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Prophylactic Antibiotics Are Passé

The AHA has moved away from routine use of preprocedure prophylaxis, including for skin surgery.

The American Heart Association (AHA) has revised its guidelines, last published 10 years ago, on prescribing prophylactic antibiotics (PAs) for prevention of endocarditis. Now, committee members have completed a new meta-analysis of the current literature to evaluate the usefulness of PAs, with a primary focus on dental procedures.

They concluded that because transient bacteremia frequently occurs during routine daily activities — such as tooth brushing, flossing, and eating — dental procedures are just one of many thousands of an individual’s annual bacterial exposures, and PAs probably prevent only a tiny percentage of potential endocarditis infections. The cumulative exposure to bacteremia from routine daily activities during 1 year is estimated to be 5.6 million times greater than that from one tooth extraction. Very few endocarditis infections result from dental procedures. No evidence exists that PAs reduce the risk for endocarditis in susceptible individuals.

Nevertheless, the AHA suggests that a single dose of PA may be reasonable in patients with an especially high risk for adverse effects of endocarditis, including patients with prosthetic heart valves, heart transplants and cardiac valve disease, endocarditis history, or certain congenital heart diseases. PAs for endocarditis are not advised for patients undergoing gastrointestinal or genitourinary procedures.

No data are presented regarding the benefits of PAs for patients undergoing routine skin surgery. The AHA recommends a single dose of PAs for skin surgery patients at high risk for severe adverse endocarditis events — but only if the tissue is clearly infected at the time of surgery. Coverage should be for Staphylococcus aureus and ß-hemolytic streptococcus — for example, dicloxacillin given 30 to 60 minutes before the procedure.

Comment: The AHA recommendations move away from the routine use of PAs in high-risk patients. In dermatology, PAs need not be prescribed to prevent endocarditis for surgery in noninfected skin. Patients with infected skin are usually already taking therapeutic antibiotics covering the skin flora, and the physician need not add a separate prophylactic antibiotic. However, it will take a lot of reeducation to alter prescribing habits and the practice of defensive medicine. Although this study did not address use of PAs in patients with artificial joints, similar reasoning regarding the frequency of transient bacteremia resulting from daily activity would likely make their use unnecessary in these patients as well.

— George J. Hruza, MD

Published in Journal Watch Dermatology August 10, 2007

Citation(s):

Wilson W et al. Prevention of infective endocarditis: Guidelines from the American Heart Association. A guideline From the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 2007 Apr 19; [e-pub ahead of print]. (http://dx.doi.org/10.1161/CIRCULATIONAHA.106.183095)