Perspectives on the 2007 AHA Endocarditis Prevention Guidelines.

From 2005 to 2007, the American Heart Association convened a consensus panel of experts to revisit the guidelines for the premedication of patients with cardiac defects prior to dental treatment. Presented in this article is a summary of the guidelines as well as commentary on the process.

Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America.

BACKGROUND: Despite advances in medical, surgical, and critical care interventions, infective endocarditis remains a disease that is associated with considerable morbidity and mortality. The continuing evolution of antimicrobial resistance among common pathogens that cause infective endocarditis creates additional therapeutic issues for physicians to manage in this potentially life-threatening illness. METHODS AND RESULTS: This work represents the third iteration of an infective endocarditis "treatment" document developed by the American Heart Association under the auspices of the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease of the Young. It updates recommendations for diagnosis, treatment, and management of complications of infective endocarditis. A multidisciplinary committee of experts drafted this document to assist physicians in the evolving care of patients with infective endocarditis in the new millennium. This extensive document is accompanied by an executive summary that covers the key points of the diagnosis, antimicrobial therapy, and management of infective endocarditis. For the first time, an evidence-based scoring system that is used by the American College of Cardiology and the American Heart Association was applied to treatment recommendations. Tables also have been included that provide input on the use of echocardiography during diagnosis and treatment of infective endocarditis, evaluation and treatment of culture-negative endocarditis, and short-term and long-term management of patients during and after completion of antimicrobial treatment. To assist physicians who care for children, pediatric dosing was added to each treatment regimen. CONCLUSIONS: The recommendations outlined in this update should assist physicians in all aspects of patient care in the diagnosis, medical and surgical treatment, and follow-up of infective endocarditis, as well as management of associated complications. Clinical variability and complexity in infective endocarditis, however, dictate that these guidelines be used to support and not supplant physician-directed decisions in individual patient management.

Dentistry and Endocarditis.

Bacterial endocarditis (BE), a rare heart infection caused by a bacteremia, has frequently been blamed on but rarely caused by dental procedures. Viridans group streptococci are found abundantly in the mouth and the gingival sulcus but have been surpassed by staphylococci as the leading cause of BE. Antibiotic prophylaxis has been recommended before dental procedures in patients at risk for BE, but it remains controversial because studies have failed to show that antibiotic prophylaxis is an effective preventive for BE or that dental procedures are an important cause of BE. The risks and costs of antibiotic prophylaxis, including antibiotic resistance, cross-reactions with other drugs, allergy, anaphylaxis, and even death, may exceed the benefits in preventing BE. The rationale for the use of antibiotic prophylaxis to prevent BE allegedly caused by dental procedure bacteremias must be seriously reexamined based on recent evidence, particularly the absolute risk rates for endocarditis after a given dental procedure.

Diagnosis, treatment, and long-term management of Kawasaki disease: a statement for health professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, American Heart Association.

BACKGROUND: Kawasaki disease is an acute self-limited vasculitis of childhood that is characterized by fever, bilateral nonexudative conjunctivitis, erythema of the lips and oral mucosa, changes in the extremities, rash, and cervical lymphadenopathy. Coronary artery aneurysms or ectasia develop in approximately 15% to 25% of untreated children and may lead to ischemic heart disease or sudden death. METHODS AND RESULTS: A multidisciplinary committee of experts was convened to revise the American Heart Association recommendations for diagnosis, treatment, and long-term management of Kawasaki disease. The writing group proposes a new algorithm to aid clinicians in deciding which children with fever for > or =5 days and < or =4 classic criteria should undergo echocardiography [correction], receive intravenous gamma globulin (IVIG) treatment, or both for Kawasaki disease. The writing group reviews the available data regarding the initial treatment for children with acute Kawasaki disease, as well for those who have persistent or recrudescent fever despite initial therapy with IVIG, including IVIG retreatment and treatment with corticosteroids, tumor necrosis factor-alpha antagonists, and abciximab. Long-term management of patients with Kawasaki disease is tailored to the degree of coronary involvement; recommendations regarding antiplatelet and anticoagulant therapy, physical activity, follow-up assessment, and the appropriate diagnostic procedures to evaluate cardiac disease are classified according to risk strata. CONCLUSIONS: Recommendations for the initial evaluation, treatment in the acute phase, and long-term management of patients with Kawasaki disease are intended to assist physicians in understanding the range of acceptable approaches for caring for patients with Kawasaki disease. The ultimate decisions for case management must be made by physicians in light of the particular conditions presented by individual patients.

Diagnosis, treatment, and long-term management of Kawasaki disease: a statement for health professionals from the Committee on Rheumatic Fever, Endocarditis and Kawasaki Disease, Council on Cardiovascular Disease in the Young, American Heart Association.

BACKGROUND: Kawasaki disease is an acute self-limited vasculitis of childhood that is characterized by fever, bilateral nonexudative conjunctivitis, erythema of the lips and oral mucosa, changes in the extremities, rash, and cervical lymphadenopathy. Coronary artery aneurysms or ectasia develop in approximately 15% to 25% of untreated children and may lead to ischemic heart disease or sudden death. METHODS AND RESULTS: A multidisciplinary committee of experts was convened to revise the American Heart Association recommendations for diagnosis, treatment, and long-term management of Kawasaki disease. The writing group proposes a new algorithm to aid clinicians in deciding which children with fever for > or =5 days and < or =4 classic criteria should undergo echocardiography, receive intravenous gamma globulin (IVIG) treatment, or both for Kawasaki disease. The writing group reviews the available data regarding the initial treatment for children with acute Kawasaki disease, as well for those who have persistent or recrudescent fever despite initial therapy with IVIG, including IVIG retreatment and treatment with corticosteroids, tumor necrosis factor-alpha antagonists, and abciximab. Long-term management of patients with Kawasaki disease is tailored to the degree of coronary involvement; recommendations regarding antiplatelet and anticoagulant therapy, physical activity, follow-up assessment, and the appropriate diagnostic procedures to evaluate cardiac disease are classified according to risk strata. CONCLUSIONS: Recommendations for the initial evaluation, treatment in the acute phase, and long-term management of patients with Kawasaki disease are intended to assist physicians in understanding the range of acceptable approaches for caring for patients with Kawasaki disease. The ultimate decisions for case management must be made by physicians in light of the particular conditions presented by individual patients.

Antibiotic resistance.

Through billions of years of evolution, microbes have developed myriad defense mechanisms designed to ensure their survival. This protection is readily transferred to their fellow life forms via transposable elements. Despite very early warnings, humans have chosen to abuse the gift of antibiotics and have created a situation where all microorganisms are resistant to some antibiotics and some microorganisms are resistant to all antibiotics. When antibiotics are used, six events may occur with only one being beneficial: when the antibiotic aids the host defenses to gain control and eliminate the infection. Alternatively, the antibiotic may cause toxicity or allergy, initiate a superinfection with resistant bacteria, promote microbial chromosomal mutations to resistance, encourage resistance gene transfer to susceptible species, or promote the expression of dormant resistance genes.

Antibiotic prophylaxis: problems in paradise.

The age of antibiotic prophylaxis may be receding into its twilight years because the assumption upon which it was based has not proved generally true. Although antibiotics treat infections, limited benefit has been demonstrated in preventing infections. These are two entirely different biologic entities, a distinction which appears to have gone unappreciated by many for more than 50 years. If the principles of antibiotic prophylaxis established more than 40 years ago had been assiduously followed, many of its abuses could have been avoided. This may not have stopped our legal colleagues, but it would have been worth an effort on behalf of our patients. It is likely that the massive overuse of antibiotics as litigation prevention has contributed to the global epidemic of antibiotic-resistant micro-organisms and an unknown number of serious adverse effects to the antibiotics themselves. Even with this abuse, much money has still flowed from defendant to plaintiff. Substantial data exist that antibiotics do not prevent bacteremias. The absolute risk rate for bacterial endocarditis after dental treatment even in at-risk patients is very low. Antibiotic prophylaxis for surgical infections requires specific dosing schedules (perioperative surgical prophylaxis) to be successful. Hopefully the difficulties presented herein regarding antibiotic prophylaxis will lead to their more enlightened use in the future.

Antifungal and antiviral chemotherapy.

Fungal and viral infections are difficult to treat, since fungal infections commonly rebound after suppression by the antifungal agent and current antiviral drugs are only virustatic, allowing the virus to reassert its pathogenicity if not eliminated by the host defenses. In addition, fungal infections commonly are associated with significant biofilms, retarding drug penetration, and the fluid nature of the oral cavity does not promote drug-fungus contact for long periods of time. Both mycotic and viral pathogens are developing sophisticated methods to elude the toxic effects of drugs intended to eliminate their existence. The drug therapy of oral fungal and viral infections is therefore limited but occasionally successful (more with fungal than viral infections) and is often relegated to palliative care. The specter of drug resistance and its promotion by prolonged, repetitive and frivolous use must always be foremost in the clinician's mind.