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• Does antibiotic prophylaxis really prevent streptococci infective endocarditis?
  Didier Raoult, cédric Abat
  Published on: 12 July 2017

• Published on: 12 July 2017

  Does antibiotic prophylaxis really prevent streptococci infective endocarditis?

  • Didier Raoult, Pr IHU Méditerranée Infection, Faculté de Médecine et de Pharmacie, Aix-Marseille Université
  • Other Contributors:
    • cédric Abat, Dr

  To the Editor,
  We read with interest the work presented by Cahill et al. [1] in which the authors evaluate the impact of antibiotic prophylaxis to prevent bacteremia and infective endocarditis in patients undergoing dental procedures. The analysis was performed based on 36 studies, including 21 bacteremia studies, five case controls and cohort studies, and 10 time trend studies.
  It is generally well established that dental cares cause bacteremia, and that most are due to streptococcal strains [1,2]. It is, consequently, reasonable to think that prescribing antibiotics before dental cares decreases the incidence of such bacteremia. Globally, the discordant results between the different kinds of studies analyzed in the paper by Cahill et al. [1] are clearly insufficient to conclude that antibiotic prophylaxis prevents bacteremia due to streptococci. In our view, this observation can be explained by the fact that dental care is not the only cause of streptococcal bacteremia. Indeed, such bacteremia are extremely common, and it has been demonstrated that they can occur after chewing and after brushing in patients with periodontitis (cumulatively in 25% and 20% of cases, respectively) [2]. It is, therefore, fairly unlikely that bacteremias due to dental cares are more responsible for endocarditis than other kinds of bacteremias. In practice, this implies that the only reasonable antibiotic prophylaxis to prevent almost every bacteremia due to oral streptococci wou...

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  To the Editor,
  We read with interest the work presented by Cahill et al. [1] in which the authors evaluate the impact of antibiotic prophylaxis to prevent bacteremia and infective endocarditis in patients undergoing dental procedures. The analysis was performed based on 36 studies, including 21 bacteremia studies, five case controls and cohort studies, and 10 time trend studies.
  It is generally well established that dental cares cause bacteremia, and that most are due to streptococcal strains [1,2]. It is, consequently, reasonable to think that prescribing antibiotics before dental cares decreases the incidence of such bacteremia. Globally, the discordant results between the different kinds of studies analyzed in the paper by Cahill et al. [1] are clearly insufficient to conclude that antibiotic prophylaxis prevents bacteremia due to streptococci. In our view, this observation can be explained by the fact that dental care is not the only cause of streptococcal bacteremia. Indeed, such bacteremia are extremely common, and it has been demonstrated that they can occur after chewing and after brushing in patients with periodontitis (cumulatively in 25% and 20% of cases, respectively) [2]. It is, therefore, fairly unlikely that bacteremias due to dental cares are more responsible for endocarditis than other kinds of bacteremias. In practice, this implies that the only reasonable antibiotic prophylaxis to prevent almost every bacteremia due to oral streptococci would be lifetime treatment with penicillin or ampicillin [3]. However, even doing so, it would be impossible to prevent all infective endocarditis, as the authors observe[1].
  The main limitation of the study by Cahill et al. [1] is that it did not include negative controls for bacteremia and that the frequency of bacteremia was measured only after dental care rather than after different day-to-day situations. This is an important methodological error which makes it an unreasonable basis for justifying particular conclusions.
  Thus, and for the reasons mentioned above, there is still no evidence that dental prophylaxis during dental care changes the incidence of infective endocarditis [4], and this is the only reasonable conclusion of this study.

   
  References
  [1] Cahill TJ, Harrison JL, Jewell P, Onakpoya I, Chambers JB, Dayer M, et al. Antibiotic prophylaxis for infective endocarditis: a systematic review and meta-analysis. Heart 2017;103:937–44. doi:10.1136/heartjnl-2015-309102.
  [2] Forner L, Larsen T, Kilian M, Holmstrup P. Incidence of bacteremia after chewing, tooth brushing and scaling in individuals with periodontal inflammation. J Clin Periodontol 2006;33:401–7. doi:10.1111/j.1600-051X.2006.00924.x.
  [3] Diene SM, Abat C, Rolain J-M, Raoult D. How artificial is the antibiotic resistance definition? Lancet Infect Dis 2017;17:690. doi:10.1016/S1473-3099(17)30338-9.
  [4] Million M, Grisoli D, Griffiths K, Raoult D. Antibiotic prophylaxis of endocarditis. Lancet Infect Dis 2016;16:773–4. doi:10.1016/S1473-3099(16)30084-6.

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  Conflict of Interest:
  None declared.

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