Original Contributions
Antibiotic Prophylaxis
Prescribing of antibiotic prophylaxis to prevent infective endocarditis

https://doi.org/10.1016/j.adaj.2020.07.021Get rights and content

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.

Section snippets

Data source

The IBM MarketScan Databases8,9 are a collection of Health Insurance Portability and Accountability Act10–compliant data sets that integrate deidentified patient-level health data across the different databases. Because data are statistically deidentified in a Health Insurance Portability and Accountability Act–compliant manner to protect patient privacy, studies using the data are exempt from institutional review board review. The databases provide one of the largest convenience US health care

Patient characteristics

Our study comprised 160 cases: 80 high risk, 40 medium risk, and 40 low or unknown risk. The high-risk group was 63% men and the mean age (65 years) was significantly higher than the mean age of all patients (59 years). In contrast, the low or unknown risk group was 60% women and the mean age (47 years) was significantly lower than that for all patients (Table 2).

There was no significant difference in the number of days of study or number of dental visits per patient available for us to examine

Discussion

The finding that there was no evidence of AP being prescribed before any dental procedure in 40% of high-risk patients is high. When all high-risk patients were considered, 64% of red dental procedures were unlikely to have been covered with AP. This suggests significant underprescribing of AP. It is unclear whether this lack of compliance with the AHA recommendations is consistent with continued widespread confusion about AP in general, a lack of awareness of patient comorbidities, prescriber

Conclusions

This study identified substantial underprescribing of AP in patients at high risk of developing IE complications undergoing invasive dental procedures. Of the invasive dental procedures performed, scaling accounted for most (80%-90%). The study also identified a number of different prescribing strategies to provide AP, particularly for repeat dental visits, some of which might not be consistent with modern antibiotic stewardship recommendations. In addition, this study validates, for the first

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.

References (23)

  • The Truven Health MarketScan Databases for Health Services Researchers: White Paper

    (2019)

    • Cited by (17)

    • World Workshop on Oral Medicine VIII: Dentists’ compliance with infective endocarditis prophylaxis guidelines for patients with high-risk cardiac conditions: a systematic review

      2023, Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology

    • Quantifying the risk of prosthetic joint infections after invasive dental procedures and the effect of antibiotic prophylaxis

      2023, Journal of the American Dental Association
      Citation Excerpt :

      However, we have validated our methodology previously and had 88% (95% CI, 82% to 92%) sensitivity and 96% (95% CI, 94% to 97%) specificity for identification of AP prescribing and distinction from antibiotic use to treat infections.28 Although the levels of AP cover of IDPs that we identified were low, they are not much lower than those in patients at high risk of infective endocarditis,28 for which there are clear guidelines recommending AP cover,29,35 and dentists are more motivated to provide AP cover.59,68 Several other studies have also found poor compliance with AP prescribing guidelines among US dentists.59,69-71

    • Antibiotic Prophylaxis Against Infective Endocarditis Before Invasive Dental Procedures

      2022, Journal of the American College of Cardiology
      Citation Excerpt :

      However, these findings are similar to those of other recent U.S. studies. Another study using U.S. national data from the same source found only 27% of IDP dental visits in high–IE-risk patients were likely to have had AP cover, 9% were possibly covered, and 64% were unlikely to have had AP cover,16 and a U.S. Veterans’ Administration study found that only 15% of AP prescriptions were compliant with AHA guidelines.32 Similarly, a large study using French national data found low compliance with ESC AP guidelines, with only 52,280 (50.1%) of 103,463 IDPs performed in high-risk patients covered by AP.24

    • Factors that affect dentists’ use of antibiotic prophylaxis: Findings from The National Dental Practice-Based Research Network questionnaire

      2022, Journal of the American Dental Association
      Citation Excerpt :

      For example, a group previously reported that most dentists (70%) had patients assigned to the AHA moderate-risk group who were still receiving AP more than 5 years after publication of the 2007 AHA guidelines, which recommended against this practice.8 The literature on antibiotic use in US dental practices comes from both patient cohort data and from surveys, and they suggest confusion, misuse, and overuse in general.4,9,10,12,19-22 Similar findings have been documented in other countries as well.23-25

    • The 2021 American Heart Association Statement on prevention of infective endocarditis: What's new?

      2021, Journal of the American Dental Association

    • Re: Estimating the cost of inappropriate antibiotic prophylaxis prior to dental procedures

      2023, Infection Control and Hospital Epidemiology
    View all citing articles on Scopus

    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.

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

    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.

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

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

    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.

    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.

    Disclosures. Drs. Thornhill, Gibson, Lockhart, and O’Gara received support from the Delta Dental Research and Data Institute for the submitted work. Dr. O'Gara received support from Medtronic, Edwards Scientific, and the National Heart Lung Blood Institute, National Institutes of Health, which was unconnected to the submitted work. Dr. Dayer received reports from Biotronik, which was unconnected to the submitted work. None of the other authors reported financial relationships with companies that might have an interest in the submitted work. Drs. Thornhill, Gibson, Durkin, and O’Gara have no nonfinancial interests that might be relevant to the submitted work. Dr. Lockhart is a member of the Writing Committee for the next American Heart Association’s guidelines on antibiotic prophylaxis to prevent infective endocarditis. Drs. Baddour and Lockhart were members of the American Heart Association’s Committee on Rheumatic Fever, Endocarditis and Kawasaki Disease and were involved in producing the 2007 American Heart Association guideline on prevention of infective endocarditis. Dr. Dayer was a consultant to the review committee that produced the 2015 update to National Institute for Health and Care Excellence (UK) clinical guideline 64 on prophylaxis against infective endocarditis.

    This study was funded by a research grant from Delta Dental of Michigan and its Research and Data Institute. The funding source had no role in the study design, collection, analysis or interpretation of the data, in the writing of the report, or in the decision to submit the article for publication.

    The authors acknowledge the indispensable free advice, comments, and assistance of several colleagues in general and specialty dental practice in regard to matters of dental practice and coding. In particular, they wish to acknowledge the assistance of Dr. Richard Potter and colleagues of the Texas Dental Association 20th District, San Antonio District Dental Society, Dr. Julianne K. Ruppel (Ruppel Orthodontics, St. Louis, MO), Dr. Thomas Paumier (general dentist, Ohio), Dr. Jeffery Johnston (Delta Dental of Michigan, Ohio, and Indiana), and Dr. Jed Jacobson (Ann Arbor, MI). Although they provided invaluable advice to the research team, their views might not reflect any views expressed in this article.

    View full text
    © 2020 American Dental Association. All rights reserved.