Prophylaxis and treatment of infective endocarditis in adults,how to remove sweat stains from shirt armpits hurt,how do you get rid of little white bumps on your tongue yellow,bacterial eye infection nhs adults - Step 1

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IntroductionInfective endocarditis (IE) is an inflammation of the endocardium, principally affecting the heart valves, of mainly bacterial origin. Materials and MethodsIndividually tailored anonymous questionnaires (Appendices 1a-c), cover letters and a summary of the NICE guideline on antibiotic prophylaxis were sent to dental practitioners, cardiologists and patients with a history of antibiotic prophylaxis usage.
ResultsDental practitionersOf the 500 questionnaires sent to dental practitioners, 290 replied, giving a response rate of 58%.
CardiologistsA total of 20 questionnaires were returned from cardiologists, giving a response rate of 37%.A wide range of figures was given in response to the question of how many patients had been diagnosed with infective endocarditis (2-500). PatientsOf the 50 questionnaires sent to patients, 34 were returned, giving a response rate of 68%.The results of the patient questionnaires are contained in Table 3. DiscussionThe use of antibiotic prophylaxis against infective endocarditis in a dental setting is a topic that has generated much discussion in the past. ConclusionIn conclusion, a lack of uniformity of approach exists among Irish dental practitioners and cardiologists regarding the treatment of patients with cardiac conditions in a dental setting.
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Infective endocarditis is a rare but life-threatening infection of the endocardium that affects the heart valves and neighboring structures. While a healthy immune system typically prevents circulating microbes from causing harm, circulating bacteria can cause problems throughout the body in some individuals. To limit the likelihood of infective endocarditis and prosthetic joint infections, the American Dental Association (ADA), American Heart Association (AHA), and American Academy of Orthopaedic Surgeons (AAOS) previously recommended prophylactic antimicrobial therapy for patients with certain heart conditions and some or all patients with prosthetic joints prior to invasive dental procedures.
After publication of the new AHA guidelines, a number of research studies have been conducted in the United States to examine the impact of these new guidelines on the incidence of infective endocarditis within the first 2 years after implementation.14–17 The studies found no evidence of increased incidence for infective endocarditis.
For many years, dental procedures have been considered a potential cause of infections that threaten orthopedic implants. In light of the flurry of recent recommendations—as well as the data revealing an increasing incidence of infective endocarditis in England in the wake of ending antibiotic premedication for patients historically thought prone to the infection—the dental professional and the individual patient must weigh the risks and benefits of antibiotic use. A decision to use a certain type of antibiotic should be based on a thorough medical and dental history with emphasis on the effects of past antibiotic use.
There is also evidence that oral microflora is becoming increasingly more resistant to antibiotics.3,9–11,20 Repeated use of antibiotics can lead to antibiotic-resistant microorganisms in the oral cavity. The AHA and the ADA suggest that patients already on chronic antibiotic therapy should be prescribed an antibiotic from a different class for infective endocarditis prophylaxis, rather than increasing the dosage of the current antibiotic.
Amoxicillin (for patients not allergic to penicillin or cephalosporin drugs) is the preferred choice for oral therapy because it is well absorbed in the gastrointestinal tract and provides high and sustained serum concentrations.
There are no current recommendations for antibiotic premedication for dental patients with prosthetic implants. Prophylactic antibiotics should be consumed in a single dose 30 minutes to 60 minutes prior to dental treatment. The effectiveness of antibiotic prophylaxis to prevent infective endocarditis or prosthetic joint infection is questionable.
Acknowledging the downsides to antibiotic use mentioned above and in light of limited supportive evidence, combined AAOS-ADA recommendations in 2013 suggested that practitioners consider not premedicating certain patients with orthopedic implants. The ADA suggests that practitioners use their discretion to decide whether a particular patient receives antibiotic prophylaxis. Allied Health, Dental Hygiene Unit, at Eugenio Maria de Hostos Community College in New York.
Two thirds of patients surveyed would be concerned about the possible cessation of antibiotic prophylaxis before dental treatment and would require either verbal or written confirmation from a cardiologist.
A list of 500 dental practitioners was randomly derived from the 2,500 dentists on the dental register as provided by the Dental Council in Ireland. A similar range was seen in relation to the number of patients with IE suspected to be related to a dental cause (0-50%).
The debate has been fuelled of late with the publication of the new NICE guideline regarding the prevention of infective endocarditis. The introduction of the NICE guideline has met with mixed reaction from all three groups surveyed. Answer the questions correctly and you will be placed in a drawing to WIN the ultimate Dimensions of Dental Hygiene gift basket.
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A similar study was conducted in England after the National Institute for Health and Clinical Excellence recommended cessation of antibiotic prophylaxis for infective endocarditis prevention in 2008.18 Similar to the studies in the US, the study found no early changes in the incidence of infective endocarditis after 2 years of implementation.
Therefore, premedication prior to dental procedures was common for patients with joint replacements.


The ADA review concluded more definitively that the use of prophylactic antibiotics prior to dental procedures was not recommended for patients with prosthetic joint implants. Practitioners need to be especially aware of any previous adverse reactions to relevant antibiotics. For example, if the patient is taking amoxicillin, the practitioner might select clindamycin, azi­thro­my­cin, or clari­thro­my­cin for prophylaxis.1,10,13,26 Patients who are allergic to penicillin can be treated 1 hour before the dental procedure with an alternate antibiotic such as second-generation erythromycin, azi­thro­my­cin, or clari­thro­my­cin. Two grams of amoxicillin is sufficient to reach adequate serum levels for several hours, and the inhibitory effect of the drug is enough to eliminate the need for a post-operative dose.2,12 Patients who are unable to take medications orally can be treated with an antibiotic injection 30 minutes prior to the procedure. In the wake of the ADA's 2015 recommendations, which were developed and published independent of the AAOS, both organizations are now involved in a joint effort to develop appropriate use criteria to better guide future behaviors. This allows the antibiotic to reach adequate blood levels, thereby limiting the viability of bacteria introduced into the bloodstream. For reasons unclear, in early 2015 the ADA published newer guidelines independent of the AAOS that recommended no prophylactic antibiotics for dental patients with orthopedic implants. Prevention of infective endocarditis: Guidelines from the American Heart Association—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 Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group.
Epidemiological trends of infective endocarditis: A population based study in Olmsted County, Minnesota.
The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints: Evidence-based clinical practice guideline for dental practitioners--a report of the American Dental Association Council on Scientific Affairs.
Incidence of infective endocarditis caused by viridans group streptococci before and after publication of the 2007 American Heart Association's endocarditis prevention guidelines. Trends in endocarditis hospitalizations at US children's hospitals: impact of the 2007 American Heart Association Antibiotic Prophylaxis Guidelines. Impact of the first nine months of revised infective endocarditis prophylaxis guidelines at a university hospital: so far so good. Incidence of infective endocarditis in England, 2000–13: a secular trend, interrupted time-series analysis.
Lancet article suggests increase in infective endocarditis tied to reduction in antibiotics use. The American Academy of Orthopaedic Surgeons and the American Dental Association clinical practice guideline on the prevention of orthopaedic implant infection in patients undergoing dental procedures. Among the dental practitioners surveyed a significant majority were not willing to implement the NICE guideline without further information from the patient general medical practitioner, cardiologist or an official Irish body.Conclusion To enable patient re-education regarding antibiotic prophylaxis, dental practitioners must keep abreast of changes to current guidelines and understand the rationale driving these changes.
Significant mortality and morbidity is associated with the condition and annual mortality has been reported to approach 40%.2Accepted clinical practice has been to use antibiotic prophylaxis in those at risk of IE who are having dental procedures, in order to prevent the development of infective endocarditis. A total of 54 cardiologists registered with the Irish Cardiac Society and a list of 50 patients previously requiring antibiotic prophylaxis before dental treatment, were obtained from the drug register of Cork University Dental School and Hospital.
This reflected the varying duration in clinical practice and relevant experience of each cardiologist.The remainder of the results from the cardiologist questionnaires are contained in Table 2.
We decided to use a postal questionnaire to collect information from three groups of people to whom this topic would be of particular importance – dental practitioners, cardiologists and patients with cardiac conditions.
Re-education of patients about the changes to antibiotic prophylactic practices has been highlighted as an area of importance. The March 2016 issue comprises information about the topics that matter most to oral health professionals.
While the oral cavity harbors more than 700 strains of bacteria, only a small number are associated with infective endocarditis, including Staphylococci and Viridans streptococci as well as Enterococcus, Pseudomonas, and Serratia species. Analysis of 5-year data, however, revealed the incidence of infective endocarditis had significantly increased in England. Premedication was also routinely prescribed for patients with other implants, such as orthopedic screws, pins, etc.
In January 2015, the ADA Council on Scientific Affairs continued to discourage prophylactic antibiotic use for most patients with prosthetic joint implants. Current medications and the possibilities for drug interactions, and risks of microbial resistance are other important considerations.3,9–11,20 Practitioners should select an antibiotic that is active against the pathogens likely to cause the relevant infection. For individuals who are to be premedicated, practitioners must always ask if the patient has consumed the prescribed drugs before starting a dental procedure. Antibiotic misuse and overuse also lead to the development of antibiotic-resistant bacteria. The AAOS and ADA have since collaborated to establish joint appropriate use criteria for premedication, which should be released soon. The use of a postal questionnaire is considered a cost- and time-effective method of collating information from people over a wide geographic area. However, before re-education of patients can take place, practitioners themselves must become familiar with both the guidelines and the rationale behind them. This includes the status of local anesthesia administration by dental hygienists across the United States, the importance of creating a culture of safety in the dental setting, and the effects of national origin on caries status. Maecenas ac tempor odio.Click here to view all articles in other categories not listed above.


The fungus Candida is another cause.1–3 The incidence of infective endocarditis ranges from five cases to seven cases per 100,000 people each year.
In light of the fact that this study was not designed to demonstrate causality, the authors suggested a need for additional studies to explore the temporal association between changes in guidelines and increased incidence. To prevent possible cross-reactions, cephalosporin should not be administered to patients with a history of anaphylaxis, angioedema, or urticaria after treatment with any form of penicillin, including ampicillin or amoxicillin.
In response, the updated AHA guidelines for antibiotic prophylaxis to prevent infective endocarditis include recommendations that strictly limit premedication to small numbers of patients for whom contracting infective endocarditis would likely cause major morbidities or death. They were requested to estimate the number of patients they had treated with IE and the number they felt were linked to a dental cause. Historically in Ireland we have followed best practice guidelines as laid down by bodies such as NICE on various topics. Women are more likely to develop infective endocarditis than men.4 Post-surgical infections of prosthetic joints are also rare, but the mechanisms for infection appear similar to infective endocarditis. Short-term studies in the US have not reported an increased incidence of infective endocarditis during the interval subsequent to the current AHA guidelines. Other NICE guidelines are commonly applied in Ireland in clinical situations, such as the guideline regarding removal of wisdom teeth, so although there is no legal requirement for practitioners in the Republic of Ireland to adopt the NICE guideline regarding antibiotic prophylaxis, it would certainly not be unreasonable for this guideline to be used in dental practice. Finally they were asked if they would be happy for a dental practitioner to implement the new NICE guideline without consulting them on this matter.PatientsThe patients were asked why they required antibiotic prophylaxis before dental treatment, which practitioner had informed them of the need for this prophylaxis and the number of years they have received prophylaxis.
The response rate from both dental practitioners (58%) and patients (68%) was relatively high, with a lower rate of response from cardiologists (37%).
The release of the 2008 NICE guideline on antibiotic prophylaxis against infective endocarditis was clear and unambiguous. However, a longer study in England suggests that the incidence of infective endocarditis has increased significantly since the end of antibiotic prophylaxis.
The aims of this study were firstly to investigate current practice relating to antibiotic prophylaxis against infective endocarditis, secondly to ascertain the opinions of dental practitioners, cardiologists and patients previously prescribed antibiotic prophylaxis to the new NICE guideline and finally to determine attitudes towards possible implementation of this guideline in clinical practice within the Republic of Ireland. They were asked their opinion of the new guideline as outlined in the summary presented to them and if they would be happy for their dental practitioner to implement these changes in the practice they attend.
Perhaps the incorporation of follow-up contact with further distribution of questionnaires at this point, which showed substantially higher response rates in the Cochrane review, could have yielded an improved rate of response.13A number of interesting issues are evident from the results of this survey regarding current practises and patient care.
However, it was published in quick succession to another set of clear and unambiguous guidelines from the AHA.
77.9% of dental practitioners surveyed follow the BSAC guidelines (1997) on antibiotic prophylaxis as published in the BNF.
Not unexpectedly, each set of guidelines argues very coherently for the particular protocols recommended. This situation has thrown into sharp relief the fact that in Ireland there is no national statutory body endorsing guidelines such as this and practitioners are therefore unsure regarding best practice.Top of pageReferencesMylonakis E, Calderwood S B. This could lead to conflicting advice being given to patients on what is considered best practice.If faced with uncertainty about whether or not to give antibiotic prophylaxis before dental treatment, 51% of dental practitioners surveyed would contact the patient's general medical practitioner for advice, which could introduce another, possibly different, opinion on the best course of action. In a survey conducted by Lauber et al.16 the results demonstrate considerable differences between dentists and family physicians in terms of drug prescription and regimes advised, as well as medical conditions and dental procedures requiring antibiotic prophylaxis. All of the guidelines available are definitive in their recommendations regarding antibiotic prophylaxis, therefore the difficulty lies with the fact that the NICE guidelines are not legally binding in the Republic of Ireland and so practitioners have the freedom to adopt the guidelines of their choosing.
This problem has become particularly apparent now that such variation exists between the AHA 2007 guideline and this NICE guideline.Almost 20% of dental practitioners surveyed would require an opinion from an official Irish body before considering implementation of the NICE guideline.
An institution such as NICE does not exist in Ireland and two such official Irish bodies mentioned in responses were the Irish Dental Association (IDA) and the Dental Council of Ireland. The question is, under the remit of which organisation or body in Ireland does guidance on this issue fall?
Guidance on clinical matters is not included in the role of the IDA as outlined on the association website17 and membership, although representative of 80% of dental practitioners, is voluntary. The defence union Dental Protection state on their website that each clinician has his or her own separate duty of care to the patient.
An opinion expressed by a patient's cardiologist (or general medical practitioner) can be regarded as a valid consideration in the overall assessment of a case, but it is not in itself definitive. In fact they state that following such an opinion is inadvisable and may be difficult to defend.19 The NICE guideline is designed to act as guidance only and the final decision on whether or not to use antibiotic prophylaxis should be made after the practitioner and the patient reach a consensus. However, as part of this BCS position statement it is confirmed that practitioners and patients who wish to continue with antibiotic prophylaxis will be allowed to do so.Forty-three percent of dental practitioners considered the cessation of antibiotic prophylaxis against endocarditis to be a positive change due to concern about the risk of anaphylaxis or antibiotic resistance. Guidelines from the American Heart Association: 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. Monographs in Epidemiology and Biostatistics volume 21.Edwards P, Roberts I, Clarke M et al.




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