Endocarditis and endocarditis prophylaxis
Endocarditis is an infectious inflammation of the inner lining of the heart (endocardium). This inner lining of the heart can be particularly susceptible to infection in children with congenital heart disease. Endocarditis occurs in the case of structural abnormalities of the heart or the great vessels when turbulence occurs in the context of shunts, stenoses or insufficiencies. As a result, bacteria in the blood can easily settle there and cause inflammation. Bacteria enter the bloodstream during dental procedures, for example, but piercings and tattoos can also flush bacteria into the blood system. Special care is required for all operations other than heart surgery. Most children with a congenital heart defect have an increased risk of endocarditis. There is a particular risk in patients with prosthetic heart valves or patients with implanted foreign material. There are 2 different forms of endocarditis: the acute form and the subacute form (endocarditis lenta).
90% of the pathogens are bacteria of the Streptococcus viridans, Streptococcus faecalis and Staphylococcus aureus groups. These bacteria attach themselves to the heart valves or to the inner lining of heart defects and destroy the tissue. This can lead to the destruction of the heart valve and thus to a life-threatening situation for the patient. Clinical signs of endocarditis can begin unspecifically with fever, fatigue, loss of appetite and pallor. High fever and a new heart murmur in patients with a heart defect should always be an alarm signal for endocarditis in these patients. Enlargement of the spleen and skin lesions may also occur. These skin lesions are caused by bacterial microembolism, which is caused by the detachment of small bacterial islands from the heart valve deposits. In addition to these complications, cerebral infarctions or pulmonary infarctions can also occur, which can have serious consequences. The diagnosis is confirmed by blood cultures and echocardiographic examination. If the endocarditis is advanced, often only the consequences of the inflammation, in the sense of severe valve damage, can be determined.
Endocarditis is treated with high doses of intravenous antibiotics. The therapy is controlled depending on the cultivated pathogen. A course of antibiotics lasting 6 weeks is recommended. In particularly difficult cases, the bacterial focus on the heart valve must be surgically removed or replaced. The recommendations for the prophylaxis of endocarditis were revised in 2008. This regulation prioritises the restoration of teeth and excellent oral hygiene. In addition, the use of antibiotics is recommended for procedures where bacteraemia is known to occur.
Such antibiotics should be given to patients at particularly high risk, i.e:
Patients with valve replacements (mechanical and biological prostheses), patients with reconstructed valves using alloprosthetic material in the first 6 months after surgery, patients who have recovered from endocarditis, patients with congenital heart defects: cyanotic heart defects that have not been operated on or have been operated on palliatively with a systemic pulmonary shunt, heart defects that have been operated on with implantation of conduits (with or without a valve) or residual defects, i.e. turbulent blood flow in the area of the prosthetic material. All heart defects treated surgically or interventional using prosthetic material in the first 6 months after surgery, heart transplant patients who develop cardiac valvulopathy.
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When should treatment be started?
1. all dental procedures that can lead to bacteraemia. These are all procedures involving manipulation of the gingiva, the periapical tooth region or perforations of the oral mucosa. Prophylaxis is not recommended for local anaesthetic injections into healthy tissue, except for intraligamentary anaesthesia, for which high bacteraemia rates have been described. There is also no indication for prophylaxis during dental radiographs, placement or adjustment of prosthetic or orthodontic anchoring elements, placement of orthodontic brackets and suture removal. There is also no indication for prophylaxis in the case of lip trauma or trauma to the oral mucosa or physiological loss of deciduous teeth.
2. or if there is an obvious risk of bacteraemia due to surgery in the ENT, gastrointestinal or genital area.
How should it be treated?
Antibiotic, single dose 30 to 60 min before the procedure Oral administration Amoxicillin, adults 2 g p.o., children 50 mg/kg p.o. Oral administration not possible
Ampicillin, 2 g i.v., 50 mg/kg i.v.
Penicillin or ampicillin allergy
Oral intake
Clindamycin, adults 600 mg p.o., children 20 mg/kg p.o.
Penicillin or ampicillin allergy
Oral intake not possible
Clindamycin, adults 600 mg i.v., children 20 mg/kg i.v.
See also:
Der Kardiologe Volume 1, Issue 4, 243 250 Dec 2007, or
Deutsche Herzstiftung.