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Infective endocarditis is a preventable infectious heart disease that
invades to endocardial part of heart. The occurrence of IE is still seen and
has impacted to high risk morbidity patients. Despite it can easily be
prevented, it is still been a challenge to prevent especially in low economic
and developing countries. Antibiotic prophylaxis alone is not recommended to
prevent infective endocarditis because there is no strong association between
having an interventional procedures and development of IE. Preventive antibiotics are no longer
recommended for any other congenital heart disease but may be considered in
high-risk cardiac conditions. According to recent NICE and ESC guideline,
prevention IE with antibiotic is needed to give clear information about the
benefits and risks of antibiotics prophylaxis. Thus, it is very important to
know how to give effective antibiotics prophylaxis in high risk patients.
Keywords: Infectious
diseases, Endocarditis, Cardiovascular diseases, Prophylaxis
INTRODUCTION
Because of the high risk of mortality seen in patients who live in
developing nations, it is essential to provide effective treatment of
endocarditis in developing countries. This article discusses about the
effective management and prophylaxis of IE.
PREVALENCE OF INFECTIVE
ENDOCARDITIS IN MID AFRICA AND SOME DEVELOPING COUNTRIES
Early in the 2014, I worked with Medicines Sans Frontier (Holland) in
some developing nations including South East Asia countries in Myanmar;
prevention of infectious diseases has been challenging matter in those areas.
According to the Global Burden Disease 2013 Study of sixteen poorest countries [1],
Infective endocarditis has impacted to the rate of DALY (disability-adjusted
life-year) per 100000 in these regions was 60.0% in % of cardiovascular diseases
DALYs was 1.7% [3]. Those static data shows it has been still a challenging
issue to prevent and compact infective endocarditis sin these countries.
The Prevalence of IE is high in South Africa and other developing
countries, is predominantly a disease of young patients with rheumatic heart.
Although the microbiological features of
infective endocarditis in Africa are similar
to
PREVENTION AND EFFECTIVE IE
PROPHYLAXIS IN DEVELOPING COUNTRIES
As my experienced working with MSFs (Holland) in developing nation, in
Myanmar, the MSFs has adopted South Africa National Guideline and some of the
clinical management are revised for specific nations to make more suitable in
recourse limited settings. South Africa Heart is an affiliated member of the
European Society of Cardiology (ESC) and hence adopts the practice guidelines
of the ESC [5]. The ESC Guideline states that antibiotic prophylaxis should be
limited to those with the highest risk of IE. Both European Society of
cardiology and ACC/AHA guideline still recommended the IE prevention with
antibiotics for prosthetic valve or material used for repair, previous IE and
Congenital heart disease (IIa/B, C) but 2015 ESC new guideline has no longer
recommended for cardiac transplant with valvulopathy. In addition, both ESC and
ACC/AHA recommend IE prophylaxis for Dental Procedure (Class IIb, LOE C).
Patients with a prosthetic valve or prosthetic material used for cardiac repair
have a higher risk of IE, greater mortality and develop more complications than
those with native valve and an identical pathogen; this recommendation also
applies to transcatheter-implanted prostheses.
As being a former physician of Medicines Sans Frontiers, had to care
HIV patients. What I had noticed in that was despite HIV infection is not
directly associated with an increased risk of IE, Infective Endocarditis with
valvular heart diseases especially involvement of tricuspid valve lesion was
seen in HIV infected in Africa and South East Asia where intravenous drug users
are commonly seen. Koegelenberg et al. [6] stated that the main risk factors
included RHD, in addition to prosthetic valves, CHD and a previous history of
IE in their South African prospective observational study that examined the
risk factors for IE but only 1 of their cohort of 92 patients was HIV seropositive
[7]. Though antibiotic prophylaxis is not recommended, it is therefore
indicated only in those with high-risk cardiac lesion.
The prevention of endocarditis in patients with RHD in Africa and South
America are needed since RHD would promote as cardiac conditions associated
with the highest risk of adverse outcome from endocarditis and has not improved
over decades. The Infective Endocarditis Prophylaxis Expert Group has
recommended that indigenous Australian and Pacific Oceana’s patients with RHD
are a special population at high risk for IE that should receive antibiotic
prophylaxis [8] RHD is the major cause of valvular heart disease in Latin
America countries where the oral health of the general population is extremely
poor. The Brazilian Society of Cardiology and the Inter-American Society of
Cardiology therefore recommends prophylaxis to all with valvular or CHD (that
represents a risk for IE), before dental interventional procedures [9]. There
are also no recommendations issued by local professional organizations in
India, Pakistan, Myanmar, Bangladesh and Sri Lanka and hence the decision is
left to the clinical judgment of the individual physician/dentist by revised
the NICE and ESC Guideline.
BENEFITS AND RISKS OF
ANTIBIOTIC PROPHYLAXIS
IE prophylaxis has been thought to get benefit by killing the pathogen
in the bloodstream before it can affect to the heart valve. It is also
traditionally thought to prevent adherence of bacteria to the thrombus forming
on the valve and to eradicate the causal organisms that adhere to the thrombus.
Although there is strong evidence that the risks and low cost-effectiveness of
antibiotic prophylaxis might outweigh the benefits, widespread use of
antibiotic prophylaxis might contribute to antibiotic resistance. Moreover, it
is an important thing that the adjustment of risk and benefit of prophylaxis
depend on patient’s conditions especially in developing countries where are
probably higher prevalence of drug resistance than developed nations. Thornhill
et al. [10] showed that adverse event from the use of antibiotic prophylaxis
with single dose amoxicillin resulted only two adverse events per year and no
deaths and prophylaxis by clindamycin resulted in twice as many adverse events
and one death every three years. Nevertheless, the level of evidence of
antibiotic prophylaxis efficiency is usually depend on underlying high risk
conditions of Infective endocarditis and the indications of its prescription
have been revised in recent international guidelines.
ESC 2015 RECOMMENDATION
Cardiac conditions at highest
risk of IE for which prophylaxis is recommended when a high-risk procedure is
performed
Patients with previous IE have a greater risk for new IE, higher
mortality and develop more complications than patients with a first episode of
IE.
Patients with congenital heart
disease (CHD):
· Any
type of cyanotic CHD.
·
Any type of CHD repaired with prosthetic
material, whether placed surgically or by percutaneous technique, up to 6 months
after the procedure or lifelong if residual shunt or valvular regurgitation
remains.
Recommendations for prophylaxis
of IE in the highest risk patients, according to the type of dental procedure
According to the revised South Africa guideline, antibiotic prophylaxis
is not recommended for local anesthetic injections in non-infected tissue,
treatment of superficial carries, removal of sutures, dental X-rays, placement
of removable prosthodontics or orthodontic appliances or braces or following
shedding of deciduous teeth or trauma to the lips or oral mucosa. Antiseptic
mouth rinses (chlorhexidine or povidone-iodine) may reduce the incidence or
magnitude of bacteremia occurring.
SUGGESTIONS FOR THE FUTURE
There are many ongoing trails and analysis about antibiotic prophylaxis
in the field of infectious medicine including infective endocarditis to improve
effective treatment with reducing the occurrence of antibiotic resistance.
Although preventive antibiotic for infective endocarditis on indicated patients
use significantly lowers the risk for infection in patient, it is still
challenging to follow the outcome of effectiveness in case series from
single-center analysis. There would be good idea to analyses the effective
infection control by Good oral hygiene, including daily flossing as an
important preventative measure for all patients.
The threatened of antibiotic resistance by widespread use of
antibiotics for this purpose, an important issue today, as well as needlessly
expose patients to antibiotic side effects such as allergic reactions. For this
reason, International Collaboration of Endocarditis (ICE) has been hopefully
formed and large randomized clinical trials can be done by collecting various
cohort data from multicenter internationally.
CONCLUSION
1. Aref ABA, Larry MB, Patricia JE, Bruno H,
Vivian HC, et al. (2014) Global and regional burden of infective endocarditis,
1990-2010: A systematic review of the literature. Global Heart 9: 131-143.
2. Garg N, Kandpal B, Garg N, Tewari S, Kapoor
A, et al. (2005) Characteristics of infective endocarditis in a developing
country-clinical profile and outcome in 192 Indian patients, 1992-2001. Int J
Cardiol 98: 253-260.
3. Global Burden of Disease Study (2013) Age-sex
specific all cause and cause-specific mortality 1990-2013. Institute for Health
Metrics and Evaluation (IHME), Seattle, WA.
4. Mariana M, Romain A, Paul BM, Hester C, Flore
L, et al. (2015) Infective endocarditis in the Pacific: Clinical
characteristics, treatment and long-term outcomes. Open Heart 2: e000183.
5. Habib G, Hoen B, Tornos P, Thuny F,
Prendergast B, et al. (2009) Guidelines on the prevention, diagnosis and
treatment of infective endocarditis (new version 2009): The task force on the
prevention, diagnosis and treatment of infective endocarditis of the European
Society of Cardiology (ESC). Endorsed by the European Society of Clinical
Microbiology and Infectious Diseases (ESCMID) and the International Society of
Chemotherapy (ISC) for Infection and Cancer Eur Heart J 30: 2369-2413.
6. Koegelenberg CFN, Doubell AF, Orth H, Reuter
H (2003) Infective endocarditis in the Western Cape Province of South Africa: A
three-year prospective study. QJM 96: 217-225.
7. Thornhill MH, Dayer MJ, Prendergast B,
Baddour LM, Jones S, et al. (2015) Incidence and nature of adverse reactions to
antibiotics used as endocarditis prophylaxis. J Antimicrob Chemother 70:
2382-2383.
8. National Heart Foundation of New Zealand
Advisory Group (2008) New Zealand guideline for prevention of infective
endocarditis associated with dental and other medical interventions. National
Heart Foundation of New Zealand, Auckland, New Zealand.
9. Ntsekhe M, Hakim J (2005) Impact of Human
Immunodeficiency Virus infection on cardiovascular disease in Africa. Circulation
112: 3602.
10. Thornhill MH, Dayer MJ, Prendergast B,
Baddour LM, Jones S, et al. (2005) Incidence and nature of adverse reactions to
antibiotics used as endocarditis prophylaxis. J Antimicrob Chemother 70: 23828.
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