Endocarditis prophylaxis – for whom?
In most cases, infective endocarditis develops when the inner lining of the heart is attacked by a previous disease. This could be, for example, in the case of a congenital heart or heart valve defect, but also if, for example, the aortic valve has changed due to arteriosclerosis (hardening of the arteries) in older age. Any defect in the endocardium (inner lining of the heart), which also makes up the heart valves, provides a target for pathogens. There is therefore also a risk of endocarditis after certain heart operations.
Endocarditis can therefore best be prevented if the underlying diseases are treated or operated on at an early stage. At the same time, large quantities of bacteria must be prevented from entering the bloodstream and thus the heart – or at least rendered harmless as quickly as possible. This is where endocarditis prophylaxis comes in.
According to the current status, the following patients belong to the high-risk group for endocarditis or a severe course of the disease and therefore receive endocarditis prophylaxis:
- Patients with artificial heart valves (mechanical or made of animal material)
- Patients with reconstructed heart valves with artificial material (in the first six months after surgery)
- Patients with certain congenital heart defects (“cyanotic” heart defects).
- All heart defects treated with prostheses (in the first six months after surgery, lifelong if parts of pathological changes remain, e.g. a residual shunt or valve weakness)
- Patients who have undergone heart transplantation and develop problems with the heart valves (according to European guidelines, prophylaxis no longer needs to be performed in this case since 2009, but in clinical practice some physicians still use it for safety)
Endocarditis prophylaxis – here’s how it’s done
Whether a physician initiates endocarditis prophylaxis before surgery or a procedure depends on the patient, the location of the procedure, and the procedure in question. Endocarditis prophylaxis is important if, for example, bacteria are washed directly into the bloodstream during surgery due to mucosal injuries (bacteremia). Nevertheless, the currently valid guidelines recommend endocarditis prophylaxis only in very few cases.
On the one hand, this is due to the fact that its benefit has not been clearly proven to date. On the other hand, the frequent use of antibiotics promotes resistant bacteria. The experts of the European Heart Society (ESC) now only recommend endocarditis prophylaxis for high-risk patients, as mentioned above.
Endocarditis prophylaxis is otherwise only used if the surgical or examination area is infected. This includes various examinations or procedures in which the mucous membrane can be injured, for example in the gastrointestinal tract, urinary and genital tract, or skin or soft tissues (e.g. muscles). Another area is interventions on the respiratory tract, such as tonsillectomies or lung endoscopies.
There is now a general recommendation for endocarditis prophylaxis only for certain treatments in the oral cavity and only for high-risk patients!
The patient takes an antibiotic in tablet form, for example amoxicillin, 30 to 60 minutes before the procedure. In case of existing infections, the antibiotic for endocarditis prophylaxis is adapted to the respective pathogen, for example ampicillin or vancomycin in case of an enterococcal infection in the intestine. In some cases, a drug that cannot be taken as a tablet is also needed; in that case, the doctor administers it as an infusion.
Endocarditis prophylaxis at home: oral hygiene factor
Even without medical intervention, temporary bacteremia (bacteria in the blood) can result in endocarditis. When chewing or brushing teeth, for example, bacteria can enter the bloodstream through small injuries in the oral mucosa.
