endocarditis is a nightmare

[starburstcoral]

My husband who had his AVR April 2010 porcine valve had a cut on his gum that looked red. He went to the dentist a few days later and he thought it was fine, just a little swollen. My husband took antibiotics. He wasn't feeling that great though and felt tired. A week later he had the area that was still swollen lasered off and also took antibiotics. He thought he was fine but still felt achy and just tired. Finally he took his temp and noticed he had a fever. We went to the ER, and all three of the blood cultures grew and showed infection. They started him on intravenous antibiotics and the source of the infection was from mouth strep. They did a TEE and did not find anything on his valve, but suspect the infection was on the wires or directly on his ICD which was sore to the touch. He was fortunate it didn't go any further since it had a few weeks time to grow. He went home after a week and we did 4 weeks of intravenous antibiotics at home. What a nightmare. I write this to let anyone know just in case they don't know that infective endocarditis is most commonly from tooth/teeth/ gum problems and procedures. The most effective way to take your antibiotics is a few hours before a dental procedure so that the antibiotics are at full impact in your bloodstream during the dental procedure.

 

[Mentu]

In the past, I've been careful to take my antibiotics before dental exams but after your caution, I will be especially careful tomorrow when I am to have a tooth prepared for a crown. I'm glad to hear your husband will be alright. Thanks for the caution.

Larry

 

[Superbob]

So sorry your husband had to go through this. Hope all will be well from now on.

Dental work is a worry -- but I suppose there's less risk in having the necessary work done than in letting dental problems fester and get infected. I have taken the antibiotics for dental work for many, many years. The current protocol is four amoxicillin pills an hour before the dental work, but years ago the procedure was several pills before and then several after. I can see the desirability of having antibiotics before, but I wonder why they no longer recommend for afterward, too?

I have to get a tooth worked on next week, too. The dentist and hygienist promoted me getting a crown, but the dentist admitted he could just "patch" it for now. Personally, I wonder if it would be better just to have it extracted. (It's a back tooth.) Will try to settle for a cut and paste. Anyway, whatever, I will take my antibiotics. All best wishes to your hubby!

 

[Allisoninoz]

I had a slightly cracked back molar a couple of months ago. It was very sensitive to heat and cold so the dentist put a metal band around and told me to come back if it kept hurting. I went back two weeks ago. He said he could either do root canal treatment - with no guarantee it would work - or extract it. I had it extracted after having the antibiotics beforehand. I was very cautious about ensuring the rather large hole was kept clean of food and gunk, and went back to him again when I was worried it wasn't healing after a week. He gave me an extra mouthwash. It's so important to watch the mouth/gum area!

 

[Lynlw]

Sorry to hear this. Does he have any idea how he got the cut on his gums? I know it must have been a relief to see nothing grew on his valve. Justin's had BE when he was 11 after losing a baby molar, luckily his was caught before anything grew on his heart or pacemaker wires so didnt need surgery either

 

[ski girl]

Glad to hear he's OK. IV antibiotics at home may seem like a 'nightmare', but it's nothing compared to actually getting endocarditis and requiring emergency OHS to replace a valve that you've only had for 11 months! I too had a common mouth Strep but TEE showed a 7mm thick growth of it on my valve. And I never noticed any cuts on my gums, neither did my docs who had a good look.

Your husband was very lucky not to have anything grow on his valve!!

I've posted more about my story in one of the forums ('infective endocarditis') as well as what I was told (TOO LATE!!) to reduce my chances of getting it.

 

[normofthenorth]

Like the collected scientific evidence on this subject, the evidence in this one case is confusing and contradictory, if not mostly backwards. Starburstcoral's husband's initial BE -- the invasion of oral Strep into his bloodstream -- very likely came from the gum cut, and not from any dental work. In addition, he took prophilactic antibiotics not once, but twice, and still got infected. Avoiding BE is a great idea, but the evidence that (a) a bunch of BE comes from visits to the dentist, and (b) a bunch of those BE cases would be prevented by prophilactic antibiotics, is flaky or non-existent, both (a) and (b).

Skigirl's doc recommended using an anti-bacterial mouthwash first, before brushing, flossing, using Stim-U-Dents, whatever. That might well turn out to help as much as the prophilactic antibiotics before dental visits.

 

[Lynlw]

Like the collected scientific evidence on this subject, the evidence in this one case is confusing and contradictory, if not mostly backwards. Starburstcoral's husband's initial BE -- the invasion of oral Strep into his bloodstream -- very likely came from the gum cut, and not from any dental work. In addition, he took prophilactic antibiotics not once, but twice, and still got infected. Avoiding BE is a great idea, but the evidence that (a) a bunch of BE comes from visits to the dentist, and (b) a bunch of those BE cases would be prevented by prophilactic antibiotics, is flaky or non-existent, both (a) and (b).

Skigirl's doc recommended using an anti-bacterial mouthwash first, before brushing, flossing, using Stim-U-Dents, whatever. That might well turn out to help as much as the prophilactic antibiotics before dental visits.

First i agree it most likely came from the swollen cut that was there days before the dentist, which is why I asked about the cut,. Depending what the bacteria was and what it was suspeptable to could have made a difference since he did get relatively large doses of antibiotics early, IF it was antibiotics it was suspetable too chances are it could have kept it from spreading from an infected gum to the blood stream, just like the majority of infections people get that are treated don't get into the bloodstream..Of course we will never know, well it would be interesting to know what bacteria it was and what antibiotic he had for the BE.
BUt I wouldnt say he took antibiotics twice and still got infected, since most likely he already had the infection..they couldn't prevent it.

However I think the moral of this story COULD be IF you have an infection in your mouth or gums or think you have an infection, go to the dentist, or call your doctor and get it treated. Most likely with a course, of oral antibiotics for a week or so. Justin HAS had an infected impacted wisdom tooth. They put him on antibiotics right away for a week or so until it could clear up, THEN they removed it. and that was followed up with about another week of antibiotics.
He had other smaller infections or abcesses, and was put on antibiotics for them and they cleared up so didnt get into his blood stream

 

[Phil]

Endo is indeed a nightmare. Having had it once I never want it again!

Good luck to your husband (and you too).

All the best.


Phil.

 

[OldManEmu]

Having had endocarditis in the past I can relate to this.
My cardio has reinforced to me that once having had endocarditis you are at increased risk in the future.
She detailed to me the need for antibiotic coverage for dental procedures, colonoscopies, urinary tract procedures, gastro intestinal and upper respiratory tract procedures.
Basically any procedure that has a high risk of releasing bacteria into the blood stream.
So far I have avoided contracting endocarditis again and I hope it stays that way.

 

[epstns]

Question - Am I misinterpreting something or not remembering correctly - I thought that I read some time ago that the protocol of prescribing prophylactic antibiotics prior to dental procedures was now "optional." I distinctly remember having a discussion with my dentist about it, and we both concluded that for me, there is not an option. I will continue with antibiotics before any invasive procedure, dental or otherwise.

 

[Lynlw]

Question - Am I misinterpreting something or not remembering correctly - I thought that I read some time ago that the protocol of prescribing prophylactic antibiotics prior to dental procedures was now "optional." I distinctly remember having a discussion with my dentist about it, and we both concluded that for me, there is not an option. I will continue with antibiotics before any invasive procedure, dental or otherwise.

They did change, but for groups who not only are at the higher risks of getting BE, but also would have the worst outcomes IF they got BE it is STILL reccomended in the US and most other countires. I believe the NICE Guidelines (last I read them) for the UK, dont reccomend them, but they are optional IF the patients wants them the dentisit should give them)

For the US valve patients (patients with replaced valves and some repairs like ones that use rings etc)
ARE still on the list that are reccomended to get prophalactic antibiotics.
Here is the short version/ wallet card http://www.heart.org/idc/groups/heart-public/@wcm/@hcm/documents/downloadable/ucm_307644.pdf


....Antibiotic prophylaxis with dental procedures is reasonable only
for patients with cardiac conditions associated with the
highest risk of adverse outcomes from endocarditis, including:

• Prosthetic cardiac valve or prosthetic material used in valve repair
• Previous endocarditis
• Congenital heart disease only in the following categories:
– Unrepaired cyanotic congenital heart disease, including those
with palliative shunts and conduits
– Completely repaired congenital heart disease with prosthetic
material or device, whether placed by surgery or catheter
intervention, during the first six months after the procedure*
– Repaired congenital heart disease with residual defects at the
site or adjacent to the site of a prosthetic patch or prosthetic
device (which inhibit endothelialization)
• Cardiac transplantation recipients with cardiac valvular disease

and the full article http://circ.ahajournals.org/content/116/15/1736.full

 

[bdryer]

starburstcoral

Good on you for your care and concern, by bringing this most serious matter again into the fore ground. Looking forward to your next post. Once again, Thanks.

A few threads as of late have been regarding the mandatory precautions associated with any thing dental and endocarditis.

I have resurrected an old thread that I started several months ago, regarding endocarditis as the great equalizer. I have attached it below. It is a worthwhile read for the new and a great reminder to the rest of us, to be vigilant beyond dental and oral hygiene:

http://www.valvereplacement.org/for...hink-caused-your-endocarditis&referrerid=8176

 

[bdryer]

Norm

I do not understand how you thought the history was, "flaky" or out of order.

starburstcoral's opening sentence states that the cut on his gum started the whole episode off. That is why he went to the dentist. It was the infection from the gum cut that sent him to the dentist. He started the oral antibiotics but, to late the disease was already blossoming to the level where oral anti-biotic weren't going to touch it. Then she gave us the details of the events that unfolded. Her post made perfect chronological sense to me.

What the heck? Man, all she was saying was, "I write this to let anyone know just in case they don't know that infective endocarditis is most commonly from tooth/teeth/ gum problems and procedures". Then she went on to tell us that if knowingly require dental work, to take antibiotics.

Her story is about having a cut on the gums, not taking the required action and the ensuing results. Then she closes out by giving advice on the "knowing" aspect of dental work. "Flaky", would you run this by us again? Just can't see it.

 

[yotphix]

bdryer: Norm can defend his own statement but I think you misread his intention. He appears to be referring to the evidence presented as an argument for the very idea that BE comes from dental visits generally, as flaky. I may be wrong, but I don't think he is intending to make any characterization of the original poster or her statements as flaky.

On the other hand, I recall reading over some of the controversy regarding the usefulness of taking antibiotics before dental work when you are in a susceptible group, and concluding that the principle motivation to recall the recommendation was that it is better for the herd. That is, the concern is for the overprescription of antibiotics reducing their general effectiveness by forcing an evolutionary selection of resistant strains. While this concern is valid, my recollection is that there is some NOT flaky evidence for the risk of BE from dental work in susceptible populations. This posting is not about that topic, since the infection was acquired elsewhere in this case, but I do take, and am always recommended to take, antibiotics before dental work. I take a gram dose of amoxicillin, though there are other options out there.

 

[Mom2izzy]

Yotphix/bdryer: that was my take on Norms statement as well. I believe that the risk of BE from dental procedures is real, but whether the antibiotic actually helps and whether the "heart" population is actually that much more susceptible than the general population is the "flaky" part. The statistics vary, as statistics tend to do depending on what the statistician wants them to say. I once read that I (MVP, but no surgery yet) was only 0.001% more susceptible than the general population. That was not enough risk for me...I quit taking the antibiotics then...They made me so nauseous, I was looking for the excuse! Now what I'm thinking is that it really isn't about being more susceptible, it's about how much worse it is for someone with an already compromised valve to get BE. From that perspective, it does make more sense. As much as I hate the idea of taking them, I expect that I will have to go back to it after my surgery...ugh!

 

[normofthenorth]

Ya, you last 2 read me right. Nothing flaky about starburstcoral or the post. But neither the story nor the evidence as a whole paints a straight-line picture, from cause to effect to response/solution. The pre-dosing MAY help avoid BE, and BE is so scary for us valvers, that maybe it's worth the cost, risks, & nuisance - at least 'til the next guidelines! ;-)

BTW, I may be wrong, but I think there are risks to the individual, not just the "herd". I.e. I expect that my own habitual 'cyllin use increases the probability that my own "resident" bacteria will develop antibiotic resistance. There are also suggestions (& maybe evidence?) that wiping out our gut bacteria for a while is not risk-free. (I do "dose" with some yogurt.)

 

[tom in MO]

I have BAV and was first told 30 years ago (when it was just a heart murmur) to do the anti-biotic treatment even if I had a cold, then just for dental or invasive procedures, and then not at all. My GP stated that the reason for the changes is that there has never been a documented case of infection from colds, dental cleaning, etc. for someone with a heart murmur. The treatment was initially based upon logic not science. Science proved the treatment unnecessary, and there is science to say that antibotics should not be used unless needed.

I always thought that if endo from the mouth was that bad, even the little bit of blood from flossing would be risky. My doctor or dentist had no answer for that one. Nobody tells you to rinse with an antiseptic mouth wash before brushing/flossing, maybe it would be a good idea.

 

[Bryan B]

I will just throw my story in here as an example that the mouth is not the source all endocarditis. I developed a bad case of bronchitis that turned into recurring chronic bronchitis. I went from one broad spectrum antibiotic to another and they could not knock it out. Finally when they added steroids and a strong narcotic cough medicine (which was a fun combination for a short time ) to the mix this allowed my lungs to recuperate long enough for the infection to clear. Unfortunately, because I had a VSD since birth which was also causing one of my aortic valve leaflets to prolapse I was a prime candidate for endocarditis. It was the subacute variety and it took them 4 months to diagnose it which was about the time I was on death's door. After 7 weeks of IV Rocephin and a few months of selecting a valve and a surgeon my valve was replaced. The infectious disease doc said he had no doubt that my endocarditis was caused by my festering bronchial infection.

I am on the bandwagon with dental hygiene and pre-dental antibiotics for procedures in which they expect possible bleeding (cleaning, extraction, etc) and agree this is probably the way the majority of people contract the infection, but there are other ways. That is why it is important for all of us valvers to become aware of ALL of the symptoms of endocarditis and act early before vegetations start forming on the valve. The vegetations are what damages the valve and has the potential to break off into the bloodstream causing a potential catastrophic stroke or embolism.

 

[ski girl]

Tom in Mo - no-one told me to rinse with antiseptic mouthwash before brushing . . . until I got endocarditis and had emergency OHS to replace my tissue valve! Then I got told that I should always have been doing that. I do now, and so should we all! My infectious diseases doctor says the mouthwash is more effective than pre-medicating before going to the dentist too.