BACKGROUND: In 2007, the American Heart Association published updated evidence-based guidelines on the recommended use of antibiotic prophylaxis to prevent viridans group streptococcal (VGS) infective endocarditis (IE) in cardiac patients undergoing invasive procedures. The 2007 guidelines significantly scaled back the underlying conditions for which antibiotic prophylaxis was recommended, leaving only 4 categories thought to confer the highest risk of adverse outcome. The purpose of this update is to examine interval evidence of the acceptance and impact of the 2007 recommendations on VGS IE and, if needed, to make revisions based on this evidence. METHODS AND RESULTS: A writing group was formed consisting of experts in prevention and treatment of infective endocarditis including members of the American Dental Association, the Infectious Diseases Society of America, and the American Academy of Pediatrics, in addition to the American Heart Association. MEDLINE database searches were done for English language articles on compliance with the recommendations in the 2007 guidelines and the frequency of and morbidity or mortality from VGS IE after publication of the 2007 guidelines. Overall, there was good general awareness of the 2007 guidelines but variable compliance with recommendations. There was no convincing evidence that VGS IE frequency, morbidity, or mortality has increased since 2007. CONCLUSIONS: On the basis of a review of the available evidence, there are no recommended changes to the 2007 VGS IE prevention guidelines. We continue to recommend VGS IE prophylaxis only for categories of patients at highest risk for adverse outcome while emphasizing the critical role of good oral health and regular access to dental care for all. Randomized controlled studies to determine whether antibiotic prophylaxis is effective against VGS IE are needed to further refine recommendations.

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Background The American Heart Association (AHA) published updated guidelines for infective endocarditis (IE) prevention in 2007 that markedly restricted the use of antibiotic prophylaxis in certain at-risk patients undergoing dental and other invasive procedures. The incidence of IE due to viridans group streptococci (VGS) in the United States following publication of the 2007 AHA guidelines has not been reported. Methods and Results We performed a population-based review of all definite or possible cases of VGS-IE using the Rochester Epidemiology Project of Olmsted County, Minnesota. Patient demographics and microbiologic data were collected for all VGS-IE cases diagnosed from January 1, 1999 through December 31, 2010. We also examined the Nationwide Inpatient Sample (NIS) hospital discharge database to determine the number of VGS-IE cases included between 1999 and 2009. We identified 22 cases with VGS-IE in Olmsted County over the 12-year study period. Rates of incidence (per 100,000 person-years) during time intervals of 1999–2002, 2003–2006, and 2007–2010, were 3.19 (95% confidence interval [CI], 1.20–5.17), 2.48 (95% CI, 0.85–4.10), and 0.77 (95% CI, 0.00–1.64), respectively (p-value=0.061 from Poisson regression). The number of hospital discharges with a VGS-IE diagnosis in the NIS database during 1999–2002, 2003–2006, and 2007–2009 ranged between 15,318–15,938, 16,214–17,433, and 14,728–15,479, respectively. Conclusions Based on data complete through 2010, there has been no perceivable increase in incidence of VGS-IE in Olmsted County, MN following publication of the 2007 AHA Endocarditis prevention guidelines.