04 August 2006
Publication of new guidelines on the prevention of endocarditis, by the British Society of Antimicrobial Chemotherapy (1), has, together with an editorial in the British Dental Journal (2), caused dismay among cardiologists and confusion among patients and dentists. The guidance argues that in view of the lack of evidence that prophylactic antibiotic therapy is effective in preventing endocarditis and in the knowledge that bacteraemia in every day life associated with dental sepsis is of greater magnitude than from that resulting from dental procedures, treatment should be restricted to patients who would be at particularly high risk were they to develop the disease. These are patients who have previously had an episode of endocarditis, those with prosthetic heart valves and those with a surgically-constructed systemic or pulmonary artery shunt or conduit. Despite a similar lack of evidence for the value of prophylaxis in association with non-dental procedures the authors of the new guidance suggest caution in withdrawing existing advice and continue to recommend treatment for many, though not all, gastro-intestinal, urogenital, gynaecological and upper respiratory procedures in all patients at risk of endocarditis. The new guidance in relation to dental procedures is radically different from the guidelines of the European Society of Cardiology (which are endorsed by the BCS) and from the recommendations of the Societys own working group. The Society feels that it was unhelpful for it to have been published without consultation with those most closely involved in the treatment of patients with endocarditis - cardiologists. The BSAC paper was reviewed prior to publication by the Societys Medical Practice committee who argued that lack of evidence of benefit is not necessarily the same as lack of benefit, pointed out the illogicality of the fudge in continuing to recommend prophylaxis for very high risk patients (endocarditis is always dangerous) and expressed the opinion that insufficient new evidence exists to justify such a radical change in policy. The Society is doing everything it can to resolve the ensuing confusion. Through the offices of Roger Boyle, National Director for Heart Disease and Stroke, NICE has agreed to undertake an urgent review of the subject and the Chief Dental Officer has agreed to write to all dentists with the recommendation that they should adhere to existing guidance until NICE has reported; the Society has approached the CMO for Scotland with the request that a similar letter is written to Scottish dentists. A letter has been sent to the editors of both journals to express the Societys concerns. 1. Gould FK, Elliott TSJ, Foweraker M et al. Guidelines for the prevention of endocarditis: report of the Working Group of the British Society for Antimicrobial Chemotherapy. Journal of Antimicrobial Chemotherapy 2006;10:1093 2. Martin M. A victory for science and common sense. British Dental Journal 2006;200:471
Number of views: 3237 Add Comments
Comments: 3
| bacterial endocarditis |
| neither dentists nor bug drs are responsible for diagnosis or management of this serious disease. they have a support role and their advice is often sought and can be useful in conjunction with the experience of informed clinicians . to write such documents without full consultation with those who are responsible and informed confirms foolishness and lack of undestanding .of course bacteraemia occurs without dental manipulations but not with such intensity or bacterial concentrations in those with infection around teeth and gingivitis whe n dental procedures are performed if giving of prophylaxis prevents a few attacks of a disease which can change disastrously a patients life then it should be given . it is not for the dentist or bacterialloolgist to risk the patients let them stay within their specialty and perform expertly what they know. too many young patients have acquired the disease with strep viridans genus when dentists have refused protection or not bothered . |
| By: Jane Somerville |
| 08 August 2006 at 19:37:44 |
| respect |
| I have to say, with great respect to Dr Sommerville and Dr Brooks, that I disagree. Yes, cardiologists are responsible for the diagnosis and management of IE, but that does not make us the final authority on the interpretation of the evidence (or lack of it) regarding prevention and antibiotic prophylaxis. Anybody with training, experience and good judgement in matters of science can look at the evidence and come to a conclusion - clinical experience and judgement (our particular strengths) and our knowledge of the severe effects of IE when it occurs, are just about irrelevant. So I think we need to get off our high horse and show a bit more respect for the authors of these guidelines, frankly. Then we can enter into discussion with them and anyone else interested in the subject and, in an environment of mutual respect, expect to make some progress towards a guideline that everyone can work with (which is not the current BCS one, in my view). Michael Cave (Durham) |
| By: Michael Cave |
| 08 August 2006 at 23:55:06 |