is why the ACC and the AHA (American College of Cardiologists and American Heart Association) changed the guidelines, of their own volition. The quote above indicates that somehow the cardiologists were against their own vote - which they were not. Not only the two organizations above, but all those listed below (and many more) are in tune with the new guidelines.

http://www.aafp.org/afp/20080215/practice.html (this is the American Academy of Family Physicians):

The AHA no longer recommends antibiotic prophylaxis based on an increased lifetime risk of infective endocarditis. No data prove that antibiotic prophylaxis prevents bacteremia-associated infective endocarditis that occurs after an invasive procedure.

Revised AHA Guidelines for Prevention of Infective EndocarditisThe 2007 guidelines reflect questions about the effectiveness of antimicrobial prophylaxis for IE associated with dental, GI, or GU tract procedures. Sponsoring Organizations: American Heart Association, American Dental Association, Infectious Diseases Society of America, Pediatric Infectious Diseases Society. http://cardiology.jwatch.org/cgi/content/full/2007/530/1 :

Key Points:
1. Prophylactic antibiotics based on a patient?s lifetime risk for acquiring IE are no longer recommended for dental, GI, or GU tract procedures. This recommendation follows from the observation that most cases of IE result from bacteremia caused by routine activities such as chewing food, brushing teeth, and flossing. Moreover, no published data clearly indicate that prophylaxis prevents IE from invasive procedures.

Prevention of Bacterial Endocarditis
Recommendations by the American Heart Association from AHA journals do not sound unconvinced. http://www.circ.ahajournals.org/cgi/content/full/96/1/358 :

There are currently no randomized and carefully controlled human trials in patients with underlying structural heart disease to definitively establish that antibiotic prophylaxis provides protection against development of endocarditis during bacteremia-inducing procedures. Further, most cases of endocarditis are not attributable to an invasive procedure.

Quotes from a publication from the Cleveland Clinic regarding the guidelines: http://www.clevelandclinicmeded.com...infectiousdisease/prophylaxis/prophylaxis.htm :

Since endocarditis is a relatively uncommon condition, and many episodes of endocarditis are not linked to procedures

The American Dental Association and American Academy of Orthopaedic Surgeons have issued an advisory statement which states that antibiotic prophylaxis is not routinely indicated for most dental patients with total joint replacements

NICE (UK?s National Institute for Health and Clinical Excellence) has published a very similar set of guidelines in a printable booklet form http://www.nice.org.uk/nicemedia/pdf/CG64PIEQRG.pdf , including this quote:

Antibiotics have been offered routinely as a preventative measure to people at risk of infective endocarditis undergoing interventional procedures. However, there is little evidence to support this practice. Antibiotic prophylaxis has not been proven to be effective and there is no clear association between episodes of infective endocarditis and interventional procedures.

The British Society for Antimicrobial Chemotherapy (BASC) has also agreed to support the NICE guidelines.

Here is a handy prophylactic antibiotic use table borrowed from the National Marfan Foundation Site, who borrowed it from the ADA http://www.marfan.org/marfan/2565/NMF-PAB-Endocarditis-Prophylaxis-Guidelines--2007 :