Routinemäßiger Einsatz von Antibiotika bei zahnärztlicher Behandlung?

Als Folge bestimmter zahnärztlicher Eingriffe -mit Einschwemmung von hochinfektiösen Bakterien in die Blutbahn- kommt es gelegentlich zu einer infektiösen Endokarditis. Das ist eine ansteckende Entzündung der Herzinnenhaut. Diese Komplikation zahnärztlicher Tätigkeit ist selten - wenn es aber zu dieser Infektion kommt, ist sie sehr gefährlich.  Die American Heart Association hat nun die bereits vor Jahren publizierten Richtlinien geändert, aus denen sich ablesen lässt wann die Herz-Kreislaufexperten eine vorbeugende Antibiotika-Behandlung durch den Zahnarzt sinnvoll ist.

Das Fazit: Antibiotika sollten nicht routinemäßig eingesetzt werden. Sie sind nur dann erforderlich wenn die Patienten unter einer von mehreren genannten Herzkrankheiten leiden. Krankheiten, die den Verlauf einer Endokarditis deutlich komplizieren würden.

Gefährlich sind in dieser Hinsicht zahnärztliche Eingriffe bei denen das Zahnfleisch und/oder die Schleimhaut der Mundhöhle stark in Mitleidenschaft gezogen werden.  Die Experten sind außerdem der Meinung, dass sich nur ein sehr kleiner Teil der Endokarditis-Infektionen durch Antibiotika verhindern ließe. Dies selbst dann, wenn die Therapie zu 100% wirksam wäre.

Die vollständige englischsprachige Kurzversion dieser Studie (sog. MEDLINE Abstract) finden Sie hier

Peter B. Lockhart, DDS, chairman
 

The full 2007 American Heart Association (AHA) guidelines for prevention of infective endocarditis were published online ahead of print in the AHA journal Circulation on April 19, 2007. The portions of the guidelines pertinent to dentistry were adopted by the American Dental Association (ADA) and were published both on ADA.org in April 2007 and in JADA in June 2007. However, the decision was made to reprint this dental version because of corrections made by the AHA to the full guidelines before their publication in the print version of Circulation in October 2007.¹

These AHA recommendations were developed by the AHA guidelines writing group over a three-year period. The document then went through a lengthy and thorough review process whereby adult and pediatric cardiologists, infectious diseases specialists, dentists, epidemiologists, surgeons and others carefully reviewed the document and made suggestions for improvement. After this process was completed, the manuscript was approved for publication by the AHA and was submitted to Circulation for electronic publication. After the April 2007 publication, the AHA writing group learned that there was confusion among the readership regarding the use of the language "Recommended" in the title of Tables 3 and 4 (in this supplement, Boxes 3 and 4) and "may be reasonable" or "may be considered" in the text when referring to the Class IIb recommendations. The writing group has clarified this by revising the wording in the tables and changing the language in the text to "is reasonable." According to AHA policy for wording of classes of recommendations, this change in language is accompanied by a shift in the class of recommendation from IIb to IIa (see Box 1 on page 5S of this supplement).

These adjustments in wording have little impact on dental practice, since they do not change either the cardiac patients or the dental procedures indicated for antibiotic prophylaxis. These changes have been made in the current print¹ and online² versions of the article, and in this JADA supplement, which replaces the version published in the June issue of JADA. Furthermore, the errata have been made available separately online.³

As announced in April 2007, these 2007 AHA recommendations update the previous 1997 AHA recommendations, and there are significant differences in the nature of the patients now considered for prophylaxis. By eliminating the moderate risk group of people who were considered for prophylaxis in the 1997 AHA recommendations, about 90 percent of people no longer are thought to be at risk of developing infective endocarditis as a result of dental procedures to the extent that antibiotic prophylaxis should be considered. In addition, the description of dental procedures to be covered has changed from one of listing procedures that should or should not be covered to a simple sentence that describes the nature of procedures of concern. This is a change that will have little, if any, impact on the nature of dental procedures that are covered with antibiotics.

 

—Peter B. Lockhart, DDS, chairman, Department of Oral Medicine, Carolinas Medical Center, Charlotte, N.C.; member, American Heart Association Rheumatic Fever, Endocarditis and Kawasaki Disease Committee

1. Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association—a guideline from the American Heart Association Rheumatic Fever, Endocarditis and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 2007;116:1736–1754.[Abstract/Free Full Text]
   
   

2. Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association—a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 2007; 116:1736–1754. Available at: "http://circ.ahajournals.org/cgi/content/full/116/15/1736". Accessed Oct. 20, 2007.[Abstract/Free Full Text]
   
   

3. Correction for Wilson et al., Circulation 2007;116(15):1736–54. Available at: "http://circ.ahajournals.org/cgi/content/full/circulationaha;116/15/e376". Accessed Oct. 20, 2007.[Abstract/Free Full Text]
    

Walter Wilson, MD, Kathryn A. Taubert, PhD, FAHA, Michael Gewitz, MD, FAHA, Peter B. Lockhart, DDS, Larry M. Baddour, MD, Matthew Levison, MD, Ann Bolger, MD, FAHA, Christopher H. Cabell, MD, MHS, Masato Takahashi, MD, FAHA, Robert S. Baltimore, MD, Jane W. Newburger, MD, MPH, FAHA, Brian L. Strom, MD, Lloyd Y. Tani, MD, Michael Gerber, MD, Robert O. Bonow, MD, FAHA, Thomas Pallasch, DDS, MS, Stanford T. Shulman, MD, FAHA, Anne H. Rowley, MD, Jane C. Burns, MD, Patricia Ferrieri, MD, Timothy Gardner, MD, FAHA, David Goff, MD, PhD, FAHA and David T. Durack, MD, PhD
 

 
Background. The purpose of this statement is to update the recommendations by the American Heart Association (AHA) for the prevention of infective endocarditis, which were last published in 1997.

Methods and Results. A writing group appointed by the AHA for their expertise in prevention and treatment of infective endocarditis (IE) with liaison members representing the American Dental Association, the Infectious Diseases Society of America and the American Academy of Pediatrics. The writing group reviewed input from national and international experts on IE. The recommendations in this document reflect analyses of relevant literature regarding procedure-related bacteremia and IE; in vitro susceptibility data of the most common microorganisms, which cause IE; results of prophylactic studies in animal models of experimental endocarditis; and retrospective and prospective studies of prevention of IE. MEDLINE database searches from 1950 through 2006 were done for English language articles using the following search terms: endocarditis, infective endocarditis, prophylaxis, prevention, antibiotic, antimicrobial, pathogens, organisms, dental, gastrointestinal, genitourinary, streptococcus, enterococcus, staphylococcus, respiratory, dental surgery, pathogenesis, vaccine, immunization and bacteremia. The reference lists of the identified articles were also searched. The writing group also searched the AHA online library. The American College of Cardiology/AHA classification of recommendations and levels of evidence for practice guidelines were used. The article subsequently was reviewed by outside experts not affiliated with the writing group and by the AHA Science Advisory and Coordinating Committee.

Conclusions. The major changes in the updated recommendations include the following. (1) The committee concluded that only an extremely small number of cases of IE might be prevented by antibiotic prophylaxis for dental procedures even if such prophylactic therapy were 100 percent effective.
 

(2) IE prophylaxis for dental procedures should be recommended only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from IE.

(3) For patients with these underlying cardiac conditions, prophylaxis is recommended for all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa. (4) Prophylaxis is not recommended based solely on an increased lifetime risk of acquisition of IE. (5) Administration of antibiotics solely to prevent endocarditis is not recommended for patients who undergo a genitourinary or gastrointestinal tract procedure. These changes are intended to define more clearly when IE prophylaxis is or is not recommended and to provide more uniform and consistent global recommendations.

Key Words: AHA Scientific Statements; cardiovascular disease; endocarditis; prevention; antibiotic prophylaxis

Abbreviations: ACC: American College of Cardiology • ADA: American Dental Association • AHA: American Heart Association • CFU: Colony-forming unit • CHD: Congenital heart disease • FimA: Fimbrial adhesion protein • GI: Gastrointestinal • GU: Genitourinary • IE: Infective endocarditis • LOE: Level of evidence • MVP: Mitral valve prolapse • NBTE: Nonbacterial thrombotic endocarditis • PVE: Prosthetic valve endocarditis • RHD: Rheumatic heart disease

Infective endocarditis (IE) is an uncommon but life-threatening infection. Despite advances in diagnosis, antimicrobial therapy, surgical techniques and management of complications, patients with IE still have substantial morbidity and mortality related to this condition. Since the last American Heart Association (AHA) publication on prevention of IE in 1997,¹ many authorities, societies and the conclusions of published studies have questioned the efficacy of antimicrobial prophylaxis to prevent IE in patients who undergo a dental, gastrointestinal (GI) or genitourinary (GU) tract procedure and have suggested that the AHA guidelines should be revised.^2–5 Members of the Rheumatic Fever, Endocarditis and Kawasaki Disease Committee of the AHA Council on Cardiovascular Disease in the Young (the Committee), and a national and international group of experts on IE extensively reviewed data published on the prevention of IE. The revised guidelines for IE prophylaxis are the subject of this report.

The writing group was charged with the task of performing an assessment of the evidence and giving a classification of recommendations and a level of evidence (LOE) to each recommendation. The American College of Cardiology (ACC)/AHA classification system was used (Box 1).