Journal of Infectious Diseases &
Research
JIDR, 1(1): 9-11
www.scitcentral.com
Original Review Article: Open Access
How to Perform Effective Prophylaxis of Endocarditis in Developing
Countries?
Han Naung Tun1* and Muhammad Waqas Mazha2
*1
Department of Cardiology, Pun Hlaing Siloam Hospital, Yangon, Myanmar
2
Chaudhary Pervaiz Elahi Institute of Cardiology, Multan, Pakistan.
Received July 09, 2018; Accepted July 25, 2018; Published November 24, 2018
ABSTRACT
Infective endocarditis is a preventable infectious heart disease that invades to endocardial part of heart. The occurrence of IE
is still seen and has impacted to high risk morbidity patients. Despite it can easily be prevented, it is still been a challenge to
prevent especially in low economic and developing countries. Antibiotic prophylaxis alone is not recommended to prevent
infective endocarditis because there is no strong association between having an interventional procedures and development of
IE. Preventive antibiotics are no longer recommended for any other congenital heart disease but may be considered in highrisk cardiac conditions. According to recent NICE and ESC guideline, prevention IE with antibiotic is needed to give clear
information about the benefits and risks of antibiotics prophylaxis. Thus, it is very important to know how to give effective
antibiotics prophylaxis in high risk patients.
Keywords: Infectious diseases, Endocarditis, Cardiovascular diseases, Prophylaxis
INTRODUCTION
Heart Infections, even though uncommon compared to other
organs infection, endocarditis and rheumatic heart disease
are usually seen as common infection of heart. Infective
Endocarditis (IE) that basically affects the inner membrane
of the heart (endocardium). Although patients with infective
endocarditis in both children and adult can be seen around
the world, risk of cardiovascular morbidity and mortality are
significantly high in developing countries [1]. It is associated
with older patients with co-morbidities and no known
structural heart disease while the trend of IE has also
evolved to affect young patients with pre-existing structural
heart disease [2].
Because of the high risk of mortality seen in patients who
live in developing nations, it is essential to provide effective
treatment of endocarditis in developing countries. This
article discusses about the effective management and
prophylaxis of IE.
PREVALENCE OF INFECTIVE ENDOCARDITIS IN
MID
AFRICA
AND
SOME
DEVELOPING
COUNTRIES
Early in the 2014, I worked with Medicines Sans Frontier
(Holland) in some developing nations including South East
Asia countries in Myanmar; prevention of infectious
diseases has been challenging matter in those areas.
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According to the Global Burden Disease 2013 Study of
sixteen poorest countries 1, Infective endocarditis has
impacted to the rate of DALY (disability-adjusted life-year)
per 100000 in these regions was 60.0% in % of
cardiovascular diseases DALYs was 1.7% [3]. Those static
data shows it has been still a challenging issue to prevent
and compact infective endocarditis sin these countries.
The Prevalence of IE is high in South Africa and other
developing countries, is predominantly a disease of young
patients with rheumatic heart. Although the microbiological
features of infective endocarditis in Africa are similar to
Corresponding author: Dr. Han Naung Tun, MBBS, MD, Department of
Cardiology, Pun Hlaing Siloam Hospital, Yangon, Myanmar, Tel:
09450397578; E-mail: annasxhan@gmail.com
Citation: Tun HN & Mazhar MW. (2018) How to Perform Effective
Prophylaxis of Endocarditis in Developing Countries? J Infect Dis Res,
1(1): 9-11.
Copyright: ©2018 Tun HN & Mazhar MW. This is an open-access article
distributed under the terms of the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any
medium, provided the original author and source are credited.
1
Sixteen poorest countries [Niger, Ethiopia, South Sudan, Chad,
Burkina Faso, Somalia, Sierra Leone (Guinea-Bissau, Guinea,
Mali, Burundi, Central African Republic, Democratic Republic of
the Congo, Mozambique, Liberia and Uganda)]
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J Infect Dis Res, 1(1): 9-11
those of economically wealthier nations of the world. About
50% of IE in developing countries occurs in patients with no
known history of valve disease. There is limited data
mentioned the trend of particulars bacteria and pattern of IE
incident in ASEANs and Southeast countries but Mirabel et
al. [4] reported rheumatic heart disease remains a major
predisposing factor of IE in Pacific tropical islands.
PREVENTION AND EFFECTIVE IE PROPHYLAXIS
IN DEVELOPING COUNTRIES
As my experienced working with MSFs (Holland) in
developing nation, in Myanmar, the MSFs has adopted
South Africa National Guideline and some of the clinical
management are revised for specific nations to make more
suitable in recourse limited settings. South Africa Heart is an
affiliated member of the European Society of Cardiology
(ESC) and hence adopts the practice guidelines of the ESC
[5]. The ESC Guideline states that antibiotic prophylaxis
should be limited to those with the highest risk of IE. Both
European Society of cardiology and ACC/AHA guideline
still recommended the IE prevention with antibiotics for
prosthetic valve or material used for repair, previous IE and
Congenital heart disease (IIa/B, C) but 2015 ESC new
guideline has no longer recommended for cardiac transplant
with valvulopathy. In addition, both ESC and ACC/AHA
recommend IE prophylaxis for Dental Procedure (Class IIb,
LOE C). Patients with a prosthetic valve or prosthetic
material used for cardiac repair have a higher risk of IE,
greater mortality and develop more complications than those
with native valve and an identical pathogen; this
recommendation also applies to transcatheter-implanted
prostheses.
As being a former physician of Medicines Sans Frontiers,
had to care HIV patients. What I had noticed in that was
despite HIV infection is not directly associated with an
increased risk of IE, Infective Endocarditis with valvular
heart diseases especially involvement of tricuspid valve
lesion was seen in HIV infected in Africa and South East
Asia where intravenous drug users are commonly seen.
Koegelenberg et al. [6] stated that the main risk factors
included RHD, in addition to prosthetic valves, CHD and a
previous history of IE in their South African prospective
observational study that examined the risk factors for IE but
only 1 of their cohort of 92 patients was HIV seropositive
[7]. Though antibiotic prophylaxis is not recommended, it is
therefore indicated only in those with high-risk cardiac
lesion.
The prevention of endocarditis in patients with RHD in
Africa and South America are needed since RHD would
promote as cardiac conditions associated with the highest
risk of adverse outcome from endocarditis and has not
improved over decades. The Infective Endocarditis
Prophylaxis Expert Group has recommended that indigenous
Australian and Pacific Oceana’s patients with RHD are a
special population at high risk for IE that should receive
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Tun HN & Mazhar MW
antibiotic prophylaxis [8] RHD is the major cause of
valvular heart disease in Latin America countries where the
oral health of the general population is extremely poor. The
Brazilian Society of Cardiology and the Inter-American
Society of Cardiology therefore recommends prophylaxis to
all with valvular or CHD (that represents a risk for IE),
before dental interventional procedures [9]. There are also
no recommendations issued by local professional
organizations in India, Pakistan, Myanmar, Bangladesh and
Sri Lanka and hence the decision is left to the clinical
judgment of the individual physician/dentist by revised the
NICE and ESC Guideline.
BENEFITS
AND
PROPHYLAXIS
RISKS
OF
ANTIBIOTIC
IE prophylaxis has been thought to get benefit by killing the
pathogen in the bloodstream before it can affect to the heart
valve. It is also traditionally thought to prevent adherence of
bacteria to the thrombus forming on the valve and to
eradicate the causal organisms that adhere to the thrombus.
Although there is strong evidence that the risks and low
cost-effectiveness of antibiotic prophylaxis might outweigh
the benefits, widespread use of antibiotic prophylaxis might
contribute to antibiotic resistance. Moreover, it is an
important thing that the adjustment of risk and benefit of
prophylaxis depend on patient’s conditions especially in
developing countries where are probably higher prevalence
of drug resistance than developed nations. Thornhill et al.
[10] showed that adverse event from the use of antibiotic
prophylaxis with single dose amoxicillin resulted only two
adverse events per year and no deaths and prophylaxis by
clindamycin resulted in twice as many adverse events and
one death every three years. Nevertheless, the level of
evidence of antibiotic prophylaxis efficiency is usually
depend on underlying high risk conditions of Infective
endocarditis and the indications of its prescription have been
revised in recent international guidelines.
ESC 2015 RECOMMENDATION
Cardiac conditions at highest risk of IE for which
prophylaxis is recommended when a high-risk procedure
is performed
Patients with previous IE have a greater risk for new IE,
higher mortality and develop more complications than
patients with a first episode of IE.
Patients with congenital heart disease (CHD):
• Any type of cyanotic CHD.
• Any type of CHD repaired with prosthetic material,
whether placed surgically or by percutaneous technique, up
to 6 months after the procedure or lifelong if residual shunt
or valvular regurgitation remains.
High-risk is defined as those with underlying cardiac
conditions associated with the greatest risk of adverse
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J Infect Dis Res, 1(1): 9-11
outcome from IE and not necessarily those with an increased
lifetime risk of endocarditis. For more details, refer to read
and learn 2015 ESC Guidelines for the management of
infective endocarditis
Recommendations for prophylaxis of IE in the highest
risk patients, according to the type of dental procedure
According to the revised South Africa guideline, antibiotic
prophylaxis is not recommended for local anesthetic
injections in non-infected tissue, treatment of superficial
carries, removal of sutures, dental X-rays, placement of
removable prosthodontics or orthodontic appliances or
braces or following shedding of deciduous teeth or trauma to
the lips or oral mucosa. Antiseptic mouth rinses
(chlorhexidine or povidone-iodine) may reduce the
incidence or magnitude of bacteremia occurring.
Tun HN & Mazhar MW
REFERENCES
1.
Aref ABA, Larry MB, Patricia JE, Bruno H, Vivian HC,
et al. (2014) Global and regional burden of infective
endocarditis, 1990-2010: A systematic review of the
literature. Global Heart 9: 131-143.
2.
Garg N, Kandpal B, Garg N, Tewari S, Kapoor A, et al.
(2005) Characteristics of infective endocarditis in a
developing country-clinical profile and outcome in 192
Indian patients, 1992-2001. Int J Cardiol 98: 253-260.
3.
Global Burden of Disease Study (2013) Age-sex
specific all cause and cause-specific mortality 19902013. Institute for Health Metrics and Evaluation
(IHME), Seattle, WA.
4.
Mariana M, Romain A, Paul BM, Hester C, Flore L, et
al. (2015) Infective endocarditis in the Pacific: Clinical
characteristics, treatment and long-term outcomes. Open
Heart 2: e000183.
5.
Habib G, Hoen B, Tornos P, Thuny F, Prendergast B, et
al. (2009) Guidelines on the prevention, diagnosis and
treatment of infective endocarditis (new version 2009):
The task force on the prevention, diagnosis and
treatment of infective endocarditis of the European
Society of Cardiology (ESC). Endorsed by the European
Society of Clinical Microbiology and Infectious
Diseases (ESCMID) and the International Society of
Chemotherapy (ISC) for Infection and Cancer Eur Heart
J 30: 2369-2413.
6.
Koegelenberg CFN, Doubell AF, Orth H, Reuter H
(2003) Infective endocarditis in the Western Cape
Province of South Africa: A three-year prospective
study. QJM 96: 217-225.
7.
Thornhill MH, Dayer MJ, Prendergast B, Baddour LM,
Jones S, et al. (2015) Incidence and nature of adverse
reactions to antibiotics used as endocarditis prophylaxis.
J Antimicrob Chemother 70: 2382-2383.
8.
National Heart Foundation of New Zealand Advisory
Group (2008) New Zealand guideline for prevention of
infective endocarditis associated with dental and other
medical interventions. National Heart Foundation of
New Zealand, Auckland, New Zealand.
9.
Ntsekhe M, Hakim J (2005) Impact of Human
Immunodeficiency Virus infection on cardiovascular
disease in Africa. Circulation 112: 3602.
SUGGESTIONS FOR THE FUTURE
There are many ongoing trails and analysis about antibiotic
prophylaxis in the field of infectious medicine including
infective endocarditis to improve effective treatment with
reducing the occurrence of antibiotic resistance. Although
preventive antibiotic for infective endocarditis on indicated
patients use significantly lowers the risk for infection in
patient, it is still challenging to follow the outcome of
effectiveness in case series from single-center analysis.
There would be good idea to analyses the effective infection
control by Good oral hygiene, including daily flossing as an
important preventative measure for all patients.
The threatened of antibiotic resistance by widespread use of
antibiotics for this purpose, an important issue today, as well
as needlessly expose patients to antibiotic side effects such
as allergic reactions. For this reason, International
Collaboration of Endocarditis (ICE) has been hopefully
formed and large randomized clinical trials can be done by
collecting various cohort data from multicenter
internationally.
CONCLUSION
According to real world data analysis, there is no different
strategy and special guidelines of IE prophylaxis in both
developed and developing countries. There has been still
challenging due to the low incidence of diseases and small
retrospective analysis or case series to revise the IE
prophylaxis for particular region. Generally, the most
common pathogenic organisms in many developing
countries setting are oral streptococci and the antibiotic
choice should therefore be no different to that of the
international guidelines. Overall, according to recent ESC
guideline, NICE guideline and other consensus guidelines,
prevention IE with antibiotic is needed to give clear
information about the benefits and risks of antibiotic
prophylaxis.
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10. Thornhill MH, Dayer MJ, Prendergast B, Baddour LM,
Jones S, et al. (2005) Incidence and nature of adverse
reactions to antibiotics used as endocarditis prophylaxis.
J Antimicrob Chemother 70: 23828.
10