The Journal of the American Dental Association
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J Am Dent Assoc, Vol 131, No 5, 668-669.
© 2000 American Dental Association
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CLINICAL DIRECTIONS

SUBACUTE BACTERIAL ENDOCARDITIS: CONSIDERATIONS FOR THE PEDIATRIC PATIENT



JANE A. SOXMAN, D.D.S.

The American Heart Association’s recommendations for prescribing antibiotic prophylaxis against bacterial endocarditis were last revised in 1997.1 Each revision of these recommendations has decreased the recommended antibiotic dosage. There is confusion regarding the need for antibiotics for prophylaxis in a pediatric patient with excellent oral hygiene (but not for the placement of a rubber dam clamp). Toxic and adverse reactions to these medications lead to questions about risks vs. gains from this protocol. Much of the following information is also applicable to adults.

In a recent article, Strom and colleagues2 concluded that dental treatment does not appear to be a risk factor for infective endocarditis; however, parents should be advised to notify their child’s physician should fever, malaise, night chills, weakness, myalgia, arthralgia or lethargy occur after a dental procedure. The time between treatment and manifestation of symptoms can vary. Most cases of procedure-related bacterial endocarditis occur within a short incubation period of approximately two weeks or less.1

There is confusion regarding the need for antibiotics for prophylaxis in a pediatric patient with excellent oral hygiene.

When any cardiac disease or surgical procedure is reported on the medical history form, a telephone consultation with the patient’s pediatrician or cardiologist is recommended. Some cardiac surgical procedures permit cessation of antibiotic coverage six months after surgery1; however, scarring may create a need for continued coverage. If a patient has a heart murmur, the specific type must be determined before the dentist prescribes antibiotic prophylaxis. An innocent or functional heart murmur may be recorded on the health history form as a heart murmur; however, this type of murmur does not require antibiotic coverage.

Children require antibiotic treatment more frequently than do adults. Amoxicillin remains the preferred drug for otitis media and sinusitis when there is no allergy to penicillin. Common antibiotic protocols for treating otitis media may create antibiotic-resistant oral streptococci. This may interfere with the efficacy of the prophylactic amoxicillin.3 If a child is receiving antibiotic therapy at the time of the dental appointment, the dentist should prescribe an antibiotic from a different class rather than increase the dosage of the current antibiotic. Another option would be to reschedule the dental appointment to take place at least nine days after the patient has completed his or her current antibiotic therapy. If multiple appointments are necessary, an interval of nine to 14 days between them is suggested. This protocol will reduce the potential for the emergence of resistant organisms and permit the reestablishment of antibiotic-susceptible organisms.

Streptococci are the most common cause of endocarditis, with the viridans group most often the pathogen. Fixed acrylic appliances, which often harbor these pathogens, should be avoided in children with cardiac defects. Removable appliances and toothbrushes should be cleaned thoroughly. The number of microbes can be minimized by rinsing daily with an alcohol-containing mouthrinse during the course of orthodontic treatment.4

The dose of amoxicillin is 50 milligrams per kilogram (2.2 pounds) of body weight. If a report of the child’s weight is inaccurate by two pounds, the dose will be inaccurate by about 50 mg. Therefore, obtaining an accurate weight is of utmost importance.

Many children are overweight. The maximum pediatric dose should never exceed the adult dose no matter what the calculated dose may be. The maximum dose of amoxicillin is 2 grams and of clindamycin, 600 mg.1

Children require various forms of medications. Some 12-year-olds are unable to swallow a capsule or tablet. The patient’s preferred form of the antibiotic, such as suspension, chewable tablet, capsule or tablet should be prescribed. The tableGo illustrates how amoxicillin and clindamycin are supplied.5 At the time of treatment, the dentist should note the time at which the patient received the antibiotic. Every attempt should be made to treat the child one hour after the oral antibiotic has been taken.


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  		TABLE FORMS OF AMOXICILLIN AND CLINDAMYCIN.5

 
Two or three days before the appointment, a dental staff member should call the child’s parent, obtain the following information and record it on an index card. The completed card can then be used by the dentist to order the appropriate antibiotic:

– patient’s name;
– current date;
– patient’s telephone number;
– appointment date;
– weight;
– drug allergies;
– medications currently being taken;
– date of last dose of recent medication;
– pharmacy telephone number;
– form of medication requested.

These tips will ensure accurate and appropriate antibiotic prophylaxis for your pediatric patients, and will save time for the practice.

DO YOU HAVE A TIP TO SHARE?
Do you have a time- or work-saving clinical technique to share with your colleagues? Submit it to JADA’s Clinical Directions department. A Clinical Directions item should be a maximum of two double-spaced typed pages and should include no more than one figure or illustration. Submit items to Clinical Directions, JADA, 211 E. Chicago Ave., Chicago, Ill. 60611.

FOOTNOTES

Dr. Soxman is a pediatric dentist in private practice, 3960 William Flynn Highway, Allison Park, Pa. 15101. Address reprint requests to Dr. Soxman.

REFERENCES

  1. Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis: recommendations by the American Heart Association. JAMA 1997;277(22):1794–801.[Abstract/Free Full Text]

  2. Strom BL, Abrutyn E, Berlin JA, et al. Dental and cardiac risk factors for infective endocarditis: a population-based, case-control study. Ann Intern Med 1998;129(10):761–9.[Abstract/Free Full Text]

  3. Erickson PR, Herzberg MC. Emergence of antibiotic resistant Streptococcus sanguis in dental plaque of children after frequent antibiotic therapy. Pediatr Dent 1999;21(3):181–5.[Medline]

  4. Brook I, Gober AE. Persistance of group A beta-hemolytic streptococci in toothbrushes and removable orthodontic appliances following treatment of pharyngotonsillitis. Arch Otolaryngol Head Neck Surg 1998;124(9):993–5.[Abstract/Free Full Text]

  5. Siberry GK, Iannone R, eds. The Harriet Lane handbook. 15th ed. Mosby: St. Louis; 2000:630, 676.




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