New Insights For Antibiotics Preoperative Administration In Rheumatic Heart disease Patient

1. New Insights For Antibiotics Preoperative Administration In Rheumatic Heart disease Patient Presented by Dr. Noura M. Youssri Ahmed Mahmoud Lecturer of Anesthesia, Intensive Care and Pain Management at Ain Shams University . Dr. Aya ShaarawyAbdelshafy Head of Clinical Pharmacy Department at Obstetric and Gynecology Hospital.

2. A 28 years old female patient scheduled for tooth extraction. Patient suffered from rheumatic mitral stenosis. 1hr prior the procedure patient received amoxicillin as prophylaxis against infective endocarditis. Patient developed allergic reaction that was managed and procedure was postponed.

3. Was the Antibiotic prophylaxis for infective endocarditis indicated here ? and What is the recommended regimen?

4. Infective endocarditis (IE) is a deadly disease, associated with high mortality and severe complications • The principle of antibiotic prophylaxis for IE was developed on the basis of observational studies and animal models and aimed at preventing the attachment of bacteria onto the endocardium after transient bacteremia following invasive procedures • This concept previously led to the recommendation for antibiotic prophylaxis in a large number of patients with predisposing cardiac conditions undergoing a wide range of procedures.

5. History of antibiotic prophylaxis In 1955 the use of antibiotic prophylaxis (AP) to prevent IE was first recommended by the American Heart Association for rheumatic or congenital heart disease in dental and other invasive procedures in the form of parenteral combination of penicillins and streptomycin 1n 2007 The Move to Restrict the Number of Individuals Who Should Receive Antibiotic Prophylaxis AHA they recommended that the use of AP should be restricted to those at the highest risk of IE or its complications . In March 2008, the NICE recommended complete cessation of AP (for all procedures and all patients) to prevent IE In September 2015, the AHA and the ESC announced their updated guidance having evaluated exactly the same evidence and recommend restriction to high risk of IE patients undergoing at risk procedures . In 1982 the British Society for Antimicrobial Chemotheray (BSAC) produced the first UK guidelines The Move Towards Single Oral Dose Antibiotic Prophylaxis Regimens

6. The reason for restriction of antibiotic prophylaxis • The risk of IE may be related more to cumulative low-grade bacteraemia during daily life rather than sporadic high-grade bacteraemia after dental procedures, so estimated risk of IE following dental procedures is very low • Widespread use of antibiotics may result in the emergence of resistant microorganisms • Risk of anaphylaxis and drug eruption from antibiotic is very low but become significant with wide spread use . • The efficacy of antibiotic prophylaxis on the occurrence of IE has only been proven in animal models but controversial in human model

7. Why restrict antibiotic prophylaxis to high risk patients and not completely cease it ? • The 2015 ESC Guidelines for the management of infective endocarditis maintain the principle of antibiotic prophylaxis in high-risk patients for the following reasons: • The worse prognosis of IE in high-risk patients, in particular those with prosthetic IE. • The fact that high-risk patients account for a much smaller number than patients at intermediate risk, thereby reducing potential harm due to adverse events of antibiotic prophylaxis. • The remaining uncertainties regarding estimations of the risk of IE.

8. Which patients are at high risk of developing infective endocarditis?

9. Patient with highest risk of Infective Endocarditis Acc to both ESC (2015) and AHA (2017) guidelines patients with the highest risk of IE can be placed in 3 categories • Patients with a prosthetic valve or with prosthetic material used for cardiac valve repair, or with transcatheter-implanted prostheses and homografts . • Patients with previous IE • Patients with untreated cyanotic congenital heart disease (CHD) and those with CHD who have postoperative palliative shunts, conduits or other prostheses. After surgical repair with no residual defects, the Task Forces recommends prophylaxis for the first 6 months after the procedure until endothelialisation of the prosthetic material has occurred.

10. American Heart Association/American College of Cardiology guidelines also recommended prophylaxis in cardiac transplant recipients who develop cardiac valvulopathy, this is not supported by strong evidence and is not recommended by the ESC Task Force. • Antibiotic prophylaxis is NOT RECOMMENDED for patients at intermediate risk of IE, i.e. any other form of native valve disease (including the most commonly identified conditions: bicuspid aortic valve, mitral valve prolapse and calcific aortic stenosis).

11. What is the recommended regimen for antibiotic prophylaxis?

12. Recommended regimen

13. The 2007 AHA guidelines state that an antibiotic for prophylaxis should be administered in a single dose30 to 60 min before the procedure and if not administered before the procedure, it may be administered up to 2 hours after the procedure. • In situations where patients are receiving long-term parenteral antibiotic for IE, the procedure should be timed to occur 30 to 60 min after delivery of the parenteral antibiotic ( as parenteral antibiotic therapy is administrated in such high doses that the high concentration would overcome any possible low level resistance in normal flora)

14. 5 years later the patient was readmitted to obstetric and gynecology ER 38 weeks pregnant in labor for normal vaginal delivery . She gave history of mitral valve replacement 2 years before.

15. The question is whether Antibiotic prophylaxis for infective endocarditis is indicated?

16. Antibiotic prophylaxis should only be considered for patients at highest risk for endocarditis undergoing at-risk procedures

17. What are the procedures at-risk requiring antibiotic prophylaxis for infective endocarditis?

18. Prophylaxis for at risk Procedures Dental procedures • At-risk procedures involve manipulation of the gingival or periapical region of the teeth or perforation of the oral mucosa (including scaling and root canal procedures) non-dental procedures • Prophylaxis for (Respiratory tract, Gastrointestinal, Genitourinary procedures, TOE • Systematic antibiotic prophylaxis is not recommended for non-dental procedures. • Antibiotic therapy is ONLY needed when invasive procedures are performed in the context of INFECTION.

20. Cardiac or vascular interventions • In patients undergoing implantation of a prosthetic valve, any type of prosthetic graft or pacemakers, perioperative antibiotic prophylaxis should be considered due to the increased risk and adverse outcome of an infection • The most frequent microorganisms underlying early (1 year after surgery) prosthetic valve infections are coagulase-negative staphylococci (CoNS) and Staphylococcus aureus. • Prophylaxis should be started immediately before the procedure, repeated if the procedure is prolonged and terminated 48 h afterwards.

21. Preoperative screening of nasal carriage of S. aureus is recommended before elective cardiac surgery in order to treat carriers using local mupirocin and chlorhexidine. • It is strongly recommended that potential sources of dental sepsis should be eliminated at least 2 weeks before implantation of a prosthetic valve or other intracardiac or intravascular foreign material, unless the latter procedure is urgent.

22. Recommendations for antibiotic prophylaxis before cardiac or vascular interventions

23. Healthcare-associated infective endocarditis • Healthcare-associated IE represents up to 30% of all cases of IEand is characterized by an increasing incidence and a severe prognosis, thus presenting an important health problem. • Aseptic measures during the insertion and manipulation of venous catheters and during any invasive procedures, including in outpatients, are mandatory to reduce the rate of this healthcare-associated IE

24. The ESC (2015) &AHA (2017) guidelines recommend continuing to limit antibiotic prophylaxis to PATIENTS AT HIGH RISK of IE undergoing the HIGHEST-RISK PROCEDURES. • Regarding invasive respiratory tract, gastrointestinal or urogenital procedures AP is NOT RECOMMENDED UNLESS established INFECTION or if Ab therapy is indicated to prevent wound infection or sepsis. • Non-specific infection control measures are of great importance to decrease incidence of healthcare-associated IE. • Although guidelines on IE prophylaxis is based on weak evidence, they have been strengthened recently by epidemiological surveys .

25. References • American College of Cardiology, American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease), Society of Cardiovascular Anesthesiologists, et al. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing Committee to Revise the 1998 guidelines for the management of patients with valvular heart disease) developed in collaboration with the Society of Cardiovascular Anesthesiologists endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. J Am Coll Cardiol2006; 48:e1. • Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol2014; 63:e57. • Nishimura RA, Otto CM, Bonow RO, et al. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol2017. • Habib G, Lancellotti P, Antunes MJ, Bongiorni MG, Casalta JP, Del Zotti F, Dulgheru R, El Khoury G, Erba PA, Iung B :2015 ESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC)Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM) European Heart Journal 2015;36(44): 3075–3128.