Home' News Bulletin : ADA News Bulletin February 2015 Contents 24 FEBRUARY 2015
New Australian guidelines for
New Australian guidelines for prevention of endocarditis have
recently been published in Therapeutic Guidelines: Antibiotic,
version 15 (2014). These guidelines have revised and updated
those published in July 2008 and which appear in the current
Therapeutic Guidelines: Oral and Dental, version 2 (2012).
The updated Australian guidelines continue to follow those
introduced in 2007 by the American Heart Association. They are
in line with guidelines published in 2009 by the European Society
of Cardiology and a 2014 update on management of valvular
heart disease by the American Heart Association and the American
College of Cardiology.
In line with the American and European guidelines, the Australian
guidelines recommend antibiotic prophylaxis for specific dental,
respiratory, gastrointestinal and genitourinary procedures only for
patients with cardiac conditions associated with the highest risk of
adverse outcomes from infective endocarditis.
CARDIAC CONDITIONS REQUIRING PROPHYLAXIS IN
THE NEW AUSTRALIAN GUIDELINES
As in the previous Australian guidelines, the cardiac conditions for
which prophylaxis is recommended are prosthetic cardiac valve or
prosthetic material used for cardiac valve repair; previous infective
endocarditis; and, in some circumstances, congenital heart disease
(see the guidelines for a complete description of this group of
In line with the previous Australian guidelines and with the
American and European guidelines, antibiotic prophylaxis is not
recommended for patients with mitral valve prolapse.
RHEUMATIC HEART DISEASE AND CARDIAC
Key changes to the previous Australian guidelines relate to the
indications for prophylaxis for patients with rheumatic heart
disease (RHD) and for patients who have had a heart transplant.
In the previous Australian guidelines, prophylaxis was
recommended only for Indigenous Australians with RHD.
Indigenous Australians with RHD are thought to be at higher risk
of developing infective endocarditis and for adverse outcomes from
the disease. However, the Antibiotic Expert Group acknowledged
that the higher risk and poorer outcomes may be associated with
socioeconomic disadvantage rather than ethnicity. Therefore, the
new guidelines recommend prophylaxis for any high-risk patient
with RHD. Such patients include Indigenous Australians with RHD,
as well as non-Indigenous patients with RHD who are at significant
socioeconomic disadvantage. In the current New Zealand
guidelines, prophylaxis is recommended for all patients with RHD,
specifically including Maori and Pacific Islander people.
The previous Australian guidelines recommended prophylaxis
for heart transplant patients only when cardiac valvulopathy
had developed. The new guidelines advise that the patient's
cardiologist should be consulted for specific recommendations.
ANTIBIOTIC RECOMMENDATIONS FOR PROPHYLAXIS IN
THE NEW AUSTRALIAN GUIDELINES
As with the previous Australian guidelines, the recommended oral
regimen for prophylaxis is amoxycillin 2 g (child: 50 mg/kg up to 2 g)
orally, one hour before the procedure. Parenteral amoxycillin or
ampicillin can also be used.
Cephalexin is now recommended as an oral option and cephazolin
as a parenteral option for prophylaxis in patients hypersensitive to
penicillins (excluding immediate hypersensitivity).
For patients with immediate hypersensitivity to penicillins,
clindamycin 600 mg orally, one hour before the procedure is
still recommended in adults; however, the paediatric dose of
clindamycin has been increased to 20 mg/kg (up to 600 mg) in
line with international recommendations. Instructions on preparing
an oral solution of clindamycin for patients unable to swallow
capsules have been added, and a parenteral option for clindamycin
is also given. Moxifloxacin is now mentioned in the text as an
alternative to clindamycin.
Amoxycillin susceptibility of oral viridans streptococci is not
significantly affected by long-term benzathine penicillin therapy
for prevention of recurrent rheumatic fever. Therefore, amoxycillin
is now recommended for endocarditis prophylaxis in this setting.
In contrast, in patients currently taking or who have recently
taken a course of beta-lactam therapy, evidence suggests that the
amoxycillin susceptibility of viridans streptococci may be affected.
Therefore, a non--beta-lactam antibiotic, such as clindamycin, may
be considered for endocarditis prophylaxis in these patients.
ACCESSING THE NEW GUIDELINES
The updated 'Prevention of infection: endocarditis' topic is freely
available through the demonstration version of eTG complete. The
demonstration version can be accessed from the homepage of
the Therapeutic Guidelines website <www.tg.org.au> or directly
via the link: http://www.tg.org.au/etg_demo/desktop/index.htm
(select 'Antibiotic' from the table of contents, and then click on
'Endocarditis' under 'Prevention of infection' in the Antibiotic
guidelines). The topic includes a background to the update along
with key references. Links to international guidelines on prevention
of endocarditis are provided in the 'Further reading' section.
On behalf of the Dental Therapeutics Committee
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