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