CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 6, July 2012
AFRICA
303
Editorial
Prevention of infective endocarditis in developing
countries
BREMINAND MAHARAJ, ANDREW PARRISH
Infective endocarditis (IE) causes substantial morbidity and
mortality despite modern antimicrobial chemotherapy and
advances in the ability to diagnose and treat complications.
1,2
Prevention of IE is, therefore, very important. Infective endo-
carditis usually develops following a bacteraemia in individuals
with underlying structural cardiac defects. Bacteraemia may
occur spontaneously, follow everyday procedures or complicate
certain interventions, such as dental extraction.
3,4
In developing countries, IE occurs most frequently in patients
with rheumatic heart disease (RHD).
1,2
The first step in the
prevention of IE would be to reduce the pool of patients who
are susceptible to this infection. This requires the effective
implementation of programmes to prevent rheumatic fever
and, therefore, RHD.
5,6
Regrettably, this has not happened in
developing countries.
5
Furthermore, prophylaxis against IE has
been neglected or seen as a separate issue.
The prevention of both IE and rheumatic fever recurrences
should be viewed as part and parcel of the care of a patient with
RHD in order to reduce unnecessary morbidity and mortality
in patients with RHD in developing countries. RHD should be
prioritised in developing countries and a greater emphasis needs
to be placed on the simple and cost-effective measures that are
currently available to combat RHD in the developing world.
5-8
Many patients with RHD are unaware of the presence of their
underlying heart disease and are, therefore, unable to request
prophylaxis against IE.
1,9,10
School-based screening programmes
are beneficial in detecting undiagnosed RHD.
1,7,9-12
It has been
proposed that in developing countries, registered nurses be
trained to detect children with cardiac abnormalities, refer them
to doctors organising the screening programme for assessment,
and thereafter maintain follow up of these patients.
9
The nurses
would be responsible for ensuring secondary prophylaxis against
rheumatic fever and prophylaxis against IE. The doctor in
such a nurse-orientated primary healthcare service would be
responsible for the organisation, monitoring and continuity of
such programmes.
Dodu and Bothig stated that in many countries, nurses are
trained to recognise certain criteria such as heart murmurs for
referral and have proved to be both reliable and efficient in
identifying children who need medical examination.
13
School-
based surveys could be made more effective if performed as
part of a general-purpose health survey of school children. The
ultimate aim should be to incorporate screening surveys into a
routine school examination system conducted on a regular basis
or to establish such services where they do not exist.
Such school-based surveys can only reach children who
attend school. Children who do not attend school belong more
often to the poorer, crowded communities where the problem of
rheumatic fever/rheumatic heart disease is of greater magnitude.
Ultimately, a strategy for the early detection of RHD in childhood
that includes non-school goers will have to be developed.
Children identified with RHD or a history of rheumatic fever
should be referred for secondary prophylaxis against rheumatic
fever as well as prophylaxis against IE. In addition, adults with
a history of rheumatic fever, RHD or cardiac valve surgery can
be referred. One team could therefore be responsible for the
prevention of both rheumatic fever/rheumatic heart disease and
IE. Health education programmes should also be designed to
motivate such patients and their families to accept secondary
prophylaxis against rheumatic fever and prophylaxis against IE
on a regular long-term basis and to enlist their co-operation for
maintaining a high level of patient compliance.
Antibiotic prophylaxis against IE has been accepted in most
countries for many years,
14-17
even though no prospective studies
have proven their effectiveness.
16-20
Antimicrobial prophylaxis has
been recommended prior to dental extraction in order to prevent
post-extraction bacteraemia and the subsequent development of
IE. In the study of amoxicillin, clindamycin or chlorhexidine
administered prior to dental extraction, none of the treatments
eliminated post-extraction bactraemia.
17
The article by Durack,
which evaluated some of the drugs used for prophylaxis prior to
dental extraction, confirmed that antimicrobials do not prevent
post-extraction bacteraemia.
18
Recent guidelines have introduced major changes to
recommendations for the use of prophylactic antibiotics.
The working party of the British Society for Antimicrobial
Chemotherapy (BSAC) stated that despite the lack of evidence
for prophylactic antibiotics to prevent IE associated with dental
procedures, they considered that many clinicians would be
reluctant to accept the radical but logical step of withholding
antibiotic prophylaxis for dental procedures.
21
They therefore
compromised and recommended prophylaxis for only those
patients in whom the risk of developing IE is high and, if
infected, would carry a particularly high mortality rate.
The new American Heart Association (AHA) guidelines
22,23
are similar to the BSAC guidelines for dental procedures,
but differ in that they do not recommend prophylaxis before
gastrointestinal or genitourinary procedures. Neither of these
guidelines included RHD as one of the cardiac conditions for
which prophylaxis is recommended. The National Institute for
Clinical Excellence (NICE) does not recommend antibiotic
prophylaxis for patients undergoing dental, gastrointestinal or
genitourinary procedures.
20
The National Essential Drug List Committee prepares and
