Re: Starting to wonder: do certain Lyme patients get $$$ for recommending antibiotics?
- From: cowabungabart@xxxxxxxxx
- Date: Mon, 11 Feb 2008 20:56:42 -0800 (PST)
In addition apparently not only is this an IDSA recommendation joined
in by the pediatric infectious disease society and the american dental
association but also the american heart association and the American
Academy of Orthopaedic Surgeons. Apparently the conspiracy has grown!
So the question is should people listen to the moon based expert or
these folks who actually went to medical school and have conducted
studies and met in committees to consider these issues prior to
publishing these guidelines?
I just don't see what the incentive is for these folks to recommend
AGAINST antibiotics, especially when this prophylactic treatment isn't
costing insurance companies a lot of money since the prophylaxis is so
limited in duration. So why would they recommend against it?
Are they just mean and cruel people who chose to go into medicine to
see their patients get sick unecessarily? Or maybe they have vaild
concerns. And no matter what one thinks of the IDSA guidelines for
Lyme treatment, that doesn't mean the IDSA is uniformly wrong or evil
(unless you are snappy or kathleen or some other reactionary
lunatics).
So are people on the moon getting paid to bash the IDSA, paid anti
steere camp plants, paid by the LDA or LLMDs or heavily invested in
pharmaceutical companies or receiving kickbacks for every antibiotic
prescribed?
LOL
Or are these moon based people just as dumb as moon rocks? Or
reactionaries? Or what? I don't know.
http://jada.ada.org/cgi/content/full/131/3/366
J Am Dent Assoc, Vol 131, No 3, 366-374.
(c) 2000 American Dental Association
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Infection Control
--------------------------------------------------------------------------------
CLINICAL PHARMACOLOGY
JADA Continuing Education
ANTIBIOTIC PROPHYLAXIS IN DENTISTRY: A REVIEW AND PRACTICE
RECOMMENDATIONS
DARRYL C. TONG, B.D.S., M.S.D. and BRUCE R. ROTHWELL, D.M.D., M.S.D.
ABSTRACT
TOP
ABSTRACT
CLINICIAL SITUATIONS CONSIDERED...
PREVENTION OF LOCAL INFECTION...
PREVENTION OF GENERALIZED SPREAD...
DENTAL PROCEDURES AND ANTIBIOTIC...
SUMMARY
REFERENCES
Background. The American Heart Association, or AHA, and the American
Dental Association recently changed their recommended protocols for
antibiotic prophylaxis against bacterial endocarditis. A new
recommendation also has been issued by the ADA and the American
Academy of Orthopaedic Surgeons, or AAOS, against routine antibiotic
prophylaxis in patients with prosthetic joint replacements. These
changes reflect increasing scientific evidence and professional
experience in opposition to widespread use of antibiotic prophylaxis
in these specific situations and others faced in dentistry.
Methods. The authors reviewed the medical and dental literature for
scientific evidence regarding the use of antibiotics to prevent local
and systemic infections associated with dental treatment. Situations
commonly considered by dentists for potential use of prophylactic
antibiotics were reviewed to determine current evidence with regard to
use of antimicrobial agents. This included prevention of distant
spread of oral organisms to susceptible sites elsewhere in the body
and the reduction of local infections associated with oral
procedures.
Results. There are relatively few situations in which antibiotic
prophylaxis is indicated. Aside from the clearly defined instances of
endocarditis and late prosthetic joint infections, there is no
consensus among experts on the need for prophylaxis. There is wide
variation in recommended protocols, but little scientific basis for
the recommendations. The emerging trend seems to be to avoid the
prophylactic use of antibiotics in conjunction with dental treatment
unless there is a clear indication.
Conclusions. Aside from the specific situations described, there is
little or no scientific basis for the use of antibiotic prophylaxis in
dentistry. The risk of inappropriate use of antibiotics and widespread
antibiotic resistance appear to be far more important than any
possible perceived benefit.
Clinical Implications. Dentists are wise to use antibiotic prophylaxis
in only those specific situations in which there is a valid scientific
basis for it. Whenever possible, dentists should follow the standard
protocols recommended by the ADA, AHA or AAOS.
The American Heart Association, or AHA, and the American Dental
Association recently changed their recommended protocols for
antibiotic prophylaxis against bacterial endocarditis. In addition,
the ADA and the American Academy of Orthopaedic Surgeons, or AAOS,
also issued a new recommendation against routine use of antibiotic
prophylaxis in patients with prosthetic joint replacements. These
changes reflect changing attitudes toward the use of antibiotics in
patients at risk of developing bacteremias from dental procedures.
There is often confusion and misinformation concerning the indications
and scientific basis for the use of antibiotics in conjunction with
dental procedures. In this review article, we highlight specific
situations that warrant the use of antibiotic prophylaxis in the
dental setting and briefly discuss the rationale behind current
recommendations.
The empiric use of antibiotic prophylaxis for dental procedures,
especially those that cause bleeding in the mouth, has become a
reasonably well-established practice among dental professionals.
However, many dentists are confused by the indications for, and the
nature of, antibiotic prophylaxis. They often rely on recommendations
from practitioners who quote anecdotal evidence or decide that, when
in doubt, the wise and conservative course is to use antibiotic
prophylaxis. Furthermore, dentists may consult with a patient's
physician and receive a recommendation for the use of antibiotics in
widely varying protocols and combinations. This presents a dilemma for
the dentist because he or she may feel obligated to use antibiotic
prophylaxis in inappropriate or unnecessary scenarios.
There is a long-held belief in the theory of focal infection such that
subclinical infectious foci in the oral region, particularly
endodontically treated teeth, result in systemic illness or cause
disease processes in distant locations.1 Although generally regarded
as not having scientific merit, this concept often drives
recommendations for the use of antibiotic prophylaxis. As a result,
dentists and physicians tend to use antibiotics in situations in which
there are no clear scientific bases.
The correlation between bacterial infection and endocarditis was
described before the turn of the 20th century.2 It was not until the
1920s, however, that the causal relationship between bacteremia,
surgical procedures and infective endocarditis, or IE, was proposed.3
Lewis and Grant3 hypothesized that surgical procedures provided
microorganisms with access to the systemic circulation, which
ultimately would result in endocarditis. The specific pathophysiology
of IE was not yet identified. Researchers subsequently showed that IE
arises from the colonization of a preexisting lesion, usually composed
of fibrin and platelets, which develops from the disruption of the
endothelial lining via abnormal development, disease or presence of
foreign bodies and turbulent blood flow.2,4
Since the 1930s and 1940s, when studies indicated a significant
correlation among dental procedures that cause bleeding, bacteremia
and the development of IE, the use of antibiotics has been standard
practice for patients identified as being at risk of developing
endocarditis. This practice has expanded to include patients at risk
of developing infections around prosthetic joints and those with
depressed immune systems.5 In addition, many medical and dental
practitioners use antibiotics in conjunction with surgical procedures
for otherwise healthy patients in the belief that such therapy will
reduce the incidence of perioperative infections.
Although the use of prophylactic antibiotics in dentistry is not a
major contributing factor to the problem of overuse, the current
situation clearly requires judicious and prudent consideration before
antibiotic therapy is administered.
Clinicians and researchers are increasingly concerned about the
overuse of antibiotics and the resulting development of resistant
strains of microorganisms.6 Although the use of prophylactic
antibiotics in dentistry is not a major contributing factor to the
problem of overuse, the current situation clearly requires judicious
and prudent consideration before antibiotic therapy is administered.7
In this article, we review the literature regarding the scientific
rationale for antibiotic prophylaxis and develop a series of practice
guidelines to use in making clinical decisions.
CLINICIAL SITUATIONS CONSIDERED FOR ANTIBIOTIC PROPHYLAXIS
TOP
ABSTRACT
CLINICIAL SITUATIONS CONSIDERED...
PREVENTION OF LOCAL INFECTION...
PREVENTION OF GENERALIZED SPREAD...
DENTAL PROCEDURES AND ANTIBIOTIC...
SUMMARY
REFERENCES
Infective endocarditis. IE, also known as acute or subacute bacterial
endocarditis, is defined as an exudative and proliferative
inflammatory alteration of the endocardium; it is characterized by
vegetations on the surface or within the endocardium that are caused
by an infection with microorganisms. A heart valve is commonly
involved and proliferation also may occur in the inner lining of the
cardiac chambers.8,9 It is well-recognized that IE arises from the
colonization of a preexisting lesion, usually composed of fibrin and
platelets, that develops from the disruption of the endothelial lining
via abnormal development, disease or presence of foreign bodies and
turbulent blood flow. This accumulation of fibrin, blood products and
platelets, known as nonbacterial thrombotic endocarditis, or NBTE,
adheres to the damaged endothelium. The endothelium is later colonized
by bacteria, which, in turn, stimulates further platelet aggregation
and the bacteria become incorporated into the vegetations of the
lesion.
Congenital or acquired cardiac defects and abnormalities may
predispose the heart to endothelial damage and formation of NBTE.4
Researchers have suggested that these conditions may alter the
hemodynamics of the heart, causing turbulence, which, in some way,
increases the exposure of predisposed cardiac endothelium to bacterial
infection (usually streptococcal).
The current AHA recommendations for the prevention of IE are
significantly changed in respect to patients with various cardiac
conditions (Box, "Cardiac Conditions Considered for Prophylaxis").10
In general, the trend has been to more specifically describe those
conditions that pose significant risk for patients and to delineate
low- or negligible-risk situations. As a result, antibiotic
prophylaxis is now recommended for fewer conditions. These changes
also reflect improvements in the understanding of these disease
processes and changing attitudes toward the use of antibiotics. The
most notable among these changes include reducing the oral dose of
amoxicillin from 3 grams to 2 g, recommending that a follow-up dose of
antibiotic be discontinued, and replacing erythromycin with other
antibiotics as alternatives to the penicillins.10,11 Dajani and
colleagues12 have reported that 2 g of amoxicillin provides several
hours of antibiotic coverage. Table 1 shows the new recommendations
for prophylactic coverage for certain dental procedures.
View this table:
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[in a new window]
CARDIAC CONDITIONS CONSIDERED FOR PROPHYLAXIS.*
View this table:
[in this window]
[in a new window]
TABLE 1 ANTIBIOTIC PROPHYLACTIC REGIMENS FOR CERTAIN DENTAL
PROCEDURES.*
Patients with mitral valve prolapse, or MVP, may be at risk of
developing tachycardia, syncope, congestive heart failure and
endocarditis.13 The risk of infection, however, is variable and
depends on age and severity of the MVP.11 The decision whether to
administer antibiotic prophylaxis is based on the results of
echocardiographic tests for regurgitation. The AHA recommmends that
patients diagnosed as having MVP with regurgitation receive antibiotic
prophylaxis before undergoing dental procedures, but patients with MVP
alone (without regurgitation) do not require antibiotic coverage. The
risk of developing IE remains greater in patients with prosthetic
heart valves and/or a history of endocarditis than in patients with
MVP.14
The current American Heart Association recommendations for the
prevention of infective endocarditis are significantly changed in
respect to patients with various cardiac conditions.
Patients often indicate on a health history form the existence of a
heart murmur at some time without having any further knowledge of the
nature or extent of the cardiac defect. Because of concerns about the
overuse of antibiotics, it is prudent for the dentist to ask for
medical evaluation before continuing dental care, rather than to
simply prescribe antibiotic prophylaxis when in doubt. Similarly, if a
dentist is treating a patient with MVP, it may be reasonable to
contact the patient's physician to determine the specific cardiac
anomaly before making a decision about antibiotic prophylaxis.
Patients with prosthetic joints. Prosthetic joint replacement is
becoming increasingly common, especially in developed countries with
an aging population. It has been estimated that more than 120,000 hips
and knees were replaced in 1990 in the United States.15 In 1997,
approximately 450,000 joints of all types were replaced, reflecting an
increasing annual trend.16 Infections of the prosthetic joints may be
classified as early- and late-onset.9
Early prosthetic joint infection is presumed to occur after microbial
contamination of the surgical site during placement of the prosthesis.
Late prosthetic joint infection, or LPJI, typically occurs three or
more months after surgery and may involve delayed infection from
microorganisms introduced at the time of surgery or via hematogenous
spread from a distant site, such as the mouth. With devastating
morbidity and a mortality rate of 18 percent, orthopedic surgeons are
justified in their concerns about LPJI.17 The incidence of LPJI
associated with dental procedures is extemely low. In a review of
2,693 patient records, Jacobson and Matthews18 found only one instance
(0.04 percent) of LPJI that could be even temporally related to dental
treatment.
Routine antibiotic prophylaxis for all patients with prosthetic joints
is very expensive ($480,000 to prevent one case of LPJI in 1990).15
Studies of relative risks show that the risk of death caused by
anaphylaxis, especially from the penicillins, far outweighed the risks
of developing LPJI. These factors have moved the current consensus
toward discontinuing routine use of antibiotic prophylaxis. In their
advisory statement, the AAOS and the ADA have recommended the use of
prophylactic antibiotics only for patients with total joint
replacements (not for patients with only pins, screws and/or plates)
and compromised immune systems, Type 1 diabetes mellitus, recent
(within two years) joint replacement, previous prosthetic joint
infections, malnourishment or hemophilia.16
Dentists still may be faced with the situation in which a physician
has recommended antibiotic prophylaxis for a patient that the dentist
feels is inappropriate. In such cases, the dentist may choose to
consult with the patient's physician in an attempt to alter that
recommendation. In any case, the dental practitioner is responsible
for assessing each patient's situation and deciding whether antibiotic
coverage would benefit the patient.
In-dwelling catheters, neurosurgical shunts and other implants. In-
dwelling catheters generally do not warrant antibiotic prophylaxis
unless the catheter is near the right side of the heart.19 In cardiac
patients with newly placed stents, the initial two weeks after
placement is the time of highest risk of infection of the stent. Once
an epithelial layer develops, the risks of infection are minimal. For
patients in whom catheters are placed to facilitate the administration
of systemic medications such as antiviral or chemotherapeutic agents
for extended periods, the antibiotic prophylaxis is administered
because of the suppressed immune system rather than the catheter
itself.
Patients with renal disease who are undergoing hemodialysis constitute
another group that warrants some form of antibiotic coverage for
dental procedures because of the presence of an arteriovenous shunt
for dialysis.20 These shunts may be made from native (autogenous)
tissue or from a silastic tube that is implanted. Regardless of type,
the shunts are particularly vulnerable to infection, which could be
devastating for the patient receiving hemodialysis. Patients receiving
continuous peritoneal dialysis, however, do not require antibiotic
prophylaxis.
The patient with hydrocephaly poses a different problem because of the
placement of shunts.21 Patients with hydrocephaly receive shunts to
aid in the drainage of cerebrospinal fluid, or CSF. Two types of
shunts are used: the ventriculoatrial, or VA, shunt and the
ventriculoperitoneal, or VP, shunt. The VA shunt allows drainage of
CSF from the lateral ventricles to the venous circulation, whereas VP
shunts drain CSF directly into the abdominal cavity.
VP shunts are currently more common than VA shunts. The overall
infection rate ranges from 5 to 30 percent, with a mortality rate of
up to 40 percent.22,23 Shunt infections usually will present in the
initial two-week postoperative period. The literature suggests that VP
shunts carry no higher risk of infection after dental treatment than
that before dental treatment, whereas VA shunts are more prone to
infection. Therefore, patients with VA shunts should be considered for
antibiotic prophylaxis.23
For other types of implants and devices, such as penile implants,
implanted defibrillators and cardiac pacemakers, there is no evidence
supporting the routine use of antibiotic coverage for dental
procedures.24
PREVENTION OF LOCAL INFECTION IN SURGICAL OR OPERATIVE SITES IN
THE MOUTH
TOP
ABSTRACT
CLINICIAL SITUATIONS CONSIDERED...
PREVENTION OF LOCAL INFECTION...
PREVENTION OF GENERALIZED SPREAD...
DENTAL PROCEDURES AND ANTIBIOTIC...
SUMMARY
REFERENCES
Surgical procedures in the mouth generally fall into the clean-
contaminated category of surgical classification (that is, native
organisms are present); this includes routine exodontics, third-molar
surgery and orthognathic surgery.25 The incidence of infection after
dentoalveolar surgery is very low; for third-molar surgery performed
by oral and maxillofacial surgeons, the infection rate is
approximately 1 percent.25 Unless the immune system is compromised,
antibiotics are not indicated in these cases. For periodontal surgery
in which the surgical site is often highly contaminated with
microorganisms, antibiotics are usually indicated for most patients
with compromised immune systems, for patients at risk of developing IE
and for patients with prosthetic joints, especially in the presence of
obvious periodontal infections.26
The periodontal literature suggests that localized juvenile
periodontitis and other forms of early-onset periodontitis may warrant
antibiotic coverage, but there is little evidence to support this
view. The American Academy of Periodontology recommends that patients
with medical conditions that predispose them to periodontal disease
also be considered for antibiotic coverage.27 The use of antibiotic
prophylaxis during placement of dental implants is controversial.
Preoperative antibiotics appear to decrease the rate of implant
failure, but studies have emphasized the prevention of implant failure
rather than prevention of the infection itself.28
PREVENTION OF GENERALIZED SPREAD OF INFECTIONS IN PATIENTS WITH
COMPROMISED IMMUNE SYSTEMS
TOP
ABSTRACT
CLINICIAL SITUATIONS CONSIDERED...
PREVENTION OF LOCAL INFECTION...
PREVENTION OF GENERALIZED SPREAD...
DENTAL PROCEDURES AND ANTIBIOTIC...
SUMMARY
REFERENCES
Patients with compromised immune systems represent a special category
for dentists. Because of their illness and/or the treatment rendered
for their specific condition, these patients are at higher risk of
developing bacteremias, which, in the absence of an adequate host
immune system, may rapidly progress to an overwhelming septicemia.
4,29
Patients undergoing chemotherapy are particularly susceptible to
systemic infections because their immunosuppressed state is caused by
their medications. Not only are these patients at higher risk of
developing an infection, but the spread and severity of the infection
can potentially be rapid and life-threatening. For these patients, we
do not recommend antibiotic coverage for routine dental procedures,
but it should be considered for invasive procedures such as dental
extractions, deep periodontal scaling and other procedures that cause
significant bleeding and seeding of bacteria into the systemic
circulation.
Patients with human immunodeficiency virus and AIDS, in the absence of
bacterial infection, do not generally require antibiotic prophylaxis.
19 However, a clinical judgment should be made when a bacteremia is
likely to occur, such as in cases of extraction of teeth with
abscesses. Practitioners should consider the use of antibiotics in
these patients because of the higher risk of overwhelming systemic
infection and an inability to defend against microbial insult because
of a depressed immune system.
The final group in this category of patients with compromised immune
systems is the population with diabetes. Diabetics, especially those
who are insulin-dependent, have a higher rate of systemic disease and
often exhibit some degree of leukocyte dysfunction, which may
contribute to higher incidences of infection.30 Insulin-dependent
diabetic patients, particularly those with poorly controlled disease,
are vulnerable to infections. Therefore, antibiotic coverage for
invasive dental procedures is recommended in patients with poorly
controlled or uncontrolled diabetes, but is generally not required for
those in whom the disease is well-controlled or for those who are not
dependent on insulin therapy.31
There is some ongoing debate among clinicians and authors over the use
of antibiotic coverage for chronic intravenous drug abusers and for
patients who have undergone splenectomy.32,33 The incidence of IE
among chronic intravenous drug abusers is several times higher than
that seen in the healthy population. Although there is no clear-cut
evidence that antibiotics are effective in cases of native valve
endocarditis, antibiotic coverage may be warranted until new evidence
suggests otherwise.33 There is also no evidence that patients who have
undergone splenectomy are at higher risk of developing infection from
dental procedures than is the general population. These patients are,
however, more susceptible to infections from encapsulated organisms
such as Pneumococcus and Hemophilus type B species; physicians often
recommend the use of antibiotic prophylaxis for invasive dental
procedures in such cases.32,34
DENTAL PROCEDURES AND ANTIBIOTIC PROPHYLAXIS
TOP
ABSTRACT
CLINICIAL SITUATIONS CONSIDERED...
PREVENTION OF LOCAL INFECTION...
PREVENTION OF GENERALIZED SPREAD...
DENTAL PROCEDURES AND ANTIBIOTIC...
SUMMARY
REFERENCES
The link between dental procedures and IE remains a controversial
subject. In 1984, Guntheroth35 reported a low incidence of bacteremia
associated with dental procedures and suggested that meticulous oral
hygiene was more important in the prevention of IE than any antibiotic
regimen. In a population-based control study involving 273 patients
with cardiac lesions, Strom and colleagues36 found that dental
procedures were not a risk factor for IE, even in patients with
valvular abnormalities. Furthermore, even when the recommended
antibiotic regimen was administered, it was not 100 percent effective
in preventing IE.36,37
The evidence is now clear that not all dental procedures warrant the
use of antibiotic prophylaxis. It is safe to perform dental procedures
(such as restorative and prosthetic treatment) in which the potential
for bleeding is minimal in at-risk patients without the use of
antibiotic prophylaxis. Invasive treatment in which bacteremia is more
likely to occur (such as periodontal scaling, periodontal surgery and
dental extractions) warrant the use of antibiotic coverage in patients
with specific conditions, such as prosthetic heart valves and a
history of endocarditis.14 The box ("Dental Procedures Considered for
Antibiotic Prophylaxis in Susceptible Patients"; see page 371) is a
proposed guideline for clinical situations in which antibiotic
prophylaxis is recommended for invasive dental procedures. Table 2
(see page 372) summarizes our recommendations for administering
antibiotic prophylaxis.
View this table:
[in this window]
[in a new window]
DENTAL PROCEDURES CONSIDERED FOR ANTIBIOTIC PROPHYLAXIS IN
SUSCEPTIBLE PATIENTS.*
View this table:
[in this window]
[in a new window]
TABLE 2 SUMMARY RECOMMENDATIONS FOR ANTIBIOTIC PROPHYLAXIS.
SUMMARY
TOP
ABSTRACT
CLINICIAL SITUATIONS CONSIDERED...
PREVENTION OF LOCAL INFECTION...
PREVENTION OF GENERALIZED SPREAD...
DENTAL PROCEDURES AND ANTIBIOTIC...
SUMMARY
REFERENCES
As a result of greater understanding of disease processes, an enhanced
awareness of cost-effectiveness and risk-benefit correlations, and
better communication between medical and dental practitioners, the
guidelines for antibiotic prophylaxis have been significantly altered.
10,16 Although the major impetus for this change was related to
prevention of IE, situations involving prosthetic joints and patients
with compromised immune systems also have been reconsidered. In
addition, the specific nature of dental procedures and the risk of
patients' developing bacteremias from them have been reconsidered, and
many common procedures have been excluded from the list of those that
require prophylaxis. It is clear that the trend is toward covering
fewer and more specific medical conditions for a limited number of
invasive dental procedures. Although some situations are well-
delineated, controversy and concern over others continue. Further
investigation and research are needed to clarify these issues.
In this article, we have delineated some of the indications for
antibiotic prophylaxis in dentistry. Our recommendations can serve as
the basis for guidelines for the practicing dentist, with the caveat,
however, that guidelines are no substitute for sound clinical
judgment.
FOOTNOTES
Dr. Tong is a lecturer, Department of Stomatology, University of
Otago, Dunedin, New Zealand.
Dr. Rothwell is an associate professor and chairman, Department of
Restorative Dentistry, and an adjunct associate professor, Oral and
Maxillofacial Surgery, University of Washington, Seattle. Address
reprint requests to Dr. Rothwell, Department of Restorative Dentistry,
Mail Stop 357456, University of Washington, Seattle, Wash. 98195.
REFERENCES
TOP
ABSTRACT
CLINICIAL SITUATIONS CONSIDERED...
PREVENTION OF LOCAL INFECTION...
PREVENTION OF GENERALIZED SPREAD...
DENTAL PROCEDURES AND ANTIBIOTIC...
SUMMARY
REFERENCES
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M. Al-Haroni and N. Skaug
Incidence of antibiotic prescribing in dental practice in Norway and
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