Infective Endocarditis Among High-risk Individuals Before and After the Cessation of Antibiotic Prophylaxis in Dentistry: A National Cohort Study.

BACKGROUND: A few years after the publication of the British guidelines, national recommendations were published by the Swedish Medical Products Agency in October 2012, promoting the cessation of antibiotic prophylaxis in dentistry for the prevention of infective endocarditis (IE). The aim of this study was to evaluate whether the incidence of oral streptococcal IE increased among high-risk individuals after October 2012. METHODS: This nationwide cohort study included all adult individuals (>17 years) living in Sweden from January 2008 to January 2018, with a diagnose code or surgical procedure code indicating high risk of IE. Cox proportional hazard models were performed to calculate adjusted ratios of oral streptococcal IE before and after October 2012 between high-risk individuals and references. RESULTS: This study found no increased incidence of oral streptococcal IE among high-risk individuals during the 5 years after the cessation, compared with before. Hazard rate ratios were 15.4 (95% confidence interval [CI]: 8.3-28.5) before and 20.7 (95% CI: 10.0-42.7) after October 2012 for prevalent high-risk individuals. Corresponding ratios for incident high-risk individuals were 66.8 (95% CI: 28.7-155.6) and 44.6 (95% CI: 22.9-86.9). Point estimates for interaction with time period were 1.4 (95% CI: .6-3.5) and 0.8 (95% CI: .5-1.3) for prevalent and incident high-risk individuals, respectively. CONCLUSION: The results suggest that the current Swedish recommendation not to administer antibiotic prophylaxis for the prevention of IE in dentistry has not led to an increased incidence of oral streptococcal IE among high-risk individuals.

Oral streptococcal infective endocarditis among individuals at high risk following dental treatment: a nested case-crossover and case-control study.

Background: It is not clear whether Viridans Group Streptococcal Infective Endocarditis (VGS-IE) among individuals at high risk is more frequent following bacteraemia caused by invasive dental procedures (IDPs) than after daily bacteraemia caused by chewing and tooth brushing. The aim of this nested study was to assess if VGS-IE was temporally associated with IDPs in a national cohort of individuals at high risk. Methods: This nested case-control and case-crossover study was based on a Swedish national cohort study of 76,762 individuals at high risk of IE due to complex congenital heart disease, prosthetic heart valve or previous IE. Participants were living in Sweden between July 1st, 2008 and January 1st, 2018. The frequency of IDPs during the 3 months before VGS-IE was calculated and compared to controls (sampled 1:10). A case-crossover study was conducted to account for residual confounders. Participants were identified using the national patient register, and IDPs were identified using the national dental health register. Findings: 98,247 IDPs were carried out in the cohort during the study period: 624 occasions of oral surgery, 44,190 extractions and 53,433 sessions of subgingival scaling. The study could not confirm that IDPs were more common among cases (4.6%) than controls (4.1%), OR = 1.22 [95% Confidence Interval (CI) 0.64-2.3], or during case- (3.3%) than reference periods (3.8%), OR = 0.89 [95% CI: 0.68-1.17]. Restricting the analysis to the period when cessation of antibiotic prophylaxis for the prevention of IE in Swedish dentistry was recommended, from the 1st of October 2012 to the 1st of January 2018, did not alter the results of the case-control study: OR 0.64, 95% CI: 0.20-2.09, or the case-crossover study: OR 0.58, 95% CI: 0.15-2.19. Interpretation: The study could not confirm that VGS-IE is associated with IDPs among individuals at high risk. A study with larger sample size could clarify whether there is a lack of association. The finding of a small (<5%) proportion of cases temporally associated with IDPs is similar to that of the previous large-scale study on IDPs and VGS-IE. Funding: Funding was provided by the Board of doctoral education at Karolinska Institutet, the Public Health Agency of Sweden, Folktandvården Stockholm AB, Steering Group for Collaborative Odontological Research at Karolinska Institutet and Stockholm City County, and the Swedish Dental Association.

Incidence of infective endocarditis caused by viridans group streptococci in Sweden - effect of cessation of antibiotic prophylaxis in dentistry for risk individuals.

INTRODUCTION: In October 2012, the Swedish Medical Products Agency published new recommendations for the cessation of prophylactic antibiotics in dentistry for the prevention of infective endocarditis (IE). Previously, 2 g of amoxicillin per os would be administered 1 h before invasive dental procedures to patients with valve prosthesis, complicated heart valve disease, and to those with previous endocarditis. OBJECTIVES: The aim of this study was to evaluate whether the total incidence of IE caused by oral viridans group streptococci (VGS) or IE caused by staphylococci, increased in Sweden after the introduction of the new recommendations. METHODS: The incidence of IE in Sweden before and after October 2012 was calculated and compared using an interrupted time series analysis. Separate analyses were conducted for the total incidence of IE, and IE caused by VGS or Staphylococcus aureus. Cases of IE were identified using the Swedish national registry of IE, which has existed since 1995 and contains data from all Swedish hospital clinics specialising in infectious disease. All cases with hospital admission date from the 1st of Jan 2008, to the 31st of Dec 2017 were included. The incidence calculations were corrected for annual changes in population size using data from the Swedish government agency Statistics Sweden. RESULTS: The results show no statistically significant increase in the slope of the trend line of the total incidence of IE, IE caused by VGS or S. aureus in the Swedish general population after October 2012, compared to before. CONCLUSION: The results suggest that the recommended cessation of prophylactic antibiotics for the prevention of IE in dentistry has not led to an increased incidence of IE caused by oral streptococci among the Swedish population.

The Impact of Stent Graft Material on the Inflammatory Response After EVAR.

BACKGROUND: Patients undergoing endovascular aneurysm repair (EVAR) due to abdominal aortic aneurysm often develop an inflammatory response, postimplantation syndrome (PIS) where fever and leukocytosis are common. Previous studies suggest that type of stent graft material (polyester or polytetrafluoroethylene [PTFE]) plays a role. OBJECTIVES: To investigate the effect of stent graft material on the inflammatory response and length of hospital stay in patients undergoing standard elective EVAR. METHODS: Sixty-nine elective EVAR patients were included in this observational study. To avoid comparing patients with a different graft location and stent graft burden, 12 cases were excluded as well as cases with complication or simultaneous open surgical procedures, leaving 45 patients (32 with polyester and 13 with PTFE graft) for final analysis. Tympanic temperature, C-reactive protein (CRP), white blood cell (WBC), and procalcitonin (PCT) were measured on days -1 and +1 and +3. Duration of in-hospital stay and frequency of PIS were recorded. RESULTS: The PIS was diagnosed in 9 (28.1%) of the 32 polyester cases and in 1 (7.7%) of the 13 cases in the PTFE group (P = .24). Median (interquartile range) in-hospital stay was 5 (5-6) days in the polyester group and 4 (4-5) days in the PTFE group (P = .009). On day +3, in the polyester group, mean CRP was 154 (95% confidence interval: 127-182) mg/L, WBC 9.5 (8.4-10.5) ×10(9)/L, and PCT 0.17 (0.12-0.21) ng/mL. In the PTFE group, mean CRP was 70 (32-109) mg/L (P = .001), WBC 8.8 (6.4-11.1) ×10(9)/L (P = .37), and PCT 0.09 (0.06-0.13) ng/mL (P = .009) on day +3. CONCLUSION: Standard EVAR with polyester stent grafts appears to result in a trend toward a more pronounced inflammatory reaction than similar EVAR using PTFE and is associated with a longer in-hospital stay.