ENDOCARDITIS PROPHYLAXIS

The American Heart Association’s Endocarditis Committee, together with national and international experts on BE, extensively reviewed published studies to determine whether dental, gastrointestinal (GI) or genitourinary (GU) tract procedures are possible causes of BE. These experts determined that no conclusive evidence links dental, GI or GU tract procedures with the development of BE.

The current practice of giving patients antibiotics prior to a dental procedure is no longer recommended EXCEPT for patients with the highest risk of adverse outcomes resulting from BE (see below on this card). The committee cannot exclude the possibility that an exceedingly small number of cases, if any, of BE may be prevented by antibiotic prophylaxis prior to a dental procedure. If such benefit from prophylaxis exists, it should be reserved ONLY for those patients listed below. The Committee recognizes the importance of good oral and dental health and regular visits to the dentist for patients at risk of BE.

Changes in these guidelines do not change the fact that your cardiac condition puts you at increased risk for developing endocarditis. If you develop signs or symptoms of endocarditis – such as unexplained fever – see your doctor right away. If blood cultures are necessary (to determine if endocarditis is present), it is important for your doctor to obtain these cultures and other relevant tests BEFORE antibiotics are started.

Antibiotic prophylaxis with dental procedures is recommended only for patients with cardiac conditions associated with the highest risk of adverse outcomes from endocarditis, including:

• Prosthetic cardiac valve
• Previous endocarditis
• Congenital heart disease only in the following categories:
  • Unrepaired cyanotic congenital heart disease, including those with palliative shunts and conduits
  • Completely repaired congenital heart disease with prosthetic material or device, whether placed by surgery or catheter intervention, during the first six months after the procedure*
  • Repaired congenital heart disease with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization)
• Cardiac transplantation recipients with cardiac valvular disease
  

*Prophylaxis is recommended because endothelialization of prosthetic material occurs within six months after the procedure.

Dental procedures for which prophylaxis is recommended in patients with cardiac conditions listed above:

All dental procedures that involve manipulation of gingival tissue or the periapical region of teeth, or perforation of the oral mucosa*

*Antibiotic prophylaxis is NOT recommended for the following dental procedures or events: routine anesthetic injections through noninfected tissue; taking dental radiographs; placement of removable prosthodontic or orthodontic appliances; adjustment of orthodontic appliances; placement of orthodontic brackets; and shedding of deciduous teeth and bleeding from trauma to the lips or oral mucosa.

Antibiotic Prophylactic Regimens Recommended for Dental Procedures

Situation	Agent	Regimen — Single dose 30-60 minutes before procedure
		Adults	Children
Oral	Amoxicillin	2 gm		50 mg/kg
Unable to take oral medication	Ampicillin OR	2 g IM or IV*		50 mg/kg IM or IV
	Cefazolin or ceftriaxone	1 g IM or IV		50 mg/kg IM or IV
Allergic to penicillins or ampicillin Oral regimen	Cephalexin**†	2 g		50 mg/kg
	Clindamycin	600 mg		20 mg/kg
	Azithromycin or clarithromycin	500 mg		15 mg/kg
Allergic to penicillins or ampicillin and unable to take oral medication	Cefazolin or ceftriaxone† OR	1 g IM or IV		50 mg/kg IM or IV
	Clindamycin	600 mg IM or IV		20 mg/kg IM or IV

*IM – intramuscular; IV – intravenous

**Or other first or second generation oral cephalosporin in equivalent adult or pediatric dosage.

† Cephalosporins should not be used in an individual with a history of anaphylaxis, angioedema or urticaria with penicillins or ampicillin.

Other Procedures:  BE prophylaxis for procedures of the respiratory tract or infected skin, tissues just under the skin, or musculoskeletal tissue is recommended ONLY for patients with the underlying cardiac conditions shown above.

Adapted from Prevention of Infective Endocarditis: Guidelines From the American Heart Association, by the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease. Circulation, e-published April 19, 2007.

Accessible at: www.americanheart.org/presenter.jhtml?identifier=3004539.

Healthcare Professionals – Please refer to these recommendations for more complete information as to which patients and which procedures need prophylaxis.