Failure of prophylaxis for bacterial endocarditis: American heart association registry

LETTERS

TO

THE

EDITOR

of future events would be made in the “middle” of the data, and that the predictions would be “less good”away from the middle and become quite poor outside the observed range.’ The 95 percent confidence limits for an observed XK are given as f2.069

require only identification of the patient and the name, address, and telephone number of the person referring the case. These postcards will be made available to physicians and dentists and to any other person or organization requesting them from the AHA or from one of us. Alternatively, a case may be reported directly to one of us, at the address or telephone number listed below. After notification, one of us will follow up with a telephone call, in order to gather sufficient information to evaluate the case. All such information will be confidential. Although there are obvious disadvantages to any retrospective evaluation such as this, the practical impossibility of conducting a prospective trial of different modes of prophylaxis has caused us to seek alternative means of gathering data. We hope that a useful body of information may be accumulated, which may influence future recommendations for prophylaxis of endocarditis.

@x&q

The plot of R/L versus PAR/R& together with calculated 95 percent confidence limits for future predictions of PAR/RS (not for the population data) are shown in Figure 1 for all 25 patients (top) and for those 11 patients with ventricular septal defects (bottom). As can be seen, these are much narrower than those shown by Hoffman and Silverman and form hyperbolae. Again using Patient 21, and the confidence limits for the 11 patients only, with R/L = 0.842, the predicted logra PAR/ RS = 0.554 f 0.105 (95 percent confidence limits), logre PAR/RS lies between -0.449 and -0.659 (p >0.95) and PARES lies between 0.22 and 0.35 (p >0.95) where the actual value was 0.301. This is rather different from their calculated range of 0.12 to 0.78, which appears to have been calculated using twice the standard error about the regression. Again, I reiterate that “the use of the regression equations should allow at least a rough estimation of PAR/RS,” but in no way should it be used as the sole criterion in timing of cardiac catheterization. Eric W. Spooner, Department Albany Albany,

MD

Division

University Center

of Infectious

Diseases

of Tennessee

Health

Sciences,

Room

241-Dobbs

95 1 Court Avenue Memphis,

Tennessee

38 163

(901)528-5786 David T. Durack, Associate

MD

of Pediatrics

Medical

Alan L. Bisno, Chief,

Division

(Cardiology)

Durham,

New York

and Chief

of Infectious

Duke University

College

D Phil, MD

Professor

Diseases

Medical

North Carolina

Center 27710

(9 19)684-2660 Reference 1. Draper

David W. Fraser,

NR, Smllh H. Applied Regression Analysis. New York: John Wiley. 1966:23.

Chief,

Special

Bacterial

Diseases

of Epidemiology

Center

for Disease

FAILURE

OF

PROPHYLAXIS AMERICAN

FOR HEART

ASSOCIATION

Edward

January

1980

The American

L. Kaplan,

Department

The American Heart Association (AHA) recognizes that its current recommendations for antibiotic prophylaxis are necessarily empiric.’ This situation has arisen because important clinical information on the efficacy of antibiotic prophylaxis of bacterial endocarditis is lacking. The present recommendations are therefore based upon secondary sources of information such as the relative propensity of various procedures to cause bacteremia, in oitro studies of bacteria recovered from the blood, the effect of antibiotics on bacteremias, the susceptibility of various heart lesions to infection, anecdotal case reports, and study of experimental models. Although over 30 individual cases of apparent prophylaxis failure have been recorded in the literature, many of our colleagues have rightly pointed out that the evidence indicating that a significant number of prophylaxis failures actually occur is inconclusive. This question is of considerable medical and medicolegal importance because of the frequency with which measures to prevent endocarditis are called for, and because of the serious consequences of failure to prevent the disease. In an attempt to accumulate useful epidemiologic data, the AHA Committee has established a Registry to record cases of apparent failure of antibiotic prophylaxis of bacterial endocarditis. We are now soliciting case reports. Notification may be made on a simple pre-printed postcard, which will

Journal of CARDIOLOGY

Control

30333

(404)329-3687

BACTERIAL

REGISTRY

188

Georgia

Branch

Division

Bureau Atlanta, ENDOCARDITIS:

MD

Pathogens

MD

of Pediatrics

Box 94, University Minneapolis,

of Minnesota

Minnesota

55455

(612)373-8938 Mr. Mark A. Oliveira Chief,

Scientific

American

Councils

Heart Association

AHA National

Center

7320 Greenville Dallas,

Texas

Avenue 75231

(214)750-5431 Reference 1.

American Heart Association Committee on Rheumatic Fever and Bacterial Endocarditis: Prevention of Bacterial Endocarditis. Circulation 56:139A, 1977

CORONARY

ANGIOGRAPHY:

PHYSICIANS’

RESPONSIBILITY

A specter is haunting cardiology-the specter of malpractice, conjured forth in these pages by Effler and Gensini.’ They propose that when coronary heart disease must be ruled in or out coronary arteriography is “the sine qua non of diagnosis” and, moreover, that all patients have a legal right to know that

Volume

45