Comparative Effectiveness, 2008
American Heart Association
American Dental Association
Many patients with heart abnormalities will no longer routinely receive antibiotics before they undergo dental treatment, thanks in part to an AHRQ-sponsored effort at the University of Pennsylvania's Center for Education and Research on Therapeutics (CERT). This accomplishment involved research studies, professional education, and persuasion undertaken by Brian Strom, MD, MPH, Professor of Biostatistics and Epidemiology at the University of Pennsylvania.
Among other considerations, evidence-based arguments put forth by Strom and colleagues led the American Heart Association (AHA) to publish new guidelines in April 2007. These guidelines made major changes to the AHA's long-standing recommendation that patients with certain heart valve abnormalities and congenital cardiac conditions be given a short-term course of antibiotics before dental procedures in order to prevent infective endocarditis, a rare but potentially fatal heart infection. The AHA recommendations were endorsed by several other groups, including the American Dental Association (ADA), which endorsed the new guidelines as they relate to dental practice.
The impact of the new guidelines may be sizeable if they are widely adopted. According to Strom, under the old guidelines about 10 percent of the population with heart problems would receive antibiotics twice a year. This usually occurred at routine dental office visits. With the new guidelines, he notes, this number could be reduced by perhaps a factor of 10, to about 1 percent of this population.
AHRQ funding through the University of Pennsylvania's participation in the nationwide CERTs program provided Strom the resources and encouragement necessary to advance the findings from his earlier research to a significant policy discussion among his medical colleagues, the associations, and the public at large. Strom was responsible for research that suggests that a change in prophylactic antibiotics was warranted. This research, funded by the National Institutes of Health (NIH), showed no benefit from preventive antibiotic therapy to prevent infective endocarditis. It also showed that neither dental treatment in general, nor any particular dental procedure except possibly tooth extraction, significantly increased the risk of contracting the infection.
The AHA had last updated its guidelines, first written in 1955, in 1997, about a year before Strom's research findings were published. Strom and his colleagues at the University of Pennsylvania CERT undertook a proactive effort to argue that the guidelines should be updated to take the new information into account. They summarized the supporting evidence and outlined arguments for policy change in a fact sheet published by the University of Pennsylvania's Leonard Davis Institute of Health Economics. They used this document in discussions with leaders in general medicine, cardiology, infectious diseases, and dentistry.
In May 2004, the AHA convened a workshop of national and international experts to review and update the guidelines. As a member of this workshop, Strom was able to explain the significance of the research findings and demonstrate to his colleagues how the new information had altered the risk-benefit ratio, especially in the light of new understanding of the dangers of excessive use of antibiotics. Strom notes that while "NIH provided the funding that allowed us to gather the data and make the case, the policy imperative—to seek change proactively—came from AHRQ and the CERTs program." AHRQ, through the University of Pennsylvania CERT, facilitated the translation of important scientific data into a policy initiative that is expected to significantly improve the rational use of prophylactic antibiotics.
According to the new AHA and ADA document, prophylactic antibiotics are recommended only for a much narrower group of patients with severe heart problems or a history of infective endocarditis—those patients who would be at greatest danger of adverse outcomes if they contracted infective endocarditis. This significant change in medical and dental practice is expected to substantially reduce the unnecessary use of antibiotics nationwide, and thereby help forestall the development of drug-resistant bacteria, without significantly increasing the risk to patients.
However, says Strom, "It remains to be seen how quickly medical and dental practice will accommodate to the new guidelines. Cardiologists and dentists may continue to be concerned about legal liability. Older patients, who have been offered antibiotics for many years, may be confused by the change."
The fact sheet on the topic published by the University of Pennsylvania's Leonard Davis Institute of Health Economics can be found at: http://www.cceb.upenn.edu/pages/cert/Materials/Issue_Brief_March_2001.pdf [PDF File, 53 KB; Plugin Software Help].
Impact Case Study Identifier: COE 08-06
Center for Education and Research on Therapeutics (CERTs)
Strom BL, Abrutyn E, Berlin JA, et al. Dental and cardiac risk factors for infective endocarditis: A population-based, case-control study. Annals of Internal Medicine 1998; 129(10): 761-769. (HS99-004)
Leonard Davis Institute of Health Economics, University of Pennsylvania. "When data conflict with practice: rethinking the use of prophylactic antibiotics before dental treatment." LDI Issue Brief March 2001, Vol. 6, No. 6.
Wilson W, Taubert KA, Gewitz M, Lockhart PB, et al. Prevention of infective endocarditis: Guidelines from the American Heart Association. Circulation 116; 1736-1754. Originally published online, April 19, 2007.
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