Andersons pediatric cardiology 1499

NICE2008recommendationsarethemostfarreachingandrecommend
cessationofprophylaxissolelytopreventIEfordentalandnondental
procedures.216NICE2016updatedrecommendationsaddedthepossibilityfor
individualdecision.5TheESC2009andAHA2007guidelinesstillrequiredthat
asmallgroupofhigh-riskpatientshaveprophylaxisfordentalprocedures,with
manipulationofthegingivalorperiapicalregionoftheteethorperforationof
theoralmucosa(seeearlierforrecommendationsextrapolatedtopiercingofthe
oralmucosa).TheESC2015recommendationsdiscardtheindicationfor
transplantedheartvalvulopathy.
ThecurrentESC2015recommendationsforantibioticprophylaxisare
summarizedinBox56.6.


Box56.6

RecommendationsontheEuropeanSocietyof
Cardiology2015GuidelinesforAntibiotic
ProphylaxisAroundDentalProcedures
AntibioticProphylaxisShouldBeConsideredfor
PatientsatHighestRiskforIE:
1.Patientswithanyprostheticvalve,includingatranscathetervalve,or
thoseinwhomanyprostheticmaterialwasusedforcardiacvalverepair.
2.PatientswithapreviousepisodeofIE.
3.PatientswithCHD:
■AnytypeofcyanoticCHD.
■AnytypeofCHDrepairedwithaprostheticmaterial,whether
placedsurgicallyorbypercutaneoustechniques,upto6months
aftertheprocedureorlifelongifresidualshuntorvalvar
regurgitationremains.
AntibioticprophylaxisisnotrecommendedinotherformsofvalvarorCHD.

RecommendedProphylaxisforHigh-RiskDental


ProceduresinHigh-RiskPatients:
Antibioticsingle-dose30–60minutesbeforeprocedure
1.Noallergytopenicillinorampicillin:Amoxicillin2gorallyorIV
(children50mg/kgorallyorIV)
2.Allergytopenicillinorampicillin:Clindamycin600mgorallyorIV
(children20mg/kgorallyorIV)
Cephalosporinsshouldnotbeusedinpatientswithanaphylaxis,angioedema,
orurticariaafterintakeofpenicillinorampicillinduetocross-sensitivity.
CHD,Congenitalheartdisease;IE,infectiveendocarditis.
RecommendationsarelargelyinlinewithUSAHA2007recommendations.
ProphylaxishasbeendowngradedinFrancesince2002.
UKNICE2008(amended2016):noprophylaxisrecommendedunlessthere
isindividualdecision.
ModifiedfromESC2009/2015IEguidelines.
Theimpressionisthatprostheticvalves,percutaneouslyimplantedpulmonary
valves,andsurgicallyimplantedbovinejugularveinconduitspresenthigherrisk
forIE.However,thedatashowthatwhiletheriskofIEinthelistedconditions
mightbehigher,therearelittledatatosupporttheeffectivenessof
prophylaxis.245Ithasbeenascertainedthatitisinvasiveheartproceduresand
notdentalproceduresthataremoresignificantlyassociatedwithIEinchildren
withCHD.246
ProphylaxisforNondentalProcedures.
Systematicantibioticprophylaxisisnotrecommendedfornondentalprocedures.
Antibiotictherapyisneededonlywheninvasiveproceduresareperformedinthe
contextofinfection.
ForPPMandICDimplantations,prophylaxisshouldbeadministeredwithin1
hourbeforetheprocedure.10ThecurrentpreferenceisforTeicoplanin,whichis

easytoadministerasabolus.Thereisnoevidenceofabenefitofarepeatdose,
althoughtheprophylaxisshouldbecontinuedfor48hoursafteraprolonged
procedure.
PreoperativescreeningofthenasalcarriageforS.aureusisrecommended


beforeelectivecardiacsurgerytotreatcarriers.Theuseoflocalmupirocinor
chlorhexidineisadvocated.247,248Systematiclocaltreatmentwithoutscreening
isnotrecommended.
Itisrecommendedthatpotentialsourcesofdentalsepsisshouldbeeliminated
atleast2weeksbeforeimplantationofaprostheticvalveorotherintracardiacor
intravascularforeignmaterial,unlessthelatterprocedureisurgent.
ProphylaxisRecommendationsof2007–2008Compliance.
TherearefewstudiesoncompliancewiththeIEprophylaxisrecommendations.
A2016paperreportsthatmorethanhalfofthepediatriccardiologistsinthe
UnitedStateswereskepticalandupto56%ofpediatriccardiologistsonthe
surveydidnottotallyadheretotheAHA2007IEprophylaxis
recommendations.249Thereisheterogeneityintheattitudesamongcardiologists
inCanadaandAustralia.250By2015,therehadbeencertainreductioninthe
prescriptionsforIEprophylaxisamongpediatricandadultcongenital
cardiologistsinCanada251;theprescriptionshavedecreasedbymorethan90%
intheUnitedKingdom.252
ProphylaxisRecommendationsof2007–2008(forFrance2002)
Impact.
TherearecurrentlycontroversialdataontheimpactofthereductioninIE
prophylaxis.253
Nochangeinincidence.
ThemajorityofpapersreportnochangeofIEincidenceinadultormixed
cohorts254–256andVGSincidence.256,257TheresultsforpurepediatricIE
cohortsalsohaveshownnoincreaseinoverallpediatricIEincidence,20,16,258,259

withsomeincreaseinVGSpediatricIEintheolderchildren259orwithoutVGS
increase.16
Increaseinincidence.
Therearetwopapersmostlyonadultcasespublishedin2015reporting
minimallyincreasedIEincidenceintheUnitedStates260andtheUnited
Kingdom261butwithoutincreaseoftherateofhospitalizationorvalve
surgery.260However,theauthorsstoppedshortofmakingacausallinkbetween
thatIEincidenceincreaseandthecessationofIEprophylaxis.