Endocarditis prophylaxis

By the preventive administration of antibiotics in the Endocarditis prophylaxis to prevent the colonization of bacteria in the heart after dental and other interventions. Today endocarditis prophylaxis is only recommended for high-risk patients.

What is endocarditis prophylaxis?

Endocarditis prophylaxis is intended to prevent endocarditis. It is usually recommended for surgical or endoscopic procedures. Above all, this includes dental interventions that involve injury to the gums.

Tooth extractions, root treatments and tartar removal are indications for endocarditis prophylaxis. Other medical interventions on the upper respiratory tract are also among the indications. In the past, endocarditis prophylaxis was recommended for many other procedures. However, the indications have been restricted more and more in recent years.

The limitation of the indications and the associated guidelines were discussed controversially. There is no clearly documented benefit for endocarditis prophylaxis. However, doctors are still free to carry out endocarditis prophylaxis after a thorough risk-benefit assessment.

Function, effect & goals

Endocarditis is inflammation of the lining of the heart. The endocardium lines the heart cavities and forms the heart valves. The germs causing endocarditis include bacteria from the so-called HACEK group.

Germs of this group are Aggregatibacter aphrophilus, Aggregatibacter actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens and Kingella kingae. The natural habitat of these bacteria is the oral cavity. If you have an operation in this area, they can penetrate the wound and travel to the heart via the bloodstream. Enterococci, staphylococci, streptococci and Brucella melitensis can also cause endocarditis.

Endocarditis is associated with fever in 90 percent of cases. Those affected are also weak, have little appetite and lose weight. Heart murmurs and signs of heart failure may occur. Petechiae or Osler nodules are visible in 30 percent of cases.

Endocarditis can damage the heart valves. Inflammatory coatings can come off the heart and get into the organs via the bloodstream. This can cause a pulmonary embolism, a stroke, or a kidney embolism. The spread of germs to other organs with subsequent abscess formation is also possible.

In uncomplicated cases, the patient is given the antibiotic amoxicillin orally one hour before the procedure to prevent endocarditis. Amoxicillin is an antibiotic from the group of aminopenicillins. The antibiotic works with gram-positive and gram-negative cocci. Escherichia coli, Listeria, Proteus species and enterococci also belong to the spectrum of activity of amoxicillin. The American Medical Association recommends a dose of 2 grams for adults. The dosage in children should be 50 milligrams per kilogram of body weight.

If the antibiotic cannot be given orally, the doctor can give the agent intravenously. Ampicillin is also used for dental interventions. Ampicillin is also used for ENT procedures or for operations on the airways and esophagus. For interventions on the intestines, the biliary tract or the urogenital tract, in addition to ampicillin i. v. also gentamycin i. v. used.

If the patient is allergic to penicillins and penicillin derivatives, oral administration of azithromycin, linezolid, cephalosporins, clindamycin and clarithromycin can be avoided. Alternatively, vancomycin can also be administered intravenously. Endocarditis prophylaxis is recommended for dental procedures and for medical procedures in the area of ​​the mouth, throat, pharynx and teeth. These include tooth extractions, root canals, tonsil removal, lymph node removal, polypectomies and tartar removal.

Prophylaxis in the context of interventions on the respiratory tract, the gastrointestinal tract or the urogenital tract are only carried out in the case of existing infections or if a focus of inflammation is opened during the interventions. Such foci of inflammation are, for example, abscesses or boils. Endocarditis prophylaxis is no longer recommended for esophagogastroduodenoscopies, colonoscopies, bronchoscopies, and endoscopic retrograde cholangiopancreatographies.

People with prosthetic heart valves or heart valve defects are at increased risk for infectious endocarditis. Congenital heart defects and previous heart transplants also increase the risk of endocarditis. The same applies to previous endocarditis or to frequent venous puncture (e.g. during dialysis or intravenous drug abuse). The American Heart Association (AHA) recommends endocarditis prophylaxis in high-risk patients with prosthetic heart valves, congenital heart defects, who have had a prior heart transplant or valvulopathy, and who have had endocarditis.

The German Society for Cardiology (DGK) largely agrees with these recommendations, but recommends prophylaxis for all heart valve defects and not only for congenital heart valve defects.

Risks, side effects & dangers

Many patients are allergic to amoxicillin. About one in 7000 patients reacts to the administration with severe allergic symptoms. The symptoms of an allergy to amoxicillin range from a slight reddening of the skin to anaphylactic shock.

Penicillins such as amoxicillin also kill the beneficial bacteria in the intestinal flora. This can cause diarrhea or other digestive problems. If harmful microorganisms spread in the intestine as part of antibiotic treatment, antibiotic-associated colitis can develop. It is an inflammation of the colon that causes severe pain and diarrhea. In addition, drug fever occasionally occurs when amoxicillin is given. Diarrhea, vomiting and nausea must also be expected. The patients rarely suffer from sleep disorders, symptoms of fatigue or states of confusion.

If you want to do without an antibiotic for prophylaxis or have to do without, dental care and dental restoration should be of particular importance. Good dental hygiene can reduce the bacterial load in the mouth and thus also prevent endocarditis.