Extraoral infections caused by oral bacteria Endocarditis Infective

Extraoral infections caused by oral bacteria Endocarditis

Infective endocarditis Infection of endocardium l acute l subacute l chronic About 2 to 3 out of 100, 000 people develop bacterial endocarditis each year in the US

Risk factors l Defective valves l Prosthetic valves l Congenital heart defects e. g. l Ventricular septal defect l Patent ductus arteriosus

Causative organisms l Viridans streptococci (50%) (S. mutans, S. sanguis) l Staphylococcus aureus Enterococcus faecalis l More uncommonly other bacteria, fungi l

Pathogenicity Bacteremia l Biofilm along valve edges l l Infectious organisms l Mass of fibrin l Platelets

Clinical Features l Valve destruction heart failure l Embolic events l Immune complex deposition vasculitis arthralgia glomerulonephritis l Malaise, fever, night sweats, weight loss, anaemia abscesses in brain, liver

Diagnosis § § § Blood cultures – repeated samples Anaemia white blood cell count erythrocyte sedimentation rate Echocardiography

Mortality l Fatal if untreated 6% sensitive streptococci l 30% Staphylococcus aureus l

Management l Antibiotics i. v. (penicillin and gentamicin before AST results) l Oral antibiotics

Bacteremia

Frequency of bacteremia Procedure Extraction % 10 -100 Scaling and root planing 8 -80 Rubber dam matrix/wedge placement 9 -32 Tooth brushing and flossing Chewing food 20 -68 7 -51

Magnitude of bacteremia Dental procedures <104 CFU/ml Routine daily activities <104 CFU/ml Experimental endocarditis 106 – 108 CFU/ml

Persistance of bacteremia l Most positive blood cultures were within 10 mins after extraction. l 6 -30 minutes with single extraction l Only a small no. of positive blood cultures between 30 -60 minutes

Control and prevention Oral hygiene l Antibiotics l

Dental procedures l l All dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa, e. g. l l l Extraction Periodontal probing, scaling, root planing and surgery Biopsy Suture removal Subgingival restorations Orthodontic band placement

ATB l One hour pre-operation l l l Amoxycillin If penicillin allergic, clindamycin 600 mg po Allergic to penicillin and unable to swallow capsules, azithromycin 500 mg po l Alternatively intravenous options l Pre-operative chlorhexidine (0. 2%) mouthrinse

Amoxycillin l Drug of 1 st choice l Well absorbed from GIT l High serum concentrations l Few side-effects l BUT increasing resistance to penicillin in viridans streptococci

Adverse reactions l Check for drug allergy l Check for antibiotic treatment in last 4 weeks l If patient is on other drugs, antibiotics may interfere with.