Dental procedures, antibiotic prophylaxis, and endocarditis among people with prosthetic heart valves: nationwide population based cohort and a case crossover study

Abstract

Objective To assess the relation between invasive dental procedures and infective endocarditis associated with oral streptococci among people with prosthetic heart valves.Design Nationwide population based cohort and a case crossover study.Setting French national health insurance administrative data linked with the national hospital discharge database.Participants All adults aged more than 18 years, living in France, with medical procedure codes for positioning or replacement of prosthetic heart valves between July 2008 and July 2014.Main outcome measures Oral streptococcal infective endocarditis was identified using primary discharge diagnosis codes. In the cohort study, Poisson regression models were performed to estimate the rate of oral streptococcal infective endocarditis during the three month period after invasive dental procedures compared with non-exposure periods. In the case crossover study, conditional logistic regression models calculated the odds ratio and 95% confidence intervals comparing exposure to invasive dental procedures during the three month period preceding oral streptococcal infective endocarditis (case period) with three earlier control periods.Results The cohort included 138 876 adults with prosthetic heart valves (285 034 person years); 69 303 (49.9%) underwent at least one dental procedure. Among the 396 615 dental procedures performed, 103 463 (26.0%) were invasive and therefore presented an indication for antibiotic prophylaxis, which was performed in 52 280 (50.1%). With a median follow-up of 1.7 years, 267 people developed infective endocarditis associated with oral streptococci (incidence rate 93.7 per 100 000 person years, 95% confidence interval 82.4 to 104.9). Compared with non-exposure periods, no statistically significant increased rate of oral streptococcal infective endocarditis was observed during the three months after an invasive dental procedure (relative rate 1.25, 95% confidence interval 0.82 to 1.82; P=0.26) and after an invasive dental procedure without antibiotic prophylaxis (1.57, 0.90 to 2.53; P=0.08). In the case crossover analysis, exposure to invasive dental procedures was more frequent during case periods than during matched control periods (5.1% v 3.2%; odds ratio 1.66, 95% confidence interval 1.05 to 2.63; P=0.03).Conclusion Invasive dental procedures may contribute to the development of infective endocarditis in adults with prosthetic heart valves.

Fig 1 Time frame of cohort study with examples of exposure during follow-up for three patients. *Death from any cause (other than oral streptococcal infective endocarditis), or admission to hospital for prosthetic heart valve or replacement of prosthetic heart valve, or lost to follow-up, or follow-up until December 2014. Participant A was exposed to an invasive dental procedure during follow-up, but did not present with oral streptococcal infective endocarditis. Participant B was exposed to both a non-invasive and an invasive dental procedure during follow-up and presented with oral streptococcal infective endocarditis; during the co-exposure period, priority was given to exposure of an invasive dental procedure. Participant C was not exposed to any dental procedure during follow-up and presented with an oral streptococcal infective endocarditis

Fig 2 Time frame of case and control periods in case crossover study, 2009-14. The case crossover design only includes cases, ie, participants who experienced the outcome events (oral streptococcal infective endocarditis), and each case acted as his or her own control

Fig 3 Flow chart of cohort study, 2008-14. Participants entered the cohort six months after the date of first identification of the presence of a prosthetic valve during the study period to be analysed in a stable condition. At cohort entry, participants had to be aged more than 18 years without a discharge diagnosis code for oral streptococcal infective endocarditis in the previous year or other specific codes related to a prosthetic heart valve during the six months preceding cohort entry