Prescribing of antibiotic prophylaxis to prevent infective endocarditis

Abstract

Background: In 2007, the American Heart Association recommended that antibiotic prophylaxis (AP) be restricted to those at high risk of developing complications due to infective endocarditis (IE) undergoing invasive dental procedures. The authors aimed to estimate the appropriateness of AP prescribing according to type of dental procedure performed in patients at high risk, moderate risk, or low or unknown risk of developing IE complications.

Methods: Eighty patients at high risk, 40 patients at moderate risk, and 40 patients at low or unknown risk of developing IE complications were randomly selected from patients with linked dental care, health care, and prescription benefits data in the IBM MarketScan Databases, one of the largest US health care convenience data samples. Two clinicians independently analyzed prescription and dental procedure data to determine whether AP prescribing was likely, possible, or unlikely for each dental visit.

Results: In patients at high risk of developing IE complications, 64% were unlikely to have received AP for invasive dental procedures, and in 32 of 80 high-risk patients (40%) there was no evidence of AP for any dental visit. When AP was prescribed, several different strategies were used to provide coverage for multiple dental visits, including multiday courses, multidose prescriptions, and refills, which sometimes led to an oversupply of antibiotics.

Conclusions: AP prescribing practices were inconsistent, did not always meet the highest antibiotic stewardship standards, and made retrospective evaluation difficult. For those at high risk of developing IE complications, there appears to be a concerning level of underprescribing of AP for invasive dental procedures.

Practical implications: Some dentists might be failing to fully comply with American Heart Association recommendations to provide AP cover for all invasive dental procedures in those at high risk of developing IE complications.

Keywords: Infective endocarditis; antibiotic prophylaxis; antibiotic stewardship; dental procedures; guidelines; prevention; risk.

Figure 1.

Percentage of different levels of invasiveness of dental procedures for which antibiotic prophylaxis coverage was likely, possible, or unlikely for those at high-risk, moderate-risk, or low or unknown risk of developing complications from infective endocarditis. * Excluding the 32 high-risk patients for whom there was no evidence of antibiotic prophylaxis coverage for any dental visit or procedure.

Figure 2.

The proportion of all red invasive dental procedures characterized as periodontal probing, all types of dental scaling (subdivided via codes representing mainly supragingival scaling and those in which subgingival scaling is also required), periodontal surgery, dental extractions, endodontic treatments, oral surgery procedures, and implant-related invasive procedures.

Figure 3.

The proportion of different red invasive dental procedures, that is, periodontal probing, all types of dental scaling (subdivided via codes representing mainly supragingival scaling and those in which subgingival scaling is also required), periodontal surgery, dental extractions, endodontic treatments, oral surgery procedures, and implant-related invasive procedures for which antibiotic prophylaxis coverage was likely, possible, or unlikely for those at high risk, moderate risk, or low or unknown risk of developing complications from infective endocarditis. AP: Antibiotic prophylaxis.

Figure 4.

Antibiotic type and number of days prescribed as a percentage of all antibiotic prophylaxis prescriptions. g: Grams. mg: Milligrams.