Profilaktyka antybiotykowa w zapobieganiu zapaleniu wsierdzia – co wiemy o jej skuteczności ?

Luty 17, 2014  |  Udostępnij  | 

Wytyczne dotyczące profilaktyki antybiotykowej u pacjentów wysokiego ryzyka infekcyjnego zapalenia wsierdzia (IZW) zmieniały się na przestrzeni lat. W ostatnich rekomendacjach Europejskiego Towarzystwa Kardiologicznego (ESC), pochodzących z roku 2009, lista sytuacji, w których rutynowa podaż amoksycyliny może być korzystna została wyraźnie skrócona. Przede wszystkim jasno określono, że profilaktyka antybiotykowa powinna być stosowana u chorych absolutnie najwyższego ryzyka. Najliczniejszą część tej grupy stanowią pacjenci z wszczepioną sztuczną zastawką, ci u których do naprawy natywnej zastawki zastosowano materiał sztuczny oraz osoby po przebytym poprzednio infekcyjnym zapaleniu wsierdzia. Poza tym do grona pacjentów, u którym antybiotykoterapię uznano za celową, zaliczono chorych z siniczą wadą serca, której nie udało się całkowicie skorygować kardiochirurgicznie. Podobnemu zawężeniu uległa lista procedur, przed wykonaniem których należy rozważyć podanie antybiotyków. Poza operacjami na sercu i dużych naczyniach z zastosowaniem sztucznych materiałów pozostawianych w ustroju, rozważenie profilaktyki zalecono jedynie w przypadku zabiegów stomatologicznych z manipulacją w obrębie dziąseł lub z naruszeniem ciągłości błony śluzowej jamy ustnej. Powyższe zalecenia otrzymały poziom C, co oznacza, że były one efektem konsensusu ekspertów. W tym czasie nie było bowiem badań, które jednoznacznie wskazywałyby na wpływ antybiotykoterapii prewencyjnej na ograniczenie częstości IZW lub na spadek śmiertelności związany z tą jednostką chorobową. Konsensus zawarty w wytycznych powstał na bazie badań pokazujących, że zabiegi stomatologiczne są związane z przemijającą bakteriemią. Ta z kolei miała związek ze wzrostem ryzyka infekcyjnego zapalenia wsierdzia w eksperymentach na modelach zwierzęcych.
O tym jak słabo poznane jest to zagadnienie może świadczyć opublikowane niedawno badanie [1], które z założenia miało być przeglądem wszystkich doniesień naukowych dotyczących występowania IZW u pacjentów wysokiego ryzyka, ze szczególnym uwzględnieniem ewentualnego związku między przebytymi zabiegami stomatologicznymi i podaniem profilaktyki antybiotykowej, a rozwojem choroby. Badacze przeszukali rejestry Cochrane, Medline oraz Embase (od 1980 roku), odnajdując 1390 prac zawierających odpowiednie słowa kluczowe. Spośród nich kryteria włączenia do analizy spełniało w pełni zaledwie jedno badanie, będące obserwacyjnym studium wszystkich przypadków infekcyjnego zapalenia wsierdzia, jakie odnotowano w Holandii w dwuletnim okresie, między 1986 a 1988 rokiem. Spośród 349 przypadków IZW, jakie wystąpiły w tym czasie, 197 dotyczyło osób z chorobą serca, wśród których 44 przebyło zabieg stomatologiczny poprzedzający pojawienie się objawów o mniej niż 180 dni. Grupę kontrolną utworzyło 181 pacjentów kardiologicznych z grupy wysokiego ryzyka, którzy nie zachorowali w tym czasie na IZW mimo przebytej manipulacji w okolicy dziąseł itp. Profilaktykę antybiotykową zgodną ze wskazaniami otrzymało 7 osób z grupy badanej oraz 16 z grupy kontrolnej. Trzeba przyznać, że przy tak niskich próbkach wykazanie istotnej statystycznie różnicy w ryzyku rozwinięcia się infekcyjnego zapalenie wsierdzia było mało prawdopodobne i takiej różnicy nie zaobserwowano.
Dysponując jedynie takimi dowodami naukowymi trudno jednoznacznie stwierdzić, czy w istocie podanie profilaktyki antybiotykowej przed zabiegami w okolicy dziąseł może chronić przed rozwojem infekcyjnego zapalenia wsierdzia. Jednocześnie należy pamiętać, że antybiotykoterapia wiąże się z możliwością powikłań, a także z kosztami, które mogą okazać się wyższe niż nie udowodnione (jak na razie) korzyści. Kwestia ta niewątpliwie wymaga dokładniejszego zbadania.
1. A M Glenny et al., Antibiotics for the prophylaxis of bacterial endocarditis in dentistry. Cochrane Database Syst Rev. 2013 Oct 9;(4):CD003813.


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