Temporal association between invasive procedures and infective endocarditis

Abstract

ObjectiveAntibiotic prophylaxis has been recommended for patients at increased risk of infective endocarditis (IE) undergoing specific invasive procedures (IPs) despite a lack of data supporting its use. Therefore, antibiotic prophylaxis recommendations ceased in the mid-2000s for all but those at high IE risk undergoing invasive dental procedures. We aimed to quantify any association between IPs and IE.MethodsAll 14 731 IE hospital admissions in England between April 2010 and March 2016 were identified from national admissions data, and medical records were searched for IP performed during the 15-month period before IE admission. We compared the incidence of IP during the 3 months immediately before IE admission (case period) with the incidence during the preceding 12 months (control period) to determine whether the odds of developing IE were increased in the 3 months after certain IP.ResultsThe odds of IE were increased following permanent pacemaker and defibrillator implantation (OR 1.54, 95% CI 1.27 to 1.85, p<0.001), extractions/surgical tooth removal (OR 2.14, 95% CI 1.22 to 3.76, p=0.047), upper (OR 1.58, 95% CI 1.34 to 1.85, p<0.001) and lower gastrointestinal endoscopy (OR 1.66, 95% CI 1.35 to 2.04, p<0.001) and bone marrow biopsy (OR 1.76, 95% CI 1.16 to 2.69, p=0.039). Using an alternative analysis, bronchoscopy (OR 1.33, 95% CI 1.06 to 1.68, p=0.049) and blood transfusions/red cell/plasma exchange (OR 1.2, 95% CI 1.07 to 1.35, p=0.012) were also associated with IE.ConclusionsThis study identifies a significant association between specific IPs (permanent pacemaker and defibrillator implantation, dental extraction, gastrointestinal endoscopy and bronchoscopy) and subsequent IE that warrants re-evaluation of current antibiotic prophylaxis recommendations to prevent IE in high IE risk individuals.

Antibiotics for prevention of endocarditis: time to scale up? Not yet!

“…In the current issue of the journal, Thornhill et al 5 tried to identify the relationship between invasive procedures (IPs) and the occurrence of IE in the UK. Between April 2010 and March 2016, 14 731 IE hospital admissions in England were identified from national admissions data and medical records.…”

“…Regarding the procedures concerned, our feeling is that it is not yet time to scale up indications for AP in guidelines. Rather, the main principle of guidelines, which is to focus on high-risk patients, is reinforced by the observation by Thornhill et al that the link between IP and IE was mainly observed in this subgroup 5…”

“…Since that time, several alarming messages arose mainly from the UK, about the potential link between the partial or total cessation of AP and the risk of increasing incidence of IE 4. In this issue of the journal, Thornhill et al 5 again sound the alarm about this risk and ask themselves the question of the need to reassess the current guidelines and to ‘scale up’ AP in some patients at risk of IE.…”

“…The excellent paper from Thornhill et al 5 gives us the opportunity to retrace the story of AP in IE and try to think about the future.…”

Heartbeat: prevention of atrial fibrillation progression

“…All agree that excellent dental hygiene is important in prevention of IE due to oral flora but the role of pre-dental procedure oral antibiotics remains unclear. Thornhill and colleagues3 highlight an additional complexity in prevention of IE with a study showing a temporal association between invasive procedures and IE in a series of 14 731 hospital admissions for IE in England between 2010 and 2016. Using a case-crossover design in which the incidence of invasive procedures in the 3 months before the episode of IE was compared with the preceding 12 months, they observed an increased risk of IE after placement of a pacer or defibrillator, dental extractions, lower gastrointestinal endoscopy, bronchoscopy and bone marrow biopsy in patients at high IE risk (figure 2).…”