Sir, Having been involved in trying to arrange a widely, even internationally, afreed schedule of prophylaxis, we read your Editorial and the abstract ofDr Oakley and others2 with considerable interest. We3 have already agreed that amoxycillin may be a good answer to the dental problem but we feel it is still premature to give it unqualified approval as the definitive prophylaxis when given in a single dose before the following points have been elucidated:(1) In the study by Oakley et al., amoxycillin was by no means 100% effective. (2) L forms or persisters were not looked for in blood and have not yet to our knowledge been studied in the laboratory. All penicillins take at least three days to "sterilise" a culture of sensitive bacteria. (3) The rabbit experimental model has not been used to test this regimen. All other regimens have been assessed by this valuable method and incidentally a single dose of benzylpenicillin failed to work in this test.4 McGowan of Glasgow and others are at present setting up a study of amoxycillin and the results are awaited with interest. The suggestion that amoxycillin should be given to all people undergoing dental extraction presents a new departure in medicine. Never before, to our knowledge, has a drug been advised to cover a very common procedure which is predominately carried out in normal people and whose use would be of possible benefit to a tiny minority. Figures for the dangers, the shortfalls, and the cost of this should be available before any general recommendations are made. While some hopeful data exist for amoxycillin, the evidence for a single dose of erythromycin as an alternative appears to have no supporting evidence. If this drug is used, surely it must be given for two to three days. Finally, we know from our own experience that much prejudice and entrenched medical opinion already exist in this difficult field. Any premature new recommendations could lead to the compounding of this situation rather than its improvement. We therefore recommend a pause while the above matters are sorted out, before the suggested changes are generally accepted. We have reviewed the wider problems of prophylaxis elsewhere.3

Prevention of infective endocarditis

Bacteremia Associated with Toothbrushing and Dental Extraction

OBJECTIVES\nTo describe the characteristics, treatment, and outcomes of active infective endocarditis (IE) in Europe.\n\n\nDESIGN\nProspective survey of medical practices in Europe.\n\n\nSETTING\n92 centres from 25 countries.\n\n\nPATIENTS\nThe EHS (Euro heart survey) on valvar heart disease (VHD) enrolled 5001 adult patients between April and July 2001. Of those, 159 had active IE.\n\n\nRESULTS\n118 patients (74%) had native IE and 41 (26%) had prosthetic IE. Mean (SD) age was 57 (16) years. Blood cultures were obtained for 113 patients (71%) before antibiotic treatment was started. Surgery was performed in 52% of patients. Reasons for surgery were heart failure in 60%, persistent sepsis in 40%, vegetation size in 48%, or embolism in 18%. Surgery was for implantation of mechanical prosthesis in 63%, bioprosthesis in 21%, aortic homograft in 5%, and valve repair in 11%. In-hospital mortality was 12.6%, being 10.4% in the medical group and 15.6% in the surgical group. Among the total population of 5001 patients, only 50% of those with native VHD had been educated on endocarditis prophylaxis and only 33% regularly attended dental follow up. Of patients with IE who had had a procedure at risk during the preceding year only 50% had received adequate prophylaxis.\n\n\nCONCLUSIONS\nThe EHS on VHD shows that patients with active IE have a high risk profile and often undergo surgery. However, there are deficiencies in obtaining blood cultures and applying prophylaxis. Mortality remains high, which is a justification for the improvement of patient management through education and the implementation of guidelines.

2502 Prophylaxis of infective endocarditis in Europe: lessons from the Euro Heart Survey

The annual incidence of infective endocarditis (IE) is estimated to be between 15 and 80 cases per million persons in population-based studies. The incidence of IE is markedly increased in patients with valve prostheses (>4 per 1,000) or with prior IE (>10 per 1,000). The interaction between platelets, microorganisms and diseased valvular endothelium is the cause of vegetations and valvular or perivalvular tissue destruction. Owing to its complexity, the diagnosis of IE is facilitated by the use of the standardized Duke–Li classification, which combines two major criteria (microbiology and imaging) with five minor criteria. However, the sensitivity of the Duke–Li classification is suboptimal, particularly in prosthetic IE, and can be improved by the use of PET or radiolabelled leukocyte scintigraphy. Prolonged antibiotic therapy is mandatory. Indications for surgery during acute IE depend on the presence of haemodynamic, septic and embolic complications. The most urgent indications for surgery are related to heart failure. In the past decade, the prevention of IE has been reoriented, with indications for antibiotic prophylaxis now limited to patients at high risk of IE undergoing dental procedures. Guidelines now emphasize the importance of nonspecific oral and cutaneous hygiene in individual patients and during health-care procedures. Infective endocarditis (IE) is not a common disease, but it has a poor prognosis. In this Review, contemporary findings concerning the epidemiology, diagnosis, therapeutic management and prevention of IE are highlighted, with a particular emphasis on innovations and changes in guidelines.

Infective endocarditis: innovations in the management of an old disease

Antibiotic prophylaxis and infective endocarditis

Position paper for the evaluation and management of oral status in patients with valvular disease: Groupe de Travail Valvulopathies de la Société Française de Cardiologie, Société Française de Chirurgie Orale, Société Française de Parodontologie et d'Implantologie Orale, Société Française d'Endodontie et Société de Pathologie Infectieuse de Langue Française.

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