Prescribing of antibiotic prophylaxis to prevent infective endocarditis

      Abstract

      Background

      In 2007, the American Heart Association recommended that antibiotic prophylaxis (AP) be restricted to those at high risk of developing complications due to infective endocarditis (IE) undergoing invasive dental procedures. The authors aimed to estimate the appropriateness of AP prescribing according to type of dental procedure performed in patients at high risk, moderate risk, or low or unknown risk of developing IE complications.

      Methods

      Eighty patients at high risk, 40 patients at moderate risk, and 40 patients at low or unknown risk of developing IE complications were randomly selected from patients with linked dental care, health care, and prescription benefits data in the IBM MarketScan Databases, one of the largest US health care convenience data samples. Two clinicians independently analyzed prescription and dental procedure data to determine whether AP prescribing was likely, possible, or unlikely for each dental visit.

      Results

      In patients at high risk of developing IE complications, 64% were unlikely to have received AP for invasive dental procedures, and in 32 of 80 high-risk patients (40%) there was no evidence of AP for any dental visit. When AP was prescribed, several different strategies were used to provide coverage for multiple dental visits, including multiday courses, multidose prescriptions, and refills, which sometimes led to an oversupply of antibiotics.

      Conclusions

      AP prescribing practices were inconsistent, did not always meet the highest antibiotic stewardship standards, and made retrospective evaluation difficult. For those at high risk of developing IE complications, there appears to be a concerning level of underprescribing of AP for invasive dental procedures.

      Practical Implications

      Some dentists might be failing to fully comply with American Heart Association recommendations to provide AP cover for all invasive dental procedures in those at high risk of developing IE complications.

      Key Words

      Abbreviation Key:

      AHA (American Heart Association), AP (Antibiotic prophylaxis), CDT (American Dental Association Code on Dental Procedures and Nomenclature), ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification), IE (Infective endocarditis), NA (Not applicable)
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      Biography

      Dr. Thornhill is a professor, Translational Research in Dentistry, University of Sheffield, Sheffield, UK; and an adjunct professor, Department of Oral Medicine, Carolinas Medical Center, Atrium Health, Charlotte, NC.

      Biography

      Dr. Gibson is a senior director, Health Outcomes Research, IBM Watson Health, Ann Arbor, MI.

      Biography

      Dr. Durkin is an assistant professor of medicine, Division of Infectious Diseases, Department of Internal Medicine, Washington University in Saint Louis School of Medicine, St Louis, MO.

      Biography

      Dr. Dayer is a consultant cardiologist, Department of Cardiology, Taunton and Somerset National Health Service Trust, Taunton, Somerset, UK.

      Biography

      Dr. Lockhart is a research professor, Department of Oral Medicine, Carolinas Medical Center, Atrium Health, Charlotte, NC.

      Biography

      Dr. O’Gara is the director of strategic planning, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA; and the Watkins Family Distinguished Chair in cardiology and a professor, Harvard Medical School, Boston, MA.

      Biography

      Dr. Baddour is an emeritus professor of medicine, Division of Infectious Diseases, Departments of Medicine and Cardiovascular Diseases, Mayo Clinic College of Medicine and Science, Rochester, MN.