Antibiotics for the prophylaxis of bacterial endocarditis in dentistry

  • Review
  • Intervention

Authors


Abstract

Background

Infective endocarditis is a severe infection arising in the lining of the heart with a high mortality rate.

Many dental procedures cause bacteraemia and it was believed that this may lead to bacterial endocarditis (BE) in a few people. Guidelines in many countries have recommended that prior to invasive dental procedures antibiotics are administered to people at high risk of endocarditis. However, recent guidance by the National Institute for Health and Clinical Excellence (NICE) in England and Wales has recommended that antibiotics are not required.

Objectives

To determine whether prophylactic antibiotic administration compared to no such administration or placebo before invasive dental procedures in people at increased risk of BE influences mortality, serious illness or endocarditis incidence.

Search methods

The search strategy from the previous review was expanded and run on MEDLINE (1950 to June 2008) and adapted for use on the Cochrane Oral Health, Heart and Infectious Diseases Groups' Trials Registers, as well as the following databases: CENTRAL (The Cochrane Library 2008, Issue 2); EMBASE (1980 to June 2008); and the metaRegister of Controlled Trials (to June 2008).

Selection criteria

Due to the low incidence of BE it was anticipated that few if any trials would be located. For this reason, cohort and case-control studies were included where suitably matched control or comparison groups had been studied. The intervention was the administration of antibiotic compared to no such administration before a dental procedure in people with an increased risk of BE. Cohort studies would need to follow those at increased risk and assess outcomes following any invasive dental procedures, grouping by whether prophylaxis was received. Included case-control studies would need to match people who had developed endocarditis (and who were known to be at increased risk before undergoing an invasive dental procedure preceding the onset of endocarditis) with those at similar risk but who had not developed endocarditis. Outcomes of interest were: mortality or serious adverse event requiring hospital admission; development of endocarditis following any dental procedure in a defined time period; development of endocarditis due to other non-dental causes; any recorded adverse events to the antibiotics; and cost implications of the antibiotic provision for the care of those patients who develop endocarditis.

Data collection and analysis

Two review authors independently selected studies for inclusion, then assessed quality and extracted data from the included study.

Main results

No randomised controlled trials (RCTs), controlled clinical trials (CCTs) or cohort studies were included. One case-control study met the inclusion criteria. It collected all the cases of endocarditis in The Netherlands over 2 years, finding a total of 24 people who developed endocarditis within 180 days of an invasive dental procedure, definitely requiring prophylaxis according to current guidelines and who were at increased risk of endocarditis due to a pre-existing cardiac problem. This study included participants who died because of the endocarditis (using proxys). Controls attended local cardiology outpatient clinics for similar cardiac problems, had undergone an invasive dental procedure within the past 180 days and were matched by age with the cases. No significant effect of penicillin prophylaxis on the incidence of endocarditis could be seen. No data were found on other outcomes.

Authors' conclusions

There remains no evidence about whether penicillin prophylaxis is effective or ineffective against bacterial endocarditis in people at risk who are about to undergo an invasive dental procedure. There is a lack of evidence to support previously published guidelines in this area. It is not clear whether the potential harms and costs of antibiotic administration outweigh any beneficial effect. Ethically practitioners need to discuss the potential benefits and harms of antibiotic prophylaxis with their patients before a decision is made about administration.

摘要

背景

預防細菌性心內膜炎(bacterial endocarditis)之抗生素在牙科的使用

感染性心內膜炎是發生在心臟內襯細胞,高死亡率的嚴重感染情況.許多牙科處理程序會造成菌血症,且被認為可能在某些病人會造成細菌性心內膜炎.許多國家建議在一些危險群的病人接受較具侵犯性的牙科治療前使用抗生素預防.然而最近在英格蘭和威爾士的國家健康及臨床卓越學會(the National Institute for Health and Clinical Excellence;NICE)提出的方針中卻建議不需術前使用抗生素.

目標

決定是否給予預防性抗生素和在侵犯性牙科治療前沒有給予抗生素或給予安慰劑做比較,後者在細菌性心內膜炎的死亡率,嚴重的身體不適或發生心內膜炎的危險性較高.

搜尋策略

從MEDLINE搜尋之前從1950年∼2008年六月的評論文章,並改寫應用在the Cochrane Oral Health, Heart and Infectious Diseases Groups' Trials Registers, 以及以下的資料庫: CENTRAL (The Cochrane Library 2008, Issue 2); EMBASE (1980 to June 2008); and the metaRegister of Controlled Trials (to June 2008).

選擇標準

由於細菌性心內膜炎發生率低,可以預期即使有任何的臨床試驗也很少.因此開始有包含了適當配對的控制組及對照組的世代研究和病例對照研究.比較在有較高發生細菌性心內膜炎的病人,牙科術前給予抗生素和沒有給予抗生素,世代研究需要追蹤增加的危險性及評估各種侵犯性牙科治療後的追蹤結果,依照是否有預防性給藥來分組.病例對照研究需將有發生心內膜炎的病人(已知在侵入性牙科治療前就會有較高風險發生心內膜炎的病人)和有相似的風險卻沒有發生心內膜炎的病人配對.重要的結論在於:需住院的死亡率或病情加劇的情形;任何牙科治療一段時間後發生心內膜炎;其他非牙科造成的心內膜炎;使用抗生素後病情加劇的情況;發生心內膜炎的病人所需的費用,包含抗生素的給予和照顧.

資料收集與分析

兩位作者回顧之前的研究,分別選擇可引用的研究,再從中評估它們的品質和挑選出資料.

主要結論

病例對照研究包含非隨機控制的試驗(randomised controlled trials; RCTs),控制的臨床試驗(controlled clinical trials; CCTs)或世代研究(cohort studies)這些準則.兩年多的時間搜集了所有在荷蘭心的內膜炎病例,發現總共有24個病人在侵犯性牙科治療後180天內發生心內膜炎,根據目前的治療方針和之前已有心臟疾病的高風險病人,術前的預防性抗生素是肯定必要的.這個實驗中包含因心內膜炎死亡的病例.對照組中在牙科治療後180天內發生相似心臟疾病的患者至心臟科門診求診,依照年齡和病例配對.結果顯示術前給予penicillin預防對於心內膜炎的發生率沒有明顯的效果.沒有資料顯示其他結果.

作者結論

目前仍沒有證據顯示在具有風險的病人接受侵犯性牙科治療時,術前給予預防性抗生素對抗細菌性心內膜炎是有效或是無效,缺乏證據去證實先前發表的治療方針.是否有潛在性的危害和抗生素的價格是否比它的效果更高還不清楚.道德上,醫生在決定是否給藥前需和他們的患者討論使用術前抗生素可能的益處和危害.

翻譯人

本摘要由臺灣大學附設醫院張妤欣翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

目前仍沒有證據顯示在具有風險的病人接受侵犯性牙科治療時,術前給予預防性抗生素對抗細菌性心內膜炎是有效或是無效,缺乏證據去證實先前發表的治療方針.是否有潛在性的危害和抗生素的價格是否比它的效果更高還不清楚.道德上,醫生在決定是否給藥前需和他們的患者討論使用術前抗生素可能的益處和危害.

Plain language summary

Antibiotics for the prophylaxis of bacterial endocarditis in dentistry

There is no evidence about whether antibiotic prophylaxis is effective or ineffective against bacterial endocarditis in people at risk who are about to undergo an invasive dental procedure.
There is a lack of evidence to support previously published guidelines in this area. It is not clear whether the potential harms and costs of antibiotic administration outweigh any beneficial effect. Ethically practitioners need to discuss the potential benefits and harms of antibiotic prophylaxis with their patients before a decision is made about administration.

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