Post on 01-Jan-2020
Le nuove linee guida della prevenzione delle endocarditi: abbiamo sbagliato tutto fino ad ora?
Oscar GaddiAzienda Ospedaliera ASMN – Reggio Emilia
Unità Operativa di Cardiologia
L’ EI è gravata ancora da un elevata mortalità e morbilità.
Negli Stati Uniti ma anche in Europa si stima che l’incidenza di EI su valvole
native vari dal 1.7 al 6.2 casi ogni 100,000 abitanti, con una prevalenza
maggiore negli uomini rispetto alle donne.
Modificazioni nell’epidemiologia dell’EIDue condizioni predisponenti fino alla fine degli anni ’70:
- valvulopatia reumatica
- cardiopatie congenite cianogene
Altri fattori predisponenti sono comparsi :
-abuso di sostanze stupefacenti per via iniettiva venosa
-impianto di protesi valvolari
-sclerosi valvolari degenerative
-l’incremento delle procedure invasive comportanti rischio di batteriemiesignificative,
La realizzazione delle raccomandazioni relative alla prevenzionedell’EI, da parte dei membri del AHA si è basata su di un consenso di opinioni
( assenza di evidenze basate su studi sperimentali , fin dal 1955)
Jones TD, Baumgartner L, Bellows MT, et al. Prevention of rheumatic fever, and bacterialendocarditis through control of streptococcal infection.
Circulation 1955;21:317-20.
- Periodici update delle linee guida.
-Indicazioni :non si discostano dalle precedenti
-Mancanza di trials randomizzati placebo-controllo per valutare l'efficacia e la sicurezza della profilassi antibiotica in procedure invasive, odontoiatriche e non
IndicationACC/AHA 1998 Valvular
Hight-RiskCategory
Moderate-RiskCategory
ACC/AHA 2006 Valvular
ESC 2004 EI
ACC/AHA 2006 Valvular
Endocarditis Profilaxis for Dental Procedure
ACC/AHA 1998 Valvular ACC/AHA 2006 Valvular
ESC 2004 EI
Endocarditis Profilaxis for Non Dental Procedure
ACC/AHA 1998 Valvular ACC/AHA 2006 Valvular
ESC 2004 EI
AHA 2007 EIAHA 2007 EI
-The vast majority of cases of IE caused by oral microflora most likely result fromrandom bacteremias caused by routine daily activities, such as chewing food, toothbrushing, flossing, use of toothpicks, use of water irrigation devices, and other activities.
- Prophylaxis may prevent an exceedingly small number of cases of IE, if any,
in individuals who undergo a dental, GI tract, or GU tract procedure.
- Maintenance of optimal oral health and hygiene may reduce the incidence
of bacteremia from daily activities and is more important than prophylactic
antibiotics for a dental procedure to reduce the risk of IE.
Primary Reasons for Revision of the IE
Prophylaxis Guidelines
1
Meglio una costante igiene orale che una
occasionale profilassi
- The risk of antibiotic-associated adverse events exceeds the benefit, if any, fromprophylactic antibiotic therapy.
- Nonfatal adverse reactions, ……. these common adverse reactions are usually
not severe and are self-limited.
- Fatal anaphylactic reactions were estimated to occur in 15 to 25 individuals per 1 million patients who receive a dose of penicillin.
- There has been a dramatic increase in the frequency of antimicrobial-resistantstrains of enterococci to penicillins, vancomycin, and aminoglycosides.
2
Primary Reasons for Revision of the IE
Prophylaxis Guidelines
La profilassi non solo non è utile ma può anche
essere dannosa
Indication
Revision
1
Table 3
AHA 2007 EI
MVP is the most common underlying condition that predisposes
to acquisition of IE in the Western world; however, the absolute
incidence of endocarditis is extremely low for the entire population
with MVP, and it is not usually associated with the grave outcome
associated with the conditions identified in Table 3.
Thus, IE prophylaxis is no longer recommended for this group of individuals.
Endocarditis Profilaxis for Dental Procedure
Revision
2
Endocarditis Profilaxis for Non Dental Procedure
Antibiotic prophylaxis with a regimen listed in Table 5 may be considered (Class IIb, LOE C) for patients with the conditions listed in Table 3 who undergo an invasive procedure of the respiratory tract that involves incision or biopsy of the respiratorymucosa, such as tonsillectomy and adenoidectomy.
This is in contrast to previous AHA guidelines that listed GI or GU tract procedures forwhich IE prophylaxis was recommended and those for which prophylaxisn was notrecommended. Moreover, no studies exist that demonstrate that the administration of antimicrobial prophylaxis prevents IE in association with procedures performed on the GI or GU tract.
Apparecchiature mediche impiantabili: pacemaker permanenti, defibrillatori (ICD), innesti vascolari ,stents, protesi mammarie, cateteri “tunnellizzati” , protesi peniene.
AHA 2003 : revisione delle suddette indicazioni . Per questa categoria di soggetti infatti non veniva più prevista la profilassi routinaria contro l’infezione del device in caso di procedure odontoiatriche e non.
Baddour LM, Bettman MA, Bolger AF, et al. Nonvalvular cardiovascular device-related infections.
Circulation 2003;108:2015-31.
Prophylactic antibiotic regimens
AHA 2007 EI
News from the Congress ESC 2007
Prevention of infective endocarditis: new US Guidelines bring major changes for at-risk patients Author: Dr Gilbert Habib
Limits to applying American guidelines in EuropeBefore applying the American guidelines in Europe, we need to consider their limitations.
First, the new guidelines are not based on randomised studies.
Second, such radical modifications may be difficult to accept and understand by both patients and practitioners, and much effort will be required to explain them carefully, particularly so that patients understand the shift from focus on dental procedures towards a greater access to dental care and oral health for those with cardiac disease associated with the worst outcome after IE.
Third, these guidelines probably will be followed by a reduction in the number of antibiotic prescriptions for preventing IE in the USA. It will be important to monitor the consequences on the epidemiologic profile of IE in the USA.
Finally, prospective placebo-controlled double-blinded studied of antibiotic prophylaxis of IE in patients at risk of IE remain necessary, as well as additional prospective case-control studies.
The ESC is developing a new version of the 2004 IE guidelines. These will focus on prevention, diagnosis and treatment of IE and are expected by 2009.
BSAC 2006
British Society for Antimicrobial Chemotherapy
Le considerazioni fatte a proposito delle procedure dentarie non
possono essere estese alle procedure GI e GU
Prophylaxis against infective endocarditis
Implementing NICE guidance
2008
NICE clinical guideline 64
The committee recognizes that decades of previous recommendations
for patients with most forms of VHD and other conditions have been
abruptly changed by the new AHA guidelines .
Because this may cause consternation among patients, clinicians should
be available to discuss the rationale for these new changes with their
patients, including the lack of scientific evidence to demonstrate a proven
benefit for infective endocarditis prophylaxis.
In select circumstances, the committee also understands that some
clinicians and some patients may still feel more comfortable continuing
with prophylaxis for infective endocarditis,particularly for those with
bicuspid aortic valve or coarctation of the aorta, severe mitral valve
prolapse, or hypertrophic obstructive cardiomyopathy.
In those settings, the clinician should determinethat the risks
associated with antibiotics are low before continuing a prophylaxis
regimen.
Documento congiunto FIC –SIMIT 2009
•Età avanzata
•Iimmunodepressione locale o sistemica
•Diabete
•Dialisi
•Infezioni concomitanti con microorganismi potenzialmente responsabili di endocardite