Infective endocarditis prophylaxis treatment review,how do you get rid of a bad smell on your hands,bacterial infection treated with metronidazole wiki - Tips For You

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Our New BMJ website does not support IE6 please upgrade your browser to the latest version or use alternative browsers suggested below. Number of cases and in-hospital deathsBefore guideline changeThe table? gives estimated annual percentage changes in the number of cases and number of deaths.
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Evidence that the general upward trend in cases of infective endocarditis before the guideline was significantly altered after the guideline was lacking (P=0.61). After the introduction of the guideline a large (78.6%) and rapid decrease occurred in prescribing of antibiotic prophylaxis.
Using a non-inferiority test, an increase in the number of cases of 9.3% or more could be excluded after the introduction of the guideline. As this is less than the prespecified limit of 139.8, the possibility of a 15% increase in cases can be excluded. However, we did not detect a significant increase in the number of infective endocarditis cases above the long term baseline trend over this period. Also plotted are separate lines for linear trend within 2 standard deviations (broken lines) for periods before and after introduction of NICE guideline. Neither was there a significant increase in the rate of infective endocarditis related deaths in hospital nor a significant increase in the number of cases due to streptococci of possible oral origin.Limitations of the studyThe study has several limitations.


Firstly, it was retrospective and limited to England and therefore may not be generalisable to other populations. Both continued to recommend antibiotic prophylaxis for patients with prosthetic heart valves undergoing invasive dental procedures, patients with cardiac valves repaired using prosthetic material, and patients with significant congenital heart lesions, a heart transplant with valvular lesions, or a history of endocarditis.We hypothesised that by studying national prescribing data as well as data recorded for all inpatient hospital activity in the United Kingdom, we would be able to quantify the effect of the new NICE guideline on prescribing of antibiotic prophylaxis and the incidence of infective endocarditis.
We describe the effect of the guideline on the prescribing of antibiotic prophylaxis in England and the changes in the incidence of cases of infective endocarditis and deaths from the disease in hospital over that period.MethodsPrior to the introduction of the NICE guideline in March 2008 a single 3 g oral dose of amoxicillin or a 600 mg oral dose of clindamycin was used as antibiotic prophylaxis to prevent infective endocarditis in people at risk undergoing invasive dental procedures. In the United Kingdom, data are collected on every patient admitted to hospital, and the coding is done by trained and accredited staff. As this is less than the prespecified limit of 22.4, the possibility of a 15% increase in deaths from infective endocarditis can be excluded. Although these data can be subject to coding errors, the coding has been shown to be more reliable and complete in capturing data on, for example, all cases of vascular surgery than a national research database specifically designed for that purpose.18 Furthermore, as the coding was done independently of the study it was not subject to study bias or influenced in any way by the introduction of the NICE guideline.
As the study sample was based on national data, the size of the dataset and the consistency of the process are likely to average out any error.Although patients with infective endocarditis may present to different hospital specialties and the disease may be difficult to diagnose initially, data from hospital episode statistics records only the discharge diagnosis and should therefore reflect as accurately as possible the actual number of cases treated. None the less, because the diagnosis of endocarditis is sometimes uncertain, some cases will undoubtedly have been missed and others will have been erroneously labelled as endocarditis. The number of deaths from infective endocarditis in hospital were obtained from hospital episode statistics data, defining the status at discharge from hospital (dead or alive). Thus the data reflect deaths that are the immediate result of a hospital admission for infective endocarditis and will not have captured deaths before admission or deaths at home as a result of the late complications of the disease. We also identified patients with such a diagnosis where a streptococcal or staphylococcal cause was also recorded (ICD-10 A40, A41 codes for septicaemia or B95 supplementary causal organism codes). We therefore had to use codes for “unspecified” or “other” streptococci to identify cases of infective endocarditis with a possible viridians group streptococcal cause. Nevertheless, these codes exclude group A, B, and D streptococci and S pneumoniae and, given the microbiology of the oral cavity and infective endocarditis, it is possible that oral viridians group streptococci account for a high proportion of the organisms in this group.19 20Fourthly, although 35-45% of cases of infective endocarditis are caused by oral viridians group streptococci,5 6 7 8 9 good data are lacking on the proportion resulting from an invasive dental procedure.
However, the strategy of giving antibiotic prophylaxis to prevent infective endocarditis is based on the premise that a high proportion of these cases result from oral bacteria entering the circulation during dental procedures.
We counted such continuous periods of illness, known as “superspells,” only once.Statistical analysisWe plotted graphically data on monthly prescribing and incidence of infective endocarditis. An alternative view, however, is growing that oral bacteria continuously enter the circulation21 22 as a result of daily activities such as chewing food and tooth brushing, and these may be far more important causes of oral viridians group streptococci associated cases of infective endocarditis. The reality could, however, lie anywhere between these two extremes.Without accurate data on the proportion of cases caused by dental procedures it is difficult for statistical analysis purposes to predefine a clinically relevant level of change after the cessation of antibiotic prophylaxis, or to determine the sample size needed to detect the change. Using the premise that a high proportion of cases are caused by dental procedures, a large increase in the number of cases would be expected if antibiotic prophylaxis was stopped and was effective, and a comparatively small population would be needed to detect a statistically significant change. We investigated non-linear trends by adding a quadratic term in the Poisson regression model, but as this term was not statistically significant for any of the outcomes it was dropped from the models. On the other hand, if the number of cases caused by dental procedures was small, it would require an infinitely large population to detect any increase in the number.
To test for over-dispersion we carried out likelihood ratio tests between “standard” Poisson regressions and negative binomial regressions, with all other settings equal.
Indeed, to exclude a 1% increase in the incidence of infective endocarditis above the baseline trend, assuming a similar incidence of infective endocarditis and variability in the numbers of cases on a month by month basis, would require a study population of 478.5 million people.
The log likelihood ratios reported for the negative binomial regressions were lower than those reported for the standard Poisson regressions, which indicated (without the need for a likelihood ratio test) that negative binomial regressions did not offer an improvement over Poisson regressions.For the primary analysis of cases of infective endocarditis and deaths we used a “non-inferiority” test.
For this reason, even with a study covering the entire population of England, the possibility of a small increase in cases after cessation of antibiotic prophylaxis cannot be excluded. However, that we identified no significant increase in cases in a population of this size, despite a large decrease in prescribing of antibiotic prophylaxis, suggests that invasive dental procedures are unlikely to account for a high proportion of the cases.Because of this, and because of the nature of the statistical test we applied, we used the quality of the available data to determine the limits of detection rather than estimate a clinically relevant level of change. We determined this by examining the number of cases and variability in the data before March 2008—that is, the limitations of the data. The 15% margin of error set for the statistical analysis was determined a priori based on the variability in monthly incidence figures for cases of and deaths from infective endocarditis in the period before March 2008. It was not determined by deciding what might be a clinically meaningful margin of indifference.An upper limit for the acceptable increase in the number of cases was therefore specified based on the quality of the data.


For the non-inferiority test we regarded the counts of cases and deaths as continuous variables.
Because of the upward trend in the outcomes before the guideline change, we based the limits on the number of cases or deaths in March 2008 estimated from our fitted Poisson regression model. However, in over 90% of cases the incubation period for infective endocarditis is less than six weeks, and other studies have used three months as the cut off for capturing all cases of infective endocarditis that will develop after exposure to the risk of infection.8 9 We therefore believe that if antibiotic prophylaxis was effective in preventing infective endocarditis the large decrease in prescribing of antibiotic prophylaxis that occurred after the introduction of the NICE guideline would have resulted in a detectable increase in cases during the 25 months of the study.
We used the monthly data before the guideline change to set the margin for the mean of the 25 months of data since the change.Based on the variability of the monthly data before the change we set as the margin a 15% increase over the fitted number for cases and deaths. Any such change should have been particularly noticeable among those cases where the causal organism was of possible oral streptococcal origin. To carry out the test we constructed a 95% confidence interval for the monthly mean number of cases or deaths for the 25 months after the guideline change. Compliance was particularly good among dentists who, as well as being strongly urged to adopt the new guidelines by the chief dental officer, NICE, and the dental press, were advised by the malpractice insurance organisations that it would be difficult to defend cases where the new guidelines had not been followed. A residual level of prescribing does, however, seem to persist at around 20% of the level before the guideline.
To compare more stable periods of prescribing for antibiotic prophylaxis, the 12 months before the introduction of the guideline was compared with the most recent 12 months of prescribing data for 14 to 25 months inclusive after the introduction of the guideline. This comparison provided a 78.6% reduction in prescribing, from a mean 10?727 (SD 1068) before the introduction of the guideline to 2292 (SD 176) after. Firstly, the guideline allows antibiotic prophylaxis to be prescribed to patients who have previously received it and insist on continuing to have it, even after the rationale for the change in policy has been fully explained. Secondly, anecdotal evidence suggests that some cardiologists are pressurising dentists or, where dentists refuse to prescribe, the patient’s general medical practitioner to provide antibiotic prophylaxis for patients they regard at particularly high risk of infective endocarditis, such as patients with significant congenital heart lesions, prosthetic heart valves, or a history of infective endocarditis. In other words, some clinicians in the United Kingdom may be implementing the European Society for Cardiology or American Heart Association guidelines rather than the NICE guideline.23 Finally, anecdotal evidence also suggests that a small proportion of dentists in the United Kingdom prescribe a 3 g dose of amoxicillin (or 600 mg dose of clindamycin) to treat acute dental infections. The precise contribution of each of these explanations to the residual 20% prescribing figure is hard to quantify.Over the past 10 years a general move has been to reduce antibiotic prescribing to save cost and to prevent the development of antibiotic resistant bacteria. Although this could have played a part in the reduction in prescribing of antibiotic prophylaxis, it seems unlikely given the size and suddenness of the reduction, its coincidence with the introduction of the NICE guideline, the low cost of a single dose of amoxicillin or clindamycin, and national prescribing data that show a slight increase in the general prescribing of penicillins and macrolide antibiotics over the same period.The results of this analysis cover a large group of patients for whom antibiotic prophylaxis was prescribed before the introduction of the NICE guideline. Our results suggest that for most of these patients, including those with a history of rheumatic fever or a heart murmur, there may be little or no benefit in giving antibiotic prophylaxis to prevent infective endocarditis. However, because we cannot exclude the possibility that residual antibiotic prophylaxis prescribing targets those perceived to be at highest risk of infective endocarditis, it does not completely tackle the problem of whether a subset of patients, particularly those with prosthetic heart valves or a history of infective endocarditis, might still benefit from antibiotic prophylaxis.
Although one small study found no cause for concern after the change in the American Heart Association guidelines24 the present trial is the first large scale study to evaluate the effect of the NICE guideline recommendation to stop antibiotic prophylaxis to prevent infective endocarditis.Although these findings lend support to the NICE guideline recommendations and suggest that antibiotic prophylaxis before invasive dental procedures is unlikely to be of value in preventing infective endocarditis in patients with a history of rheumatic fever or a heart murmur, our findings do not exclude the possibility that a small number of patients at highest risk, such as those with prosthetic valves, might benefit. PBL, GRC, and VHC contributed to the literature search, data interpretation, and writing of the manuscript. The funder played no part in the design of the study, writing of the manuscript, or decision to submit the manuscript for publication. None of the authors of this paper were members of the NICE guideline committee that introduced NICE guideline No 64.
A guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. 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).
Temporal trends in infective endocarditis: a population-based study in Olmsted County, Minnesota. Dental and cardiac risk factors for infective endocarditis: a population-based case-control study.




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