Pediatr Cardiol DOI 10.1007/s00246-014-0919-1
ORIGINAL ARTICLE
Preprocedure Prophylaxis Against Endocarditis Among United States Pediatric Cardiologists Jasminkumar Patel • Fernanda Kupferman Susana Rapaport • Jeffrey H. Kern
•
Received: 15 December 2013 / Accepted: 25 April 2014 Ó Springer Science+Business Media New York 2014
Abstract This study aimed to determine current practices regarding prophylaxis against infective endocarditis among pediatric cardiologists in the United States 5 years after publication of the most recent American Heart Association (AHA) recommendations. A descriptive, analytical, crosssectional study was conducted from June 2012 to November 2012 in the format of an anonymous selfadministered e-mailed questionnaire among pediatric cardiologists across the United States. The questionnaire inquired about demographic information of cardiologists and their current practices of prescribing preprocedure antibiotic prophylaxis against endocarditis to patients with specific preexisting cardiac conditions. Descriptive analyses were done in percentages. Frequency and exploratory statistical analyses were done by the Chi-square method. Of the 980 cardiologists invited, 221 (23 %) responded to the survey. The findings showed that pediatric cardiologists generally follow the AHA guidelines. The most common cardiac conditions in which antibiotics were administered despite AHA guidelines not requiring prophylaxis were rheumatic heart disease with aortic insufficiency, transposition of the great vessels after the Mustard procedure, bicuspid aortic valve with severe aortic stenosis, cardiac transplantation without valvar disease, and bicuspid aortic valve with severe aortic insufficiency. More experienced pediatric cardiologists were significantly more likely to administer prophylaxis to certain patients than their less
J. Patel F. Kupferman S. Rapaport J. H. Kern Flushing Hospital Medical Center, Flushing, NY, USA J. H. Kern (&) Weill Medical College of Cornell University, New York, NY 10021, USA e-mail: [email protected]
experienced peers. Many pediatric cardiologists in the United States continue to administer preprocedure antibiotic prophylaxis against endocarditis even when not recommended to do so per the 2007 AHA guidelines. With certain lesions, highly experienced pediatric cardiologists are more likely to administer prophylaxis than their less experienced counterparts. Keywords Endocarditis Congenital heart defects Antibiotic prophylaxis Cardiovascular diseases
Introduction Infective endocarditis (IE) is a potentially life-threatening infection of the endocardium, frequently of bacterial origin, mainly affecting the heart valves. Although short-term survival has improved with the advancement of treatments, long-term mortality and morbidity rates remain high [6]. Invasive procedures may lead to transient bacteremia, resulting in IE for patients with preexisting cardiac conditions. The rationale for providing preprocedural antibiotics is to prevent bacteremia and subsequent IE in high-risk patients [2]. The efficacy of antibiotic prophylaxis in preventing IE, however, is controversial [10]. The American Heart Association (AHA) first made recommendations for the prevention of IE in 1955 [4]. Since that time, several revisions to the original recommendations have been made. The most recently published guidelines in 2007 called for major changes, greatly limiting the types of patients for whom prophylaxis is recommended [16]. Controversy still exists regarding the degree to which the new recommendations should be followed. This study investigated the IE prophylaxis patterns
123
Pediatr Cardiol
of pediatric cardiologists in the United States across a broad range of pediatric cardiac lesions 5 years after publication of the most recent AHA guidelines.
Materials and Methods A descriptive, analytical, cross-sectional study was conducted in the format of an anonymous, self-administered questionnaire from June 2012 to November 2012. The e-mail addresses of pediatric cardiologists practicing in the United States were obtained from online resources. Cardiologists in training and those whose e-mail addresses could not be obtained were excluded from the study. Questionnaires were sent to the e-mail addresses via Zoomerang software during a 6-month period. Before completing the survey, the physicians were made aware that all responses would remain anonymous and confidential. Responses provided implied consent. For nonresponders, repeated attempts were made once every 4 weeks for a total of three attempts. The questionnaires included questions regarding the pediatric cardiologists’ demographic information and their current practices of prescribing preprocedural antibiotic prophylaxis against IE for patients with specific preexisting heart diseases (Tables 1 and 2). None of the cardiac conditions included in the survey require preprocedure prophylaxis as per the new AHA guidelines. Collected data were converted to categorical data for statistical analysis. Data analysis was performed using SPSS software. A p value lower than 0.05 was considered significant. Data were summarized in frequencies and percentages. The Chi-square test was used to find possible relationships between cardiologists’ demographic information and their current practices of prescribing preprocedural antibiotics to prevent IE.
Results Questionnaires were sent to 980 U.S. pediatric cardiologists, 221 (23 %) of whom responded. Table 3 shows the demographic characteristics of the responding cardiologists. The majority of the respondents (71 %) were male. The best-represented group of respondents (38 %) had at least 20 years of experience, and 82 % had more than 5 years of experience. As Table 3 shows, 59 % of respondents had community hospital type practices. Only 12 % of the cardiologists were practicing in a university type setting. The respondents were from 37 states and the District of Columbia, with a fairly even distribution from each state. Table 4 shows the cardiologists’ responses regarding IE prophylaxis for specific cardiac conditions (in order of
123
Table 1 Questionnaire regarding endocarditis prophylaxis in patients with specific cardiac lesions Questions 1.
Mitral valve prolapse with mitral regurgitation
2.
Rheumatic heart disease with aortic insufficiency
3.
Audible patent ductus arteriosus
4.
Coarctation of the aorta
5.
Status post (S/P) repair of transposition of the great arteries with no residual defects (6 months S/P last cardiac intervention)
6.
S/P repair of tetralogy of Fallot with no residual defects (6 months after last cardiac intervention)
7.
Idiopathic hypertrophic subaortic stenosis without obstruction to flow
8.
S/P cardiac transplantation without valvular disease
9.
S/P repair of single-ventricle heart (6 months after last cardiac intervention)
10.
Bicuspid aortic valve without aortic stenosis
11.
Bicuspid aortic valve with mild aortic stenosis
12.
Bicuspid aortic valve with severe aortic stenosis
13.
Bicuspid aortic valve with mild aortic insufficiency
14.
Bicuspid aortic valve with severe aortic insufficiency
15.
Acyanotic patient with tetralogy of Fallot
16.
Atrioventricular canal defect with mitral regurgitation
17.
Atrioventricular canal defect without mitral regurgitation
18.
Acyanotic Ebstein’s anomaly
19.
Dilated cardiomyopathy with mitral regurgitation
20. 21.
Primum atrium septal defect Repaired ventricular septal defect without residual shunt
22.
Silent patent ductus arteriosus
23.
Transposition of the great vessels S/P Mustard procedure
Yes
No
ascending prophylaxis rates). Most pediatric cardiologists did not prescribe preprocedural antibiotic prophylaxis to patients for whom it was not recommended. It is important to note that at least 1 % of the cardiologists continued to administer prophylaxis for each of conditions listed, even when not recommended by the AHA to do so. The most common conditions for which cardiologists administered prophylaxis were rheumatic heart disease with aortic insufficiency (39 %) and the postoperative single-ventricle patient (44 %). More than 25 % of the cardiologists surveyed also administered prophylaxis to patients after cardiac transplantation (without valvar disease) and to those with bicuspid aortic valve/severe aortic stenosis, transposition of the great vessels after the Mustard procedure, and acyanotic tetralogy of Fallot. At the opposite extreme, very few cardiologists administered prophylaxis to children
Pediatr Cardiol Table 2 Demographic characteristics of responding pediatric cardiologists
1
Table 4 Responding pediatric cardiologists’ practices of prescribing preprocedural antibiotic prophylaxis against endocarditis in patients with specific cardiac lesions
Gender Male Female
2
Type of heart disease
Cardiologists prescribing prophylaxis (%)
Repaired ventricular septal defect without residual shunt
1 3
Community hospital
Status post (S/P) repair of transposition of the great arteries with no residual defects (6 months after last cardiac intervention)
University hospital
IHSS without obstruction to flow
3
Private
Silent patent ductus arteriosus
3
Other
Bicuspid aortic valve without aortic stenosis
4
Primum atrium septal defect
4
Years of experience \5 5–10 10–15 15–20 [20
3
Type of practice
4
Table 3 Demographic characteristics of the responding cardiologists
State of medical practice
n (%) Gender Female Male No response
60 (27) 158 (71) 3 (2)
Years of experience
Mitral valve prolapse with mitral regurgitation
8
S/P repair of tetralogy of Fallot with no residual defects (6 months S/P last cardiac intervention)
9
Coarctation of the aorta
10
Acyanotic Ebstein’s anomaly
11
Dilated cardiomyopathy with mitral regurgitation
11
Bicuspid aortic valve with mild aortic stenosis
12
Bicuspid aortic valve with mild aortic insufficiency
12 13
\5
33 (15)
Atrioventricular canal defect without mitral regurgitation
5–10
20 (9)
Audible patent ductus arteriosus
15
15–20
42 (19)
[20
86 (38)
Bicuspid aortic valve with severe aortic insufficiency Atrioventricular canal defect with mitral regurgitation
23 24
S/P cardiac transplantation without valvar disease
26
Type of practice University
26 (12)
Community
132 (59)
Bicuspid aortic valve with severe aortic stenosis
28 31
Private
43 (19)
Transposition of the great vessels S/P Mustard procedure
Other
16 (7)
Acyanotic patient with tetralogy of Fallot
33
Rheumatic heart disease with aortic insufficiency
39
S/P repair of single-ventricle heart (S/P 6 months after last cardiac intervention)
44
after repair of a ventricular septal defect, to those who underwent the arterial switch procedure, or to those with hypertrophic cardiomyopathy. No statistically significant relationship between the type of practice and prophylaxis for patients with specific conditions was found, except for mitral valve prolapse with mitral regurgitation, in which 13 % of private practitioners administered prophylaxis, compared with 9 % of university-based and 4 % of community hospital-based cardiologists (p = 0.04). Table 5 shows the responses of the cardiologists by years of experience. For all but two cardiac lesions (postoperative tetralogy of Fallot and dilated cardiomyopathy with mitral regurgitation), the rates of prophylaxis administration did not differ significantly among the different groups. However, when regrouped and reanalyzed by less than or more than 15 years of experience, the more experienced cardiologists were significantly more likely to
IHSS idiopathic hypertrophic subaortic stenosistetralogy
administer prophylaxis to patients who had repaired tetralogy of Fallot without residual defect (p = 0.01), acayanotic Ebstein’s anomaly (p = 0.01), mitral valve prolapse with mitral regurgitation (p = 0.02), or dilated cardiomyopathy with mitral regurgitation (p = 0.04).
Discussion Since 1955, the AHA has issued guidelines to help prevent the development of endocarditis in individuals with congenital heart disease undergoing dental and other invasive procedures. Through the years, these guidelines have undergone several revisions. The most recently issued
123
Pediatr Cardiol Table 5 Percentage of cardiologists who administer prophylaxis by years of experience Years of experience
\5 (%)
5–10 (%)
10–15 (%)
15–20 (%)
[20 (%)
p value
Mitral valve prolapse with mitral regurgitation
0
3
5
15
12
0.25
Rheumatic heart disease with aortic insufficiency
45
42
43
50
29
0.12
Audible patent ductus arteriosus
10
18
14
24
14
0.56
Coarctation of aorta
2
15
9
14
10
0.49
Status post (S/P) repair of transposition of the great artery with no residual defects (6 months S/P last cardiac intervention)
0
0
5
9
3
0.30
S/P repair of tetralogy of Fallot with no residual defects (6 months after last cardiac intervention)
0
3
9
19
10
0.03
Idiopathic hypertrophic subaortic stenosis without obstruction to flow
0
3
0
7
5
0.52
Cardiac transplantation patient without valvular disease
26
31
20
23
30
0.98
S/P repair of single-ventricle heart (6 months S/P last cardiac intervention)
47
45
48
54
37
0.48
Bicuspid aortic valve without aortic stenosis
0
0
5
7
6
0.77
Bicuspid aortic valve with mild aortic stenosis
5
12
9
17
14
0.71
Bicuspid aortic valve with severe aortic stenosis
17
33
43
34
26
0.36
Bicuspid aortic valve with mild aortic regurgitation
7
9
5
17
15
0.21
Bicuspid aortic valve with severe aortic regurgitation Acyanotic patient with tetralogy of Fallot
12 35
21 18
38 35
32 43
22 34
0.08 0.10
Atrioventricular defect with mitral regurgitation
22
6
24
33
26
0.13
Atrioventricular defect without mitral regurgitation
17
3
5
19
14
0.26
Acyanotic Ebstein’s anomaly
5
3
9
14
17
0.27
Dilated cardiomyopathy with mitral regurgitation
5
3
9
26
10
0.04
Primum atrium septal defect
2
3
0
5
8
0.74
Repaired ventricular septal defect without residual shunt
0
0
0
0
3
0.44
Silent patent ductus arteriosus
5
3
5
5
2
0.87
Transposition of the great vessels S/P Mustard procedure
31
25
48
45
22
0.15
guidelines, however, published in 2007, marked a more substantive change. Individuals with a wide variety of conditions who previously were advised to take preprocedure antibiotic prophylaxis are currently advised that it is no longer necessary to do so. These changes, although substantial, are not as drastic as those published by the National Institute for Health and Clinical Excellence (NICE) in the United Kingdom, which entirely eliminated the use of predental antibiotics [7]. Such marked changes have been met with a certain degree of resistance in the medical community [1, 8, 9, 11, 13]. Most dentists appear to be following the new recommendations [5, 14, 15]. Although patients’ acceptance of the new guidelines is high, many patients take antibiotics before dental procedures even when not recommended to do so [3]. The practices in the pediatric cardiology community, however, have not been as well documented. This study aimed to assess, 5 years after publication of the 2007 AHA guidelines, the degree to which they are followed by pediatric cardiologists and the demographic profiles of the physicians who do and do not adhere strictly to the new recommendations.
123
To our knowledge, the only previous study investigating the issue of cardiologists’ acceptance of the guidelines was published by Pharis et al. [8] in 2011. That study involved surveying pediatric and adult cardiologists in four countries (the United States, Canada, New Zealand, and Australia) to assess changes in their practices of prophylaxis for specific conditions before and after publication of the 2007 guidelines. Our study differed from that investigation in several ways: (1) We surveyed only pediatric cardiologists, not adult cardiologists caring for older individuals with congenital heart disease. (2) We studied only American cardiologists. This might be significant because certain Canadian doctors may have adopted the British guidelines, which differ significantly from the American guidelines. Furthermore, New Zealand has its own guidelines, which may have influenced the survey responses of the Australian and New Zealand cardiologists in the Pharis et al. [8] study. (3) We examined a wider variety of conditions. (4) Finally, perhaps most importantly, our study surveyed prophylaxis practices in 2012, 5 years after publication of the guidelines, as opposed to the data of Pharis et al. [8] collected less than 1 year after publication of the revised guidelines.
Pediatr Cardiol
All the conditions listed on the questionnaire are those that do not require prophylaxis per the new recommendations. Nevertheless, at least 1 % of the respondents would administer prophylaxis for each condition listed. Generally speaking, the conditions with the highest prophylaxis administration rates were those with a significant residual structural defect. This includes the single-ventricle patient (after the Fontan procedure), those with a bicuspid aortic valve/severe aortic insufficiency or stenosis, and the posttransplantation patient. In addition, some of the patients most likely to be prophylaxed by the respondents have conditions characterized as cyanotic heart disease but are experiencing no current cyanosis. This includes patients with acyanotic tetralogy of Fallot and those with transposition of the great vessels after the Mustard procedure. This may be due to uncertainty in the medical community about whether ‘‘cyanotic heart disease’’ requiring prophylaxis also applies to situations in which the patient currently is acyanotic. Interestingly, however, patients who underwent the arterial switch procedure or tetralogy of Fallot repair had a relatively low rate of prophylaxis administration. Patients with nonobstructive hypertrophic cardiomyopathy and those with a dilated cardiomyopathy, both of which are potentially life-threatening conditions, were administered prophylaxis by only 3 and 11 % of the respondents, respectively. This does not seem to be in line with the goals of the new guidelines, which aim to prevent endocarditis in those individuals most likely to experience adverse consequences from its development [16]. If the goal was different, namely, to administer prophylaxis to those individuals most likely to experience endocarditis, then prophylaxis recommendations might be expanded in the future specifically to include children with left-sided lesions and endocardial cushion defects because children with those congenital conditions are reported, as well as those with cyanotic heart disease, to be among those with the highest risk for the development of endocarditis [12]. It is not surprising that more experienced cardiologists were less likely to adhere to all the guidelines and continue to administer antibiotics even after the 2007 publication. In the absence of definitive data, it often is difficult to change one’s longstanding practices. Part of the difficulty in accepting the new guidelines may relate to uncertainty regarding the precise risk for the development of endocarditis in the absence of antibiotic prophylaxis because available data are limited. Stricter adherence to the new guidelines may increase in the coming years if no increase in the incidence of endocarditis is demonstrated despite the decreased administration of antibiotics. In conclusion, although U.S. pediatric cardiologists generally adhere to the 2007 AHA guidelines, for several specific cardiac conditions they are more stringent in advising antibiotic prophylaxis. Pediatric cardiologists with
more than 15 years of experience are more likely to recommend prophylaxis for four specific lesions. The current study investigated prophylaxis rates 5 years after publication of the most recent AHA guidelines. It would be of great interest to reexamine the prophylaxis patterns of pediatric cardiologists after an additional 5 years have passed.
References 1. Dhoble A, Vedre A, Abdelmoneim SS et al (2009) Prophylaxis to prevent infective endocarditis: to use or no to use? Clin Cardiol 32:429–433 2. Durack DT (1995) Prevention of infective endocarditis. N Engl J Med 332:38–44 3. Elad S, Binenfeld-Alon E, Zadik Y et al (2011) Survey of acceptance of the 2007 American Heart Association guidelines for the prevention of infective endocarditis: a pilot study. Quintessence Int 42:243–251 4. Jones TD, Baumgartner L, Bellows MT, Breese BB, Kuttner AG, McCarty M, Rammelkamp CH, Committee on Prevention of Rheumatic Fever and Bacterial Endocarditis, American Heart Association, (1955) Prevention of rheumatic fever and bacterial endocarditis through control of streptococcal infections. Circulation 11:317–320 5. Lockhart PB, Hanson NB, Ristic H et al (2013) Acceptance among and impact on dental practitioners and patients of American Heart Association recommendations for antibiotic prophylaxis. J Am Dent Assoc 144:1030–1035 6. Netzer ROM et al (2012) Infective endocarditis: determinants of long-term outcome. Heart (London) 88:61–66 7. NICE Short Clinical Guidelines Technical Team (2008) Prophylaxis against endocarditis: antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures. NICE Clinical Guidelines 64. National Institute for Health and Clinical Excellence, London 8. Pharis CS, Conway J, Warren AE et al (2011) The impact of 2007 infective endocarditis prophylaxis guidelines on the practice of congenital heart disease specialists. Am Heart J 161:123–129 9. Ponnambalam Y, Love RM, Thomson WM (2007) Bacterial chemoprophylaxis and practice among New Zealand dentists. N Z Dent J 103:51–57 10. Prendergast BD (2006) The changing face of infective endocarditis. Heart (London) 92:879–885 11. Riordain R, McCreary C (2009) NICE guideline on antibiotic prophylaxis against infective endocarditis: attitudes to the guideline and implications for dental practice in Ireland. Br Dent J 206:E11 12. Rushani D, Kaufman JS, Ionescu-Ittu R et al (2013) Infective endocarditis in children with congenital heart disease: cumulative incidence and predictors. Circulation 128:1412–1419 13. Shanson D (2010) New guidelines and the development of an international consensus on recommendations for the antibiotic prophylaxis of infective endocarditis. Int Health 2:231–238 14. Soheilipour S, Scambler S, Dickinson C et al (2011) Antibiotic prophylaxis in dentistry: part I. A qualitative study of professionals’ views on the NICE guideline. Br Dent J 211:E1 15. Weiss A, Dym H (2012) Review of antibiotics and indications for prophylaxis. Dent Clin North Am 56:235–244 16. Wilson W, Taubert KA, Gewitz M et al (2007) Prevention of infective endocarditis: guidelines from the American Heart Association. Circulation 116:1736–1754
123
ORIGINAL ARTICLE
Preprocedure Prophylaxis Against Endocarditis Among United States Pediatric Cardiologists Jasminkumar Patel • Fernanda Kupferman Susana Rapaport • Jeffrey H. Kern
•
Received: 15 December 2013 / Accepted: 25 April 2014 Ó Springer Science+Business Media New York 2014
Abstract This study aimed to determine current practices regarding prophylaxis against infective endocarditis among pediatric cardiologists in the United States 5 years after publication of the most recent American Heart Association (AHA) recommendations. A descriptive, analytical, crosssectional study was conducted from June 2012 to November 2012 in the format of an anonymous selfadministered e-mailed questionnaire among pediatric cardiologists across the United States. The questionnaire inquired about demographic information of cardiologists and their current practices of prescribing preprocedure antibiotic prophylaxis against endocarditis to patients with specific preexisting cardiac conditions. Descriptive analyses were done in percentages. Frequency and exploratory statistical analyses were done by the Chi-square method. Of the 980 cardiologists invited, 221 (23 %) responded to the survey. The findings showed that pediatric cardiologists generally follow the AHA guidelines. The most common cardiac conditions in which antibiotics were administered despite AHA guidelines not requiring prophylaxis were rheumatic heart disease with aortic insufficiency, transposition of the great vessels after the Mustard procedure, bicuspid aortic valve with severe aortic stenosis, cardiac transplantation without valvar disease, and bicuspid aortic valve with severe aortic insufficiency. More experienced pediatric cardiologists were significantly more likely to administer prophylaxis to certain patients than their less
J. Patel F. Kupferman S. Rapaport J. H. Kern Flushing Hospital Medical Center, Flushing, NY, USA J. H. Kern (&) Weill Medical College of Cornell University, New York, NY 10021, USA e-mail: [email protected]
experienced peers. Many pediatric cardiologists in the United States continue to administer preprocedure antibiotic prophylaxis against endocarditis even when not recommended to do so per the 2007 AHA guidelines. With certain lesions, highly experienced pediatric cardiologists are more likely to administer prophylaxis than their less experienced counterparts. Keywords Endocarditis Congenital heart defects Antibiotic prophylaxis Cardiovascular diseases
Introduction Infective endocarditis (IE) is a potentially life-threatening infection of the endocardium, frequently of bacterial origin, mainly affecting the heart valves. Although short-term survival has improved with the advancement of treatments, long-term mortality and morbidity rates remain high [6]. Invasive procedures may lead to transient bacteremia, resulting in IE for patients with preexisting cardiac conditions. The rationale for providing preprocedural antibiotics is to prevent bacteremia and subsequent IE in high-risk patients [2]. The efficacy of antibiotic prophylaxis in preventing IE, however, is controversial [10]. The American Heart Association (AHA) first made recommendations for the prevention of IE in 1955 [4]. Since that time, several revisions to the original recommendations have been made. The most recently published guidelines in 2007 called for major changes, greatly limiting the types of patients for whom prophylaxis is recommended [16]. Controversy still exists regarding the degree to which the new recommendations should be followed. This study investigated the IE prophylaxis patterns
123
Pediatr Cardiol
of pediatric cardiologists in the United States across a broad range of pediatric cardiac lesions 5 years after publication of the most recent AHA guidelines.
Materials and Methods A descriptive, analytical, cross-sectional study was conducted in the format of an anonymous, self-administered questionnaire from June 2012 to November 2012. The e-mail addresses of pediatric cardiologists practicing in the United States were obtained from online resources. Cardiologists in training and those whose e-mail addresses could not be obtained were excluded from the study. Questionnaires were sent to the e-mail addresses via Zoomerang software during a 6-month period. Before completing the survey, the physicians were made aware that all responses would remain anonymous and confidential. Responses provided implied consent. For nonresponders, repeated attempts were made once every 4 weeks for a total of three attempts. The questionnaires included questions regarding the pediatric cardiologists’ demographic information and their current practices of prescribing preprocedural antibiotic prophylaxis against IE for patients with specific preexisting heart diseases (Tables 1 and 2). None of the cardiac conditions included in the survey require preprocedure prophylaxis as per the new AHA guidelines. Collected data were converted to categorical data for statistical analysis. Data analysis was performed using SPSS software. A p value lower than 0.05 was considered significant. Data were summarized in frequencies and percentages. The Chi-square test was used to find possible relationships between cardiologists’ demographic information and their current practices of prescribing preprocedural antibiotics to prevent IE.
Results Questionnaires were sent to 980 U.S. pediatric cardiologists, 221 (23 %) of whom responded. Table 3 shows the demographic characteristics of the responding cardiologists. The majority of the respondents (71 %) were male. The best-represented group of respondents (38 %) had at least 20 years of experience, and 82 % had more than 5 years of experience. As Table 3 shows, 59 % of respondents had community hospital type practices. Only 12 % of the cardiologists were practicing in a university type setting. The respondents were from 37 states and the District of Columbia, with a fairly even distribution from each state. Table 4 shows the cardiologists’ responses regarding IE prophylaxis for specific cardiac conditions (in order of
123
Table 1 Questionnaire regarding endocarditis prophylaxis in patients with specific cardiac lesions Questions 1.
Mitral valve prolapse with mitral regurgitation
2.
Rheumatic heart disease with aortic insufficiency
3.
Audible patent ductus arteriosus
4.
Coarctation of the aorta
5.
Status post (S/P) repair of transposition of the great arteries with no residual defects (6 months S/P last cardiac intervention)
6.
S/P repair of tetralogy of Fallot with no residual defects (6 months after last cardiac intervention)
7.
Idiopathic hypertrophic subaortic stenosis without obstruction to flow
8.
S/P cardiac transplantation without valvular disease
9.
S/P repair of single-ventricle heart (6 months after last cardiac intervention)
10.
Bicuspid aortic valve without aortic stenosis
11.
Bicuspid aortic valve with mild aortic stenosis
12.
Bicuspid aortic valve with severe aortic stenosis
13.
Bicuspid aortic valve with mild aortic insufficiency
14.
Bicuspid aortic valve with severe aortic insufficiency
15.
Acyanotic patient with tetralogy of Fallot
16.
Atrioventricular canal defect with mitral regurgitation
17.
Atrioventricular canal defect without mitral regurgitation
18.
Acyanotic Ebstein’s anomaly
19.
Dilated cardiomyopathy with mitral regurgitation
20. 21.
Primum atrium septal defect Repaired ventricular septal defect without residual shunt
22.
Silent patent ductus arteriosus
23.
Transposition of the great vessels S/P Mustard procedure
Yes
No
ascending prophylaxis rates). Most pediatric cardiologists did not prescribe preprocedural antibiotic prophylaxis to patients for whom it was not recommended. It is important to note that at least 1 % of the cardiologists continued to administer prophylaxis for each of conditions listed, even when not recommended by the AHA to do so. The most common conditions for which cardiologists administered prophylaxis were rheumatic heart disease with aortic insufficiency (39 %) and the postoperative single-ventricle patient (44 %). More than 25 % of the cardiologists surveyed also administered prophylaxis to patients after cardiac transplantation (without valvar disease) and to those with bicuspid aortic valve/severe aortic stenosis, transposition of the great vessels after the Mustard procedure, and acyanotic tetralogy of Fallot. At the opposite extreme, very few cardiologists administered prophylaxis to children
Pediatr Cardiol Table 2 Demographic characteristics of responding pediatric cardiologists
1
Table 4 Responding pediatric cardiologists’ practices of prescribing preprocedural antibiotic prophylaxis against endocarditis in patients with specific cardiac lesions
Gender Male Female
2
Type of heart disease
Cardiologists prescribing prophylaxis (%)
Repaired ventricular septal defect without residual shunt
1 3
Community hospital
Status post (S/P) repair of transposition of the great arteries with no residual defects (6 months after last cardiac intervention)
University hospital
IHSS without obstruction to flow
3
Private
Silent patent ductus arteriosus
3
Other
Bicuspid aortic valve without aortic stenosis
4
Primum atrium septal defect
4
Years of experience \5 5–10 10–15 15–20 [20
3
Type of practice
4
Table 3 Demographic characteristics of the responding cardiologists
State of medical practice
n (%) Gender Female Male No response
60 (27) 158 (71) 3 (2)
Years of experience
Mitral valve prolapse with mitral regurgitation
8
S/P repair of tetralogy of Fallot with no residual defects (6 months S/P last cardiac intervention)
9
Coarctation of the aorta
10
Acyanotic Ebstein’s anomaly
11
Dilated cardiomyopathy with mitral regurgitation
11
Bicuspid aortic valve with mild aortic stenosis
12
Bicuspid aortic valve with mild aortic insufficiency
12 13
\5
33 (15)
Atrioventricular canal defect without mitral regurgitation
5–10
20 (9)
Audible patent ductus arteriosus
15
15–20
42 (19)
[20
86 (38)
Bicuspid aortic valve with severe aortic insufficiency Atrioventricular canal defect with mitral regurgitation
23 24
S/P cardiac transplantation without valvar disease
26
Type of practice University
26 (12)
Community
132 (59)
Bicuspid aortic valve with severe aortic stenosis
28 31
Private
43 (19)
Transposition of the great vessels S/P Mustard procedure
Other
16 (7)
Acyanotic patient with tetralogy of Fallot
33
Rheumatic heart disease with aortic insufficiency
39
S/P repair of single-ventricle heart (S/P 6 months after last cardiac intervention)
44
after repair of a ventricular septal defect, to those who underwent the arterial switch procedure, or to those with hypertrophic cardiomyopathy. No statistically significant relationship between the type of practice and prophylaxis for patients with specific conditions was found, except for mitral valve prolapse with mitral regurgitation, in which 13 % of private practitioners administered prophylaxis, compared with 9 % of university-based and 4 % of community hospital-based cardiologists (p = 0.04). Table 5 shows the responses of the cardiologists by years of experience. For all but two cardiac lesions (postoperative tetralogy of Fallot and dilated cardiomyopathy with mitral regurgitation), the rates of prophylaxis administration did not differ significantly among the different groups. However, when regrouped and reanalyzed by less than or more than 15 years of experience, the more experienced cardiologists were significantly more likely to
IHSS idiopathic hypertrophic subaortic stenosistetralogy
administer prophylaxis to patients who had repaired tetralogy of Fallot without residual defect (p = 0.01), acayanotic Ebstein’s anomaly (p = 0.01), mitral valve prolapse with mitral regurgitation (p = 0.02), or dilated cardiomyopathy with mitral regurgitation (p = 0.04).
Discussion Since 1955, the AHA has issued guidelines to help prevent the development of endocarditis in individuals with congenital heart disease undergoing dental and other invasive procedures. Through the years, these guidelines have undergone several revisions. The most recently issued
123
Pediatr Cardiol Table 5 Percentage of cardiologists who administer prophylaxis by years of experience Years of experience
\5 (%)
5–10 (%)
10–15 (%)
15–20 (%)
[20 (%)
p value
Mitral valve prolapse with mitral regurgitation
0
3
5
15
12
0.25
Rheumatic heart disease with aortic insufficiency
45
42
43
50
29
0.12
Audible patent ductus arteriosus
10
18
14
24
14
0.56
Coarctation of aorta
2
15
9
14
10
0.49
Status post (S/P) repair of transposition of the great artery with no residual defects (6 months S/P last cardiac intervention)
0
0
5
9
3
0.30
S/P repair of tetralogy of Fallot with no residual defects (6 months after last cardiac intervention)
0
3
9
19
10
0.03
Idiopathic hypertrophic subaortic stenosis without obstruction to flow
0
3
0
7
5
0.52
Cardiac transplantation patient without valvular disease
26
31
20
23
30
0.98
S/P repair of single-ventricle heart (6 months S/P last cardiac intervention)
47
45
48
54
37
0.48
Bicuspid aortic valve without aortic stenosis
0
0
5
7
6
0.77
Bicuspid aortic valve with mild aortic stenosis
5
12
9
17
14
0.71
Bicuspid aortic valve with severe aortic stenosis
17
33
43
34
26
0.36
Bicuspid aortic valve with mild aortic regurgitation
7
9
5
17
15
0.21
Bicuspid aortic valve with severe aortic regurgitation Acyanotic patient with tetralogy of Fallot
12 35
21 18
38 35
32 43
22 34
0.08 0.10
Atrioventricular defect with mitral regurgitation
22
6
24
33
26
0.13
Atrioventricular defect without mitral regurgitation
17
3
5
19
14
0.26
Acyanotic Ebstein’s anomaly
5
3
9
14
17
0.27
Dilated cardiomyopathy with mitral regurgitation
5
3
9
26
10
0.04
Primum atrium septal defect
2
3
0
5
8
0.74
Repaired ventricular septal defect without residual shunt
0
0
0
0
3
0.44
Silent patent ductus arteriosus
5
3
5
5
2
0.87
Transposition of the great vessels S/P Mustard procedure
31
25
48
45
22
0.15
guidelines, however, published in 2007, marked a more substantive change. Individuals with a wide variety of conditions who previously were advised to take preprocedure antibiotic prophylaxis are currently advised that it is no longer necessary to do so. These changes, although substantial, are not as drastic as those published by the National Institute for Health and Clinical Excellence (NICE) in the United Kingdom, which entirely eliminated the use of predental antibiotics [7]. Such marked changes have been met with a certain degree of resistance in the medical community [1, 8, 9, 11, 13]. Most dentists appear to be following the new recommendations [5, 14, 15]. Although patients’ acceptance of the new guidelines is high, many patients take antibiotics before dental procedures even when not recommended to do so [3]. The practices in the pediatric cardiology community, however, have not been as well documented. This study aimed to assess, 5 years after publication of the 2007 AHA guidelines, the degree to which they are followed by pediatric cardiologists and the demographic profiles of the physicians who do and do not adhere strictly to the new recommendations.
123
To our knowledge, the only previous study investigating the issue of cardiologists’ acceptance of the guidelines was published by Pharis et al. [8] in 2011. That study involved surveying pediatric and adult cardiologists in four countries (the United States, Canada, New Zealand, and Australia) to assess changes in their practices of prophylaxis for specific conditions before and after publication of the 2007 guidelines. Our study differed from that investigation in several ways: (1) We surveyed only pediatric cardiologists, not adult cardiologists caring for older individuals with congenital heart disease. (2) We studied only American cardiologists. This might be significant because certain Canadian doctors may have adopted the British guidelines, which differ significantly from the American guidelines. Furthermore, New Zealand has its own guidelines, which may have influenced the survey responses of the Australian and New Zealand cardiologists in the Pharis et al. [8] study. (3) We examined a wider variety of conditions. (4) Finally, perhaps most importantly, our study surveyed prophylaxis practices in 2012, 5 years after publication of the guidelines, as opposed to the data of Pharis et al. [8] collected less than 1 year after publication of the revised guidelines.
Pediatr Cardiol
All the conditions listed on the questionnaire are those that do not require prophylaxis per the new recommendations. Nevertheless, at least 1 % of the respondents would administer prophylaxis for each condition listed. Generally speaking, the conditions with the highest prophylaxis administration rates were those with a significant residual structural defect. This includes the single-ventricle patient (after the Fontan procedure), those with a bicuspid aortic valve/severe aortic insufficiency or stenosis, and the posttransplantation patient. In addition, some of the patients most likely to be prophylaxed by the respondents have conditions characterized as cyanotic heart disease but are experiencing no current cyanosis. This includes patients with acyanotic tetralogy of Fallot and those with transposition of the great vessels after the Mustard procedure. This may be due to uncertainty in the medical community about whether ‘‘cyanotic heart disease’’ requiring prophylaxis also applies to situations in which the patient currently is acyanotic. Interestingly, however, patients who underwent the arterial switch procedure or tetralogy of Fallot repair had a relatively low rate of prophylaxis administration. Patients with nonobstructive hypertrophic cardiomyopathy and those with a dilated cardiomyopathy, both of which are potentially life-threatening conditions, were administered prophylaxis by only 3 and 11 % of the respondents, respectively. This does not seem to be in line with the goals of the new guidelines, which aim to prevent endocarditis in those individuals most likely to experience adverse consequences from its development [16]. If the goal was different, namely, to administer prophylaxis to those individuals most likely to experience endocarditis, then prophylaxis recommendations might be expanded in the future specifically to include children with left-sided lesions and endocardial cushion defects because children with those congenital conditions are reported, as well as those with cyanotic heart disease, to be among those with the highest risk for the development of endocarditis [12]. It is not surprising that more experienced cardiologists were less likely to adhere to all the guidelines and continue to administer antibiotics even after the 2007 publication. In the absence of definitive data, it often is difficult to change one’s longstanding practices. Part of the difficulty in accepting the new guidelines may relate to uncertainty regarding the precise risk for the development of endocarditis in the absence of antibiotic prophylaxis because available data are limited. Stricter adherence to the new guidelines may increase in the coming years if no increase in the incidence of endocarditis is demonstrated despite the decreased administration of antibiotics. In conclusion, although U.S. pediatric cardiologists generally adhere to the 2007 AHA guidelines, for several specific cardiac conditions they are more stringent in advising antibiotic prophylaxis. Pediatric cardiologists with
more than 15 years of experience are more likely to recommend prophylaxis for four specific lesions. The current study investigated prophylaxis rates 5 years after publication of the most recent AHA guidelines. It would be of great interest to reexamine the prophylaxis patterns of pediatric cardiologists after an additional 5 years have passed.
References 1. Dhoble A, Vedre A, Abdelmoneim SS et al (2009) Prophylaxis to prevent infective endocarditis: to use or no to use? Clin Cardiol 32:429–433 2. Durack DT (1995) Prevention of infective endocarditis. N Engl J Med 332:38–44 3. Elad S, Binenfeld-Alon E, Zadik Y et al (2011) Survey of acceptance of the 2007 American Heart Association guidelines for the prevention of infective endocarditis: a pilot study. Quintessence Int 42:243–251 4. Jones TD, Baumgartner L, Bellows MT, Breese BB, Kuttner AG, McCarty M, Rammelkamp CH, Committee on Prevention of Rheumatic Fever and Bacterial Endocarditis, American Heart Association, (1955) Prevention of rheumatic fever and bacterial endocarditis through control of streptococcal infections. Circulation 11:317–320 5. Lockhart PB, Hanson NB, Ristic H et al (2013) Acceptance among and impact on dental practitioners and patients of American Heart Association recommendations for antibiotic prophylaxis. J Am Dent Assoc 144:1030–1035 6. Netzer ROM et al (2012) Infective endocarditis: determinants of long-term outcome. Heart (London) 88:61–66 7. NICE Short Clinical Guidelines Technical Team (2008) Prophylaxis against endocarditis: antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures. NICE Clinical Guidelines 64. National Institute for Health and Clinical Excellence, London 8. Pharis CS, Conway J, Warren AE et al (2011) The impact of 2007 infective endocarditis prophylaxis guidelines on the practice of congenital heart disease specialists. Am Heart J 161:123–129 9. Ponnambalam Y, Love RM, Thomson WM (2007) Bacterial chemoprophylaxis and practice among New Zealand dentists. N Z Dent J 103:51–57 10. Prendergast BD (2006) The changing face of infective endocarditis. Heart (London) 92:879–885 11. Riordain R, McCreary C (2009) NICE guideline on antibiotic prophylaxis against infective endocarditis: attitudes to the guideline and implications for dental practice in Ireland. Br Dent J 206:E11 12. Rushani D, Kaufman JS, Ionescu-Ittu R et al (2013) Infective endocarditis in children with congenital heart disease: cumulative incidence and predictors. Circulation 128:1412–1419 13. Shanson D (2010) New guidelines and the development of an international consensus on recommendations for the antibiotic prophylaxis of infective endocarditis. Int Health 2:231–238 14. Soheilipour S, Scambler S, Dickinson C et al (2011) Antibiotic prophylaxis in dentistry: part I. A qualitative study of professionals’ views on the NICE guideline. Br Dent J 211:E1 15. Weiss A, Dym H (2012) Review of antibiotics and indications for prophylaxis. Dent Clin North Am 56:235–244 16. Wilson W, Taubert KA, Gewitz M et al (2007) Prevention of infective endocarditis: guidelines from the American Heart Association. Circulation 116:1736–1754
123
