units. They may then see their child once or twice a month. Several mothers have attempted suicide when their babies left prison. There is no counselling at the time of separation. Much of this justifies the claim that prison is a damaging environment for a child, although there is little evidence that any damage is lasting. Catan's study of children in a mother and baby unit in 1988 found that their performances on Griffiths development scales were similar to those of babies left outside.4 Although the scores for babies who spent longer than average in the unit declined over four months, they quickly recovered when the babies were released. Babies who were separated from their mothers experienced frequent changes in their carer and exhibited insecure behaviour. A compelling argument against the separation of mothers and babies is that all of the women who had looked after their babies in prison intended to remain with them on release, compared with only half of the mothers whose babies had been cared for outside. Catan concluded that normal development was possible in mother and baby units but that the nursing and prison staff in charge of them must consider the needs of the children and not just the custodial control of their mothers. The negative experiences of the children, such as their physical confinement, were preventable. Catan recommended that qualified child care workers should be responsible for the creches. Although the conditions in mother and baby units must be improved-and the department of health's report makes 23 recommendations on how this can be done-there is still the issue of whether these women should be in prison at all. The National Association of Probation Officers has stated that not only pregnant women but mothers of dependent children should not be sent to prison except in cases where "they pose a continuing danger to the public."2 Of the 191 women who served part or all of their sentences in a mother and baby unit in 1989, only 12 had been involved in violent crimes. A recent survey by the Home Office of 600 women in prison found that they had 1321 children.5 But only a few judges ever receive "social" information on the women they sentence, even though a custodial sentence on a mother often means that her children are put into care. They also seem to be ignorant of the Woolf report into prison disturbances, which stated that "it is important to avoid subjecting anyone to the damaging effects of imprisonment unless this cannot be avoided."6I7

In an attempt to alleviate some of the distress felt by mothers and children when they are separated by prison, Holloway has recently adopted a scheme for full day visits. Children can see their mothers on two Sundays a month. But children in care are often unable to take advantage of the scheme. In 1970 a publication by the Home Office suggested that by the end of the century there would be "fewer or no women at all being given prison sentences."8 In the past decade the likelihood of a woman being sent to prison has doubled.5 Because there are few women's prisons the women are often a long way from their families. This is even more of a problem for foreign nationals -usually serving long sentences for drug offences-who often do not know what has happened to their children at home. Some improvements have followed the Department of Health's report. Holloway's mother and baby unit is being rehoused, and prison officers and nurses are to be given courses on child care. But there will be no nursery nursesthe only group who could put the needs of the child first. It will remain a privilege and not a right for mothers to keep their babies in prison. They will still suffer a traumatic separation at a time appointed arbitrarily by the Home Office. There will be no one to speak for the children. On their release many mothers will still be homeless, in debt, and unsupported. Any changes are likely to be only cosmetic. As long as mother and baby units are run by prison officers and nurses they will retain their controlled, hospital environment. But if in 1992 we still allow judges to imprison pregnant women for theft it is unlikely that we will be compassionate enough to offer proper care for their children. LUISA DILLNER Assistant Editor, BMJ 1 Department of Health. Inspection of facilibies for mothers and babies in prison. London: Department of Health, 1992. 2 National Association of Probation Officers. Briefing on women, children and custody. London: NAPO, 1989. 3 Chief Inspector of Prisons. HAl Prison Holloway. London: HMSO, 1992. 4 Catan L. Infants with mothers in prison. In: Shaw R, ed. Prisoners' children. What are the issues? London: Routledge, 1992:19-28. 5 Howard League for Penal Reform. Women in pristmn. London: Howard League, 1992. (Factsheet 7.) 6 Woolf H, T umim S. Prison disturbances April 1990. Report of an inquiry. London: HMSO, 1991. 7 National Association for the Care and Resettlement of Offenders. A fresh start for women prisoners. London: NACRO, 1991. 8 Home Office. Treatment of women and girls in custody. London: HMSO, 1970.

Antibiotic prophylaxis for dental treatment For hearts but not for prosthetic joints Though bacteraemia had been postulated as the cause of infective endocarditis, its source in healthy people remained mysterious until Rushton reported a case of infective endocarditis after dental extractions in 1930.' Later, Okell and Eliott showed that extractions released showers of bacteria into the blood stream.2 Since then dentists have frequently been blamed for endocarditis. Indeed, Streptococcus viridans from the mouth is the single most frequent isolate and accounts for almost half the cases of infective endocarditis. Nevertheless, a review of several large series of cases found a reliable history of a dental procedure in only 5-10% of cases.3 Infective endocarditis may kill and, theoretically at least, is preventable. But many puzzling features remain about its pathogenesis. Current bacteriological techniques show that bacteraemias follow many procedures. Most of the time few BMJ






bacteria are released and whether they present an important risk is questionable. Moreover, in most cases no precipitating event is apparent. In all attempts at giving antimicrobial prophylaxis the risks have to be balanced against possible benefits. For ethical and statistical reasons carrying out the definitive experiment to prove that any form of prophylaxis is effective is now impossible. If Hillson's calculation that the risk of developing the disease was no more than one in 3000 is correct then enormous numbers of patients would be needed to establish the effectiveness of any prophylaxis. Epidemiological studies are fraught with difficulties as two recent examples show. Imperiale and Horwitz concluded that prophylaxis gave 91% protection5 while van der Meer et al believed it to give only 49%.b Even if the lower figure is correct then prophylaxis is 933

worth while if it prevents a disabling illness and the considerable costs of admission to hospital and possible open heart surgery that go with it. Antibiotic prophylaxis should, however, be given only for procedures that have a substantial risk of precipitating endocarditis. Bacteraemia after dental work is so common because of the enormous numbers of bacteria surrounding the teeth, particularly in periodontal pockets in neglected mouths. These bacteria are in concentrations similar to that in a centrifuged pellet, and the area of tissue exposed to them may equal the area of the palm of a hand. Moreover, these bacteria are close to blood vessels, and movement of teeth in their sockets may pump them into the blood. Hardly surprisingly, therefore, in the largest study of its kind (reviewing 4821 reports of infective endocarditis) McGowan found that extractions had been carried out in 95% of episodes related to dentistry.7 Disturbance ofthe gingival bacteria by extractions, scaling, or periodontal surgery is therefore the main identifiable dental risk factor and requires cover in patients at risk. Reports of infective endocarditis after other dental procedures are so rare that mere coincidence cannot be excluded. Other elective procedures that may cause important bacteraemia include some upper respiratory tract, gastrointestinal, obstetric, gynaecological, and genitourinary procedures. In many of these, however, predicting the organism that might infect the heart and suggesting appropriate cover may be difficult. What antibiotic cover should be used? Previously a prolonged regimen of penicillin was recommended to "sterilise" the mouth. Instead, it promoted proliferation of resistant streptococci, which occasionally led to deaths.8 As an alternative a single injection of benzylpenicillin rapidly achieves a high blood concentration, but excretion is so rapid that it may not eliminate all bacteria. Dentists find giving intramuscular injections inconvenient, and patients have been known to conceal a history of heart disease to avoid a painful injection every time they visited the dentist. In an attempt to resolve these problems a working party of the British Society for Antimicrobial Chemotherapy has drawn up "user friendly" guidelines for the timing and type of antibiotics and defined the procedures needing cover. With the finding by Shanson et al that a 2 g dose of oral amoxycillin reliably gave bactericidal serum concentrations for up to nine hours9 and the availability of convenient 3 g sachets, amoxycillin became the obvious choice for those not allergic to penicillin. For those who were allergic erythromycin was regarded as a safe alternative, although it can cause nausea and its absorption is so capricious that adequate blood concentrations are sometimes not achieved. Recently Cannell et al confirmed that the recommended regimen of 1 5 g of erythromycin before dental treatment and 0 5 g six hours later gave no better protection than a placebo.'" Nevertheless, no cases of endocarditis after erythromycin cover have been reported to the working party over the past 10 years. A single oral dose of clindamycin seems safe and is reliably absorbed. The published guidelines on prophylaxis against infective endocarditis can neither guarantee total efficacy nor cover every possible contingency. Nevertheless, they reflect the


current state of knowledge and have become widely used by dentists. Moreover, if complied with they provide reasonable protection against increasing medicolegal claims alleging inadequate cover. Probably the most remarkable example of this problem was that reported by Pogrel from California, where a patient with a heart defect was not given cover for dental treatment." Although he did not develop infective endocarditis, he received substantial damages for the months of anxiety that he might have done. A more vexed question is that of late infections of prosthetic joints. Orthopaedic surgeons are naturally anxious to avoid this disaster and, rarely, late, apparently haematogenous infections have been reported. Unlike infections of damaged heart valves, however, only anecdotal reports of infections of prosthetic joints by oral bacteria exist despite the hundreds of thousands of these operations that have been carried out over the past three decades. Despite the greater hazard of litigation and the greater number of patients with prosthetic joints in America the American Academy of Oral Medicine has stated that "there is insufficient scientific evidence to support routine antibiotic prophylaxis for patients with prosthetic joints who are receiving dental care."'2 Perhaps we should go further since it has been reported that penicillin may cause at least 500 deaths a year in the United States alone.'3 As the available evidence suggests that for these patients the risks of antibiotic prophylaxis for dental treatment exceed any benefits, the United Kingdom's infective endocarditis working party has concluded that exposing patients to such risks is unacceptable. " The anxieties of the authors of a short report (p 959)15 about the failure to provide antibiotic prophylaxis to patients with prosthetic joints before they undergo dental treatment may therefore be misplaced. R A CAWSON

Professor, Moorgate Laboratory, Department of Surgery, Guy's Hospital, London SEl 9RT I Rushton MA. Subacute bacterial endocarditis following the extraction of teeth. Guy's Hosp Rep

1930;80:39-44. 2 Okell CC, Eliott SD. Bacteraemia and oral sepsis-with special reference to the aetiology of

subacute endocarditis. Lancet 1935;ii:869-72. 3 Cawson RA. Infective endocarditis as a complication of dental treatment. Br Dent J 1981;151: 409-14. 4 Hillson GRF. Is chemoprophylaxis necessary? Proc R Soc Med 1970;63:267-7 1. 5 Imperiale TF, Horwitz RI. Does prophylaxis prevent postdental infective endocarditis? A controlled evaluation of protective efficacy. AmJ3Med 1990;88:131-6. 6 Van der Meer JTM, van Wijk W, Thompson J, Vandenbroucke JP, Valkenburg HA, Michel MF. Efficacy of antibiotic prophylaxis for prevention of native valve endocarditis. Lancet 1992;339: 135-9. 7 McGowan DA. Experimental evidence on the prevention of infective endocarditis in dentistry. In: Cawson RA, ed. The nature and prevention of infective endocarditis. Oxford: Medicine Publishing

Foundation, 1981:15-21. 8 Garrod LP, Lamber HP, O'Grady F. The risks of dental extractions during penicillin treatment. Br HeartJ 1962;24:39-46. 9 Shanson DC, Ashford RFU, Singh H. High dose amoxycillin for preventing infective endocarditis. BMJ 1980;280:446-7. 10 Cannell H, Kerawala C, Sefton AM, Maskell JP, Seymour A, Sun Z-M, et al. Failure of two macrolide antibiotics to prevent post-extraction bacteraemia. Br Dent3 1991;171:170-3. 11 Pogrel MA. Prophylactic antibiotics. Br DentJ 1990;170:446-7. 12 Eskinazi D. Is systematic antirnicrobial prophylaxis justified in dental patients with prosthetic

joints? Oral Surg Oral Med Oral Pathol 1988;66:430-1. 13 Valentine M. Allergic emergencies. NIAID task force report. Asthma and other allergic diseases. Washington: Department of Health, Education and Welfare, 1979:79-387. 14 Sirnmons NA, Ball AP, Cawson RA, Eykyn SJ, Hughes SPF, McGowan DA, et al. Case against antibiotic prophylaxis of patients with joint prostheses. Lancet 1992;339:301. 15 Grant A, Hoddinott C. Joint replacement, dental surgery, and antibiotic prophylaxis. BMJ



11 APRIL 1992

Antibiotic prophylaxis for dental treatment.

units. They may then see their child once or twice a month. Several mothers have attempted suicide when their babies left prison. There is no counsell...
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