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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2019  |  Volume : 30  |  Issue : 4  |  Page : 764-768
Adequacy of infective endocarditis prophylaxis before dental procedures among solid organ transplant recipients

1 Department of Cardiology, Baskent University, Ankara, Turkey
2 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Baskent University, Ankara, Turkey
3 Department of General Surgery, Division of Transplantation, Baskent University, Ankara, Turkey

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Date of Submission18-May-2019
Date of Acceptance27-Jun-2019
Date of Web Publication27-Aug-2019


Infective endocarditis (IE) is a life-threatening condition with high morbidity and mortality. The current IE guidelines recommend antibiotic prophylaxis only in patients with certain cardiac conditions and before certain dental procedures. However, there is not enough data about solid organ transplant (SOT) recipients. In this study, we aimed to investigate the IE prophylaxis in general dental and periodontal surgical procedures among our SOT recipients. Medical records of 191 SOT recipients (32 liver transplant recipients, 54 heart transplant recipients, and 105 kidney transplant recipients) who were admitted to our hospital between January 2016 and January 2018 were evaluated. A total of 65 patients who underwent dental procedures were included in the study. We investigated the adequacy of IE prophylaxis according to the current guidelines. Two groups were created according to whether they received antibiotic prophylaxis or not. The mean age was 44.2 ± 13.6 years, and 66.1% were male. The majority of patients (67.6%) received antibiotic prophylaxis. The most commonly used antibiotic was amoxicillin (48.8%). Among the procedures, 23.1% were classified as invasive and 76.9% were classified as noninvasive. No complication was observed after invasive and noninvasive dental procedures. There were no complications in both antibiotic prophylaxis and no-prophylaxis groups. According to our results, IE prophylaxis has been used appropriately in SOT recipients in our center. No serious infection has been reported. In addition, no complication due to antibiotic use was also observed.

How to cite this article:
Karacaglar E, Akgun A, Ciftci O, Altiparmak N, Muderrisoglu H, Haberal M. Adequacy of infective endocarditis prophylaxis before dental procedures among solid organ transplant recipients. Saudi J Kidney Dis Transpl 2019;30:764-8

How to cite this URL:
Karacaglar E, Akgun A, Ciftci O, Altiparmak N, Muderrisoglu H, Haberal M. Adequacy of infective endocarditis prophylaxis before dental procedures among solid organ transplant recipients. Saudi J Kidney Dis Transpl [serial online] 2019 [cited 2021 Oct 22];30:764-8. Available from: https://www.sjkdt.org/text.asp?2019/30/4/764/265450

   Introduction Top

Infective endocarditis (IE) remains a highly morbid and fatal condition. The current IE guidelines recommend prophylaxis only in a small subset of patients to avoid the development of drug-resistant microorganisms.[1] The main recommendations come from retrospective analyses and expert opinions.

Solid organ transplantation (SOT) remains the most effective treatment option for end-stage renal disease, end-stage heart failure, and hepatic insufficiency. Immunosuppressive therapies play a critical role in the prevention of rejection, but they also have several undesirable side effects. Infections by different organisms are the most common cause of mortality in the immunosuppressed SOT recipients.[2] Although infections are important cause of mortality among SOT recipients, there is very limited data in the literature supporting the endocarditis prophylaxis before dental procedures among SOT recipients.

In this study, we aim to investigate our local customs and the role of IE prophylaxis among our SOT recipients.

   Materials and Methods Top

Study design and population

This was a single-center retrospective study. Medical records of 65 patients who underwent a SOT in our hospital and seen at our dental clinic between January 2016 and January 2018 were evaluated retrospectively. Patients who did not have a dental procedure were excluded. Our study was approved by the local ethics committee, and the protocols conformed to the ethical guidelines of the 1975 Declaration of Helsinki.

The dental procedures were classified into invasive and noninvasive. Invasive procedures included periodontal surgery, connective tissue, and bone extraction from the oral cavity, such as tooth extraction, gingivitis, biopsy, and subgingival scaling, which are likely to cause transient bacteremia. Other procedures, such as whitening, polishing, root canal treatment, and dental impressions, were considered non-invasive procedures.[3]

Two groups were compared according to the administration of antibiotic prophylaxis. Comorbidities such as diabetes mellitus, any kind of atherosclerotic disease, pulmonary disease, and neurological diseases were also documented.

Adequacy of IE prophylaxis was evaluated according to 2017 American Heart Association/ American College of Cardiology (AHA/ACC) Focused Update of the 2014 AHA/ACC Guideline for the management of patients with valvular heart disease.[1]

   Statistical Analyses Top

The Statistical Package for the Social Sciences (SPSS) version 17.0 (SSPS Inc, Chicago, IL, USA) was used for statistical analyses. Continuous variables were expressed as mean ± standard deviation. Categorical variables were expressed as percentages. All continuous variables were checked with the Shapiro-Wilk normality test to show their distributions. Continuous variables with normal distributions were compared using the Student’s t-test. For categorical variables, the Chi-square test was used. Values for P <0.05 were considered statistically significant.

   Results Top

A total of 65 SOT recipients who have seen our dental clinic were included in the study. The mean age was 44.2 ± 13.6 years, and 66.1% of the patients were male. The median duration after SOT was 14 months (8–41 months). Twenty-two patients did not have any comorbidities. The most common dental procedure was tooth extraction which included broken tooth extraction, embedded tooth extraction, and rotten tooth extraction. The majority (66.1%) of patients undergoing dental procedures received antibiotic prophylaxis. Invasive procedures were more common among patients who received antibiotic prophylaxis (P = 0.001). Conversely, noninvasive dental procedures were more common among patients who did not receive antibiotic prophylaxis (P = 0.018) [Table 1]. Comorbidities were similar between groups. Amoxicillin was the most commonly used antibiotic (48.8%). The other antibiotics prescribed for prophylaxis were cefazolin (25.3%), ampicillin (13.6%), cefadroxil (11.6%), and cefotaxime (<1%). IE prophylaxis was indicated in 11 of 65 patients (16.9%) according to AHA/ACC recommendations. Indications for IE prophylaxis in the order of frequency were mechanical prosthetic valve (five patients), heart transplant recipients with valve regurgitation (four patients), previous history of IE (one patient), and percutaneously placed atrial septal defect occluder device with a residual shunt (one patient). All of these patients underwent invasive dental procedures and received adequate prophylaxis. There were no patients who did not receive IE prophylaxis although indicated according to the relevant guideline [Table 1]. Antibiotic-related skin rashes developed only in one patient and completely resolved with an antihistamine.
Table 1: Characteristics of patients.

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   Discussion Top

In this study, we showed that the current IE guideline recommendations are applied successfully among our SOT recipients.

Immunosuppressive therapies are very important, especially during the first months after SOT to prevent acute rejection. High-dose immunosuppression used in the early period posttransplant increases the risk of infections even in the oral cavity.[4] Because of this high risk, it is recommended that only emergency dental interventions is performed during the first three months after SOT and to postpone elective procedures.[5]

The median duration for dental procedures after SOT was 14 months among our patients, and this may explain the absence of any complications. Although duration for dental procedures may vary between SOT recipients, we think that detailed examination and treatment of dental problems of all patients before SOT may prolong this duration as in our patients. In most of the transplantation centers, a dental examination is performed before SOT as we do in our hospital.[6]

Another finding of our study is that clinicians are more likely to use prophylaxis for invasive dental procedures rather than noninvasive procedures. Previous research performed among doctors working at transplant centers showed similar findings; most doctors reported that they recommended the use of prophylactic antibiotic therapy for all transplanted patients before dental procedures.[7]

Evidence for IE prophylaxis in SOT recipients before dental procedures is extremely limited.[8],[9],[10],[11] No randomized trial in this special patient population has been done to date. Data available come from sporadic case reports. In the past, antibiotic prophylaxis was used to be recommended before dental procedures in all SOT recipients.[8] More recent data showed that IE is considered to be a rare complication after SOT, even in heart transplantation recipients.[12],[13] The current IE guidelines recommend prophylaxis only in a small subset of patients.[1]

The classic clinical features of IE, such as fever, new murmur, or splenomegaly, are usually not observed in SOT recipients.[14] Staphylococcus aureus Scientific Name Search  is the most common cause of IE and generally associated with inadequate treatment of previous infections.[14] Fungus- and aspergillosis- related IE are also more common in SOT recipients compared to the general population.[14] Although IE is considered to be rare after heart transplantation, the mortality rate is extremely high and found to be 80%.[15] Interestingly, despite the risk factors for heart transplant recipients, the cumulative IE incidence was found equal in liver and kidney transplant recipients.[15]

   Study Limitations Top

There are several limitations of our study. It was based on a retrospective electronic data analysis and we only evaluated SOT recipients. There was not a control group. It was a single-center study, and our study population was relatively small. Subgroup analysis could not be performed due to the small number of patients.

   Conclusion Top

Our findings demonstrate that the current IE guideline recommendations are applied successfully among our SOT recipients. Although administering antibiotic prophylaxis do not change infectious complications, clinicians seem to be prone to antibiotic prophylaxis for dental procedures. IE guideline recommends prophylaxis only in a limited group of patients, and there are no specific recommendations for SOT recipients. Larger prospective multicenter studies are needed to make specific recommendations in this special patient population.

Conflict of interest: None declared.

   References Top

Nishimura RA, Otto CM, Bonow RO, et al. 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/ American Heart Association task force on clinical practice guidelines. Circulation 2017; 135:e1159-95.  Back to cited text no. 1
Rubin RH. Infection in the organ transplant recipient. In: Rubin RH, Young LS, editors. Clinical Approach to Infection in the Compromised Host. 3rd ed. New York: Plenum Medical Book Co.; 1994. p. 629-705.  Back to cited text no. 2
Parahitiyawa NB, Jin LJ, Leung WK, Yam WC, Samaranayake LP. Microbiology of odontogenic bacteremia: Beyond endocarditis. Clin Microbiol Rev 2009;22:46-64.  Back to cited text no. 3
Suzuki JB, Chialastri SM. Dental implications for the immunocompromised organ transplant patient. Grand Rounds Oral Syst Med Mag 2007;2:36-44.  Back to cited text no. 4
Buzea CM, Cuculescu M, Podoleanu E, Preoteasa CT, Ranga R. Dental treatment considerations for the organ and bone marrow transplant patient. Wseas Trans Biol Biomed 2009;3:70-8.  Back to cited text no. 5
Ziebolz D, Hraský V, Goralczyk A, Hornecker E, Obed A, Mausberg RF. Dental care and oral health in solid organ transplant recipients: A single center cross-sectional study and survey of German transplant centers. Transpl Int 2011;24:1179-88.  Back to cited text no. 6
Guggenheimer J, Mayher D, Eghtesad B. A survey of dental care protocols among US organ transplant centers. Clin Transplant 2005; 19:15-8.  Back to cited text no. 7
Guggenheimer J, Eghtesad B, Stock DJ. Dental management of the (solid) organ transplant patient. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;95:383-9.  Back to cited text no. 8
Goldman KE. Dental management of patients with bone marrow and solid organ transplantation. Dent Clin North Am 2006;50:659-76, viii.  Back to cited text no. 9
Lockhart PB, Loven B, Brennan MT, Fox PC. The evidence base for the efficacy of antibiotic prophylaxis in dental practice. J Am Dent Assoc 2007;138:458-74.  Back to cited text no. 10
Little JW, Falace DA, Miller CS, Rhodus NL. Antibiotic prophylaxis in dentistry: An update. Gen Dent 2008;56:20-8.  Back to cited text no. 11
Defraigne JO, Demoulin JC, Piérard GE, Detry O, Limet R. Fatal mural endocarditis and cutaneous botryomycosis after heart transplantation. Am J Dermatopathol 1997;19:602- 5.  Back to cited text no. 12
Tucker PC. Infectious complications. In: Baumgartner WA, Reitz B, Kasper E, Theodore J, editors. Heart and Lung Transplantation. Philadelphia: W. B. Saunders Co.; 2002. p. 355-71.  Back to cited text no. 13
Paterson DL, Dominguez EA, Chang FY, Snydman DR, Singh N. Infective endocarditis in solid organ transplant recipients. Clin Infect Dis 1998;26:689-94.  Back to cited text no. 14
Sherman-Weber S, Axelrod P, Suh B, Rubin S, Beltramo D, Manacchio J, et al. Infective endocarditis following orthotopic heart transplantation: 10 cases and a review of the literature. Transpl Infect Dis 2004;6:165-70.  Back to cited text no. 15

Correspondence Address:
Emir Karacaglar
Department of Cardiology, Baskent University School of Medicine, Ankara
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DOI: 10.4103/1319-2442.265450

PMID: 31464231

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