Infective Endocarditis Prophylaxis

A patient presents stating, "I've been told I need to take a medicine before I have a deep dental cleaning." Which of the following patients requires antimicrobial prophylaxis prior to this dental visit?

A. A 28-year-old female taking combined oral contraceptives with a history of the murmur of mitral valve prolapse

B. An 18 year old with a physiologic murmur and a history of ACL repair

C. A 64 year old male with hypertension, type 2 diabetes, dyslipidemia, and an A1c of 9.5%

D. A 72-year-old woman with a prosthetic aortic valve

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Transcript

Voiceover: Welcome to NP Certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So, if you're ready, let's jump right in. 

Margaret Fitzgerald: A patient presents stating, "I've been told to take a medicine before I have a deep dental cleaning. Which of the following patients requires antimicrobial prophylaxis?" prior to this dental visit?

A. A 28-year-old female taking combined oral contraceptives with a history of the murmur of mitral valve prolapse

B. An 18-year-old male with a physiologic murmur and a history of ACL repair

C. A 64-year-old man with hypertension, type 2 diabetes, and dyslipidemia, with an A1C

of 9.5%

D. A 72-year-old female with a prosthetic aortic valve

The correct answer is D. A 72-year-old female with a prosthetic aortic valve. 

Where should we start? First, determine what type of question this is. Given that we're provided with four patients in a variety of clinical scenarios where the diagnosis has been established, this can be viewed as an evaluation question part of patients’ ongoing care. 

Bit of background information. Antimicrobial prophylaxis prior to dental and select other procedures is recommended for a group of individuals with increased risk conditions to prevent infective endocarditis, abbreviated IE, an infection of the inner lining of the heart. I.e. risk factors include select cardiac structural conditions. Hold on, I'll get to those shortly. 

Another significant risk is injection drug use that increases the IE risk to a 100-fold above the general population. A history of IE dramatically increases the risk of future episodes in the presence or absence of other risks. When indicated, IE prophylaxis is recommended with dental procedures that involve manipulation of the gingal tissue, dental periapical regions, or perforation of the oral mucosa. You know what that boils down to is almost any kind of dental procedure you're going to have done but in particular dental cleaning. IE presentation can develop slowly or rapidly depending on the causative organism. Signs and symptoms include fatigue, fever, night sweats, involuntary weight loss, and a new heart murmur. 

The type of murmur developed with IE is reflective of which heart valve or valves are infected. And stay tuned for more information in future podcasts on infectious endocarditis presentation and treatment. Years back, more patients qualified for IE prophylaxis. nice way of putting this or maybe not that nice way of putting this is if you're looking at a provider who's maybe of my vintage. I've been in practice for as an NP for more than 35 years. You might sometimes see those clinicians being more, shall we say liberal, with giving IE prophylaxis because years ago there were a lot more indications for it. However, over the past decade, IE prophylaxis recommendations backed by best evidence informed practice that actually few patients qualified and even in these high IE risk patients, if endocarditis does occur, that likely something like a minor cut or nick from daily living provide the portal for infection and not a distinct procedure. So, in other words, you know, you're slicing up a tomato, you accidentally nick one of your fingers, that's the portal in not going to the dentist. 

At the same time, you'll occasionally encounter a patient with a benign murmur who tells you, "I was always told I need to take an antibiotic before I went to the dentist." So in other words, even the patient is operating under the older assumption that if you ever had a heart murmur, you need to take IE prophylaxis before going to the dentist. However, one more time with current best evidence, we know that prophylaxis is not indicated in many situations. And you might say, well, even somebody who's got a benign murmur, like a physiologic murmur, shouldn't you just on er on the side of safety and provide the prophylaxis? I get it. IE is a life-threatening and life altering disease even if people survive that requires many weeks of antimicrobial therapy, usually delivered via IV. At the same time, all antimicrobial therapy carries risks. All and this includes the risk of the development of resistant pathogens as well as some very un-intended adverse effects like the development of CDIFF, allergic reactions, etc. Antimicrobials are great. Life-saving drugs should only be used when indicated and by best evidence. And that is of course the way the boards are going to operate. With this as background, let's take another look at the questions in the answers. 

A patient presents stating, "I've been told I need to take a medicine before I have a deep dental cleaning. Which of the following patients requires antimicrobial prophylaxis prior to this dental visit?

A. A 28-year-old female taking combined oral contraceptives with a history of the murmur of mitral valve prolapse. This is incorrect. Dental cleaning does not pose an IE risk for the person with MVP, which is one of the more common heart murmurs encountered in younger women. The other part is you might have gone, "Oo, but wait a minute. Does being on birth control pills, combined oral contraceptives have does that influence the answer to this question?" And the answer is no, it doesn't, but it's a great distractor. To recap, mitral valve prolapse in and of itself does not pose an increased IE risk. 

B. an 18-year-old with a physiologic murmur in a history of ACL repair. Also incorrect. Please remember any time you put the word physiologic in as part of the description of a clinical condition such as described here, physiologic murmur, this implies that the finding is noted in the lack of pathology. So physiologic heart murmurs are heart murmurs noted in the absence of cardiac pathology. They're often called benign murmurs. They're often called, I had a heart murmur when I was a kid but I outgrew it. They're sometimes called flow murmurs. The best term for them is in fact physiologic but there is no endocarditis risk with this. No prophylaxis needed. 

C. A 64-year-old male with hypertension, type 2 diabetes, dyslipidemia, and an A1C of 9.5%. Also incorrect. While this patient certainly has significant comorbidity and very poorly controlled diabetes, no cardiac issues that necessitate IE prophylaxis are mentioned. You might “yeah, but” this question and what I mean by “yeah, but, yeah, but” A1C's terrible if he gets endocarditis he's going to be that much sicker. Yep. You're right. You're right. But he has no mentioned IE risk factors. An infective endocarditis is indeed quite rare in the absence of the risk factors.

Option D. a 72-year-old woman with a prosthetic aortic valve. This is of course the correct answer. Having a prosthetic cardiac valve or prosthetic material used for cardiac valve repair is one of the most common reasons for IE prophylaxis.

Additional indications per the AHA recommendations include a history of previous endocarditis. Remember I mentioned 100 times increased risk of subsequent endocarditis if you've had it before. And then far less commonly certain congenital heart diseases. So, in other words, heart diseases that people are born with particularly if they have been uncorrected. And what I'm going to do is have you take a look at the AHA's IE prophylaxis guidelines to get full detail on what these congenital heart diseases are. For boards I wouldn't really concentrate on this because these are so uncommon. And the other part is it's more if they've been uncorrected rather than corrected.

Key takeaway. Keep in mind the NP boards are based on current best evidence, not what might have been advised years ago.

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