Professional Documents
Culture Documents
Areas of Focus
Antibiotic prophylaxis for infective endocarditis Antibiotic prophylaxis for individuals with prosthetic joints Antibiotic use for open wounds
Objectives
Review and apply the new AHA practice guidelines for the prevention of infective endocarditis. Discuss the current recommendations for the prevention of prosthetic joint infections. Identify the risk factors for infection after traumatic skin lacerations and the scenarios where antibiotic prophylaxis is indicated. Evaluate the risk of administering prophylactic antibiotics vs. the scientific evidence for benefit into clinical decision-making.
Estimated 5370 min (~90 hrs) of bacteremia/mo in dentulous persons who chew and practice standard oral hygiene
the focus on the frequency of bacteremia associated with a specific dental procedure and the AHA guidelines for prevention of IE have resulted in an overemphasis on antibiotic prophylaxis and an under-emphasis on maintenance of good oral hygiene and access to routine dental care, which are likely more important in reducing the lifetime risk of IE than the administration of antibiotic prophylaxis for a dental procedure.
Not included Bicuspid aortic valve Acquired aortic or mitral valve disease
MVP with regurgitation Prior valve repair
Respiratory procedures:
Procedures involving incision/ biopsy of the mucosa
Removal of tonsils/ adenoids TBBX but NOT bronchoscopy only
GU procedures:
ONLY during active enterococcal infection
GI procedures:
NO LONGER INCLUDED
AHA Guidelines, Circulation, May 2007
Agent
Amoxicillin Ampicillin Cefazolin or Ceftriaxone Cephalexin Clindamycin Azithromycin Cefazolin or Ceftriaxone Clindamycin
Adults*
2g 2 gm IM/IV 1 gm IM/IV 2 gm 600 mg 500 mg 1 gm IM/IV 600 mg IM/IV
Children*
50 mg/kg 50 mg/kg IM/IV for all 50 mg/kg 20 mg/kg 15 mg/kg 50 mg/kg IM/IV 20 mg/kg IM/IV
Should patients with valvular heart disease and pharyngitis be treated more readily with antibiotics? Proposed rationale #1:
Streptococci are a common cause of IE, thus antibiotic therapy will prevent bacteremia and subsequent IE.
The Facts:
Streptococci account for 60-80% of IE cases Group A Streptococci (GAS) IE is extremely rare Ratio of IE to non-IE bacteremia cases for GAS is 1:32 Conclusion: Persons with pharyngitis and valvular heart dx do not require Abx tx on the basis of preventing GAS IE.
Should patients with valvular heart disease and pharyngitis be treated more readily with antibiotics?
Proposed rationale #2:
Streptococcal pharyngitis can predispose to rheumatic fever and subsequent rheumatic heart disease, which may make underlying valvular disease worse.
The facts:
GAS pharyngitis is a known trigger of rheumatic fever (RF) Recurrent GAS pharyngitis can lead to recurrent episodes of RF and eventual valvular heart disease (<25%) Prolonged PCN prophylaxis following an episode of RF can prevent relapses and progressive valvular destruction Conclusion: Prolonged PCN prophylaxis, not repeated PCN courses, for pharyngitis is the standard of care to prevent recurrent RF.
http://www.aaos.org/about/papers/advistmt/1033.asp
Findings:
No risk of PJIs in pts undergoing high or low risk dental procedures without antibiotic prophylaxis Antibiotic prophylaxis did not the risk of PJIs No difference with subset analysis of PJIs of potential dental/oral origin Trend toward PJIs in pts with >1 dental hygiene visit
Conclusions:
Data refute the AAOS recommendation of universal antibiotic prophylaxis for dental procedures in pts with arthroplasties
Berbari EF, Clin Inf Dis 50:8, 2010
Findings:
No association between dental procedures and PJIs in either time-to-event analysis nor the case-control analysis Trend toward more dental procedures in preceding 90 days in control pts than those with PJIs
Conclusions:
Dental procedures not associated with a higher risk of PJIs The 2009 AAOS Information Statement should be reconsidered
Skaar DD, JADA 142:1343, 2011
Background
Lacerations and open wounds are the 3rd most commonly encountered problems in the ED
Account for 8% of the 95 million ED visits in US/ year
Common Goals of Treatment: Avoiding infection Optimal functional and cosmetic result
Study Population:
Univ Med Center at Stony Brook, 1992-1996 All pts with traumatic lacerations eligible, without standardizing wound tx
Results:
5521 pts enrolled, 194 infections (3.5%) over 4 yrs Mean time of presentation: 2.1 (+/- 3.6 hrs after injury) Foreign body/bite wounds accounted for <20% Most had single layer repairs 14% treated with systemic antibiotic prophylaxis
Hollander JE, Acad Emer Med 8:716, 2001
Risk of Infection
Head/scalp wounds* Blunt mechanism of injury
Open fractures or wounds into joints Wounds involving tendons or cartilage Gross contamination & cannot be adequately cleaned Puncture or crush injuries Bite wounds Oral wounds >18 hr delay in presentation
Moran GJ, Infect Dis Clin No Amer 22:117, 2008
Additional Points:
Parenteral antibiotics not shown to more effective than oral antibiotics It is not necessary to include activity against CA-MRSA For most cutaneous wounds, 24 hrs of antibiotics after wound closure is sufficient
Moran GJ, Infect Dis Clin No Amer 22:117, 2008
risk for deep, forefoot wounds, delayed presentation No randomized trials have evaluated the benefits of prophylactic Abx Prospective, observational study suggests cleansing alone likely adequate with close f/u
Singer AJ, NEJM 359:1037, 2008
Bacteriology
Primarily mixed anaerobes and aerobes Cats: Pasteurella multocida Dogs: P. multocida, Capnocytophaga canimorsus Humans: HBV, HIV
Singer AJ, NEJM 359:1037, 2008 Moran GJ, Infect Dis Clin No Amer 22:117, 2008
Duration: 3-5 days Systematic data review concludes benefit of antibiotic prophylaxis only for hand bites and cat/human bites
Singer AJ, NEJM 359:1037, 2008 Moran GJ, Infect Dis Clin No Amer 22:117, 2008