Bacterial Endocarditis Prophylaxis

TOC | Cardiology

AHA Guidelines: Bacterial Endocarditis Prophylaxis

See the new SBE Prophylaxis 2008
OLD American Heart Association SBE Guidelines- JAMA 1997;277:1794
http://circ.ahajournals.org/cgi/content/full/96/1/358

Table 1: Cardiac Conditions Associated With Endocarditis

Table 2: Dental Procedures and Endocarditis Prophylaxis

Table 3: Other Procedures and Endocarditis Prophylaxis

Table 4: Prophylactic Regimens for Dental, Oral, Respiratory Tract, or Esophageal Procedures

Table 5: Prophylactic Regimens for Genitourinary/Gastrointestinal (Excluding Esophageal) Procedures


Endocarditis prophylaxis recommended		Endocarditis prophylaxis NOT recommended: Negligible-risk category (no greater risk than the general population)
Table 1: Cardiac Conditions Associated With Endocarditis
High-risk category		Isolated secundum atrial septal defect Surgical repair of atrial septal defect, ventricular septal defect, or patent ductus arteriosus (without residua beyond 6 mo) Previous coronary artery bypass graft surgery Mitral valve prolapse without valvar regurgitation¹ Physiologic, functional, or innocent heart murmur¹ Previous Kawasaki disease without valvar dysfunction Previous rheumatic fever without valvar dysfunction *Cardiac pacemakers (intravascular and epicardial) and implanted defibrillators
Prosthetic cardiac valves, including bioprosthetic and homograft valves Previous bacterial endocarditis Complex cyanotic congenital heart disease (eg, single ventricle states, transposition of the great arteries, tetralogy of Fallot) Surgically constructed systemic pulmonary shunts or conduits
Moderate-risk category
Most other congenital cardiac malformations (other than above and below) Acquired valvar dysfunction (eg, rheumatic heart disease) Hypertrophic cardiomyopathy Mitral valve prolapse with valvar regurgitation and/or thickened leaflets

top

Table 2: Dental Procedures and Endocarditis Prophylaxis

Endocarditis prophylaxis recommended¹ Endocarditis prophylaxis not recommended

*Dental extractions
*Periodontal procedures including surgery, scaling and root planing, probing, and recall maintenance
*Dental implant placement and reimplantation of avulsed teeth
*Endodontic (root canal) instrumentation or surgery only beyond the apex
*Subgingival placement of antibiotic fibers or strips
*Initial placement of orthodontic bands but not brackets
*Intraligamentary local anesthetic injections
*Prophylactic cleaning of teeth or implants where bleeding is anticipated

*Restorative dentistry² (operative and prosthodontic) with or without retraction cord³
*Local anesthetic injections (nonintraligamentary)
*Intracanal endodontic treatment; post placement and buildup
*Placement of rubber dams
*Postoperative suture removal
*Placement of removable prosthodontic or orthodontic appliances
*Taking of oral impressions
*Fluoride treatments
*Taking of oral radiographs
*Orthodontic appliance adjustment
*Shedding of primary teeth

1 Prophylaxis is recommended for patients with high- and moderate-risk cardiac conditions.
2 This includes restoration of decayed teeth (filling cavities) and replacement of missing teeth.
3 Clinical judgment may indicate antibiotic use in selected circumstances that may create significant bleeding

Table 2: Dental Procedures and Endocarditis Prophylaxis
Endocarditis prophylaxis recommended¹	Endocarditis prophylaxis not recommended
Dental extractions Periodontal procedures including surgery, scaling and root planing, probing, and recall maintenance Dental implant placement and reimplantation of avulsed teeth Endodontic (root canal) instrumentation or surgery only beyond the apex Subgingival placement of antibiotic fibers or strips Initial placement of orthodontic bands but not brackets Intraligamentary local anesthetic injections Prophylactic cleaning of teeth or implants where bleeding is anticipated	Restorative dentistry² (operative and prosthodontic) with or without retraction cord³ Local anesthetic injections (nonintraligamentary) Intracanal endodontic treatment; post placement and buildup Placement of rubber dams Postoperative suture removal Placement of removable prosthodontic or orthodontic appliances Taking of oral impressions Fluoride treatments Taking of oral radiographs Orthodontic appliance adjustment *Shedding of primary teeth

top

Table 3: Other Procedures and Endocarditis Prophylaxis

Endocarditis prophylaxis recommended Endocarditis prophylaxis NOT recommended

Respiratory tract:

*Tonsillectomy and/or adenoidectomy
*Surgical operations that involve respiratory mucosa
*Bronchoscopy with a rigid bronchoscope
Respiratory tract:

*Endotracheal intubation
*Bronchoscopy with a flexible bronchoscope, with or without biopsy|
*Tympanostomy tube insertion

Gastrointestinal tract¹:

*Sclerotherapy for esophageal varices
*Esophageal stricture dilation
*Endoscopic retrograde cholangiography with biliary obstruction
*Biliary tract surgery
*Surgical operations that involve intestinal mucosa
Gastrointestinal tract:

*Transesophageal echocardiography|
*Endoscopy with or without gastrointestinal biopsy|

Genitourinary tract:

*Prostatic surgery
*Cystoscopy
*Urethral dilation

Genitourinary tract:

*Vaginal hysterectomy²
*Vaginal delivery³
*Cesarean section

-In uninfected tissue:

*Urethral catheterization
*Uterine dilatation and curettage
*Therapeutic abortion
*Sterilization procedures
*Insertion or removal of intrauterine
devices

Other:

*Cardiac catheterization, including balloon angioplasty
*Implanted cardiac pacemakers,implanted defibrillators, and coronary stents
*Incision or biopsy of surgically scrubbed skin
*Circumcision

¹ Prophylaxis is recommended for high-risk patients; it is optional for medium-risk patients.
² Prophylaxis is optional for high-risk patients
³ Prophylaxis is optional for high-risk patients

Table 3: Other Procedures and Endocarditis Prophylaxis
Endocarditis prophylaxis recommended	Endocarditis prophylaxis NOT recommended
Respiratory tract: Tonsillectomy and/or adenoidectomy Surgical operations that involve respiratory mucosa *Bronchoscopy with a rigid bronchoscope	Respiratory tract: Endotracheal intubation Bronchoscopy with a flexible bronchoscope, with or without biopsy\| *Tympanostomy tube insertion
Gastrointestinal tract¹: Sclerotherapy for esophageal varices Esophageal stricture dilation Endoscopic retrograde cholangiography with biliary obstruction Biliary tract surgery *Surgical operations that involve intestinal mucosa	Gastrointestinal tract: Transesophageal echocardiography\| Endoscopy with or without gastrointestinal biopsy\|
Genitourinary tract: Prostatic surgery Cystoscopy *Urethral dilation	Genitourinary tract: Vaginal hysterectomy² Vaginal delivery³ Cesarean section -In uninfected tissue:* Urethral catheterization Uterine dilatation and curettage Therapeutic abortion Sterilization procedures *Insertion or removal of intrauterine devices
Other: Cardiac catheterization, including balloon angioplasty Implanted cardiac pacemakers,implanted defibrillators, and coronary stents Incision or biopsy of surgically scrubbed skin Circumcision

top

Table 4: Prophylactic Regimens for Dental, Oral, Respiratory Tract, or Esophageal Procedures

Situation Agent Regimen¹

Standard general prophylaxis Amoxicillin

Adults: 2.0 g;
Children: 50 mg/kg orally 1 h before procedure

Unable to take oral medications Ampicillin

Adults: 2.0 g IM or IV;
Children: 50 mg/kg IM or IV within 30 min before procedure

Allergic to penicillin Clindamycin or

Adults: 600 mg;
Children: 20 mg/kg orally 1 h before procedure

Cephalexin² or cefadroxilb or

Adults: 2.0 g;
Children; 50 mg/kg orally 1 h before procedure

Azithromycin or
clarithromycin

Adults: 500 mg;
Children: 15 mg/kg orally 1 h before procedure

Allergic to penicillin and unable to take oral medications Clindamycin or

Adults: 600 mg;
Children: 20 mg/kg IV within 30 min before procedure

Cefazolin²

Adults: 1.0 g;
Children: 25 mg/kg IM or IV within 30 min before procedure

¹ Total children's dose should not exceed adult dose
² Cephalosporins should not be used in individuals with immediate-type hypersensitivity reaction (urticaria, angioedema, or anaphylaxis) to penicillins

Table 4: Prophylactic Regimens for Dental, Oral, Respiratory Tract, or Esophageal Procedures
Situation	Agent	Regimen¹
Standard general prophylaxis	Amoxicillin	Adults: 2.0 g; Children: 50 mg/kg orally 1 h before procedure
Unable to take oral medications	Ampicillin	Adults: 2.0 g IM or IV; Children: 50 mg/kg IM or IV within 30 min before procedure
Allergic to penicillin	Clindamycin or	Adults: 600 mg; Children: 20 mg/kg orally 1 h before procedure
Cephalexin² or cefadroxilb or	Adults: 2.0 g; Children; 50 mg/kg orally 1 h before procedure
Azithromycin or clarithromycin	Adults: 500 mg; Children: 15 mg/kg orally 1 h before procedure
Allergic to penicillin and unable to take oral medications	Clindamycin or	Adults: 600 mg; Children: 20 mg/kg IV within 30 min before procedure
Cefazolin²	Adults: 1.0 g; Children: 25 mg/kg IM or IV within 30 min before procedure

top

Table 5: Prophylactic Regimens for Genitourinary/Gastrointestinal (Excluding Esophageal) Procedures

Situation Agents Regimen¹,²

High-risk patients Ampicillin plus gentamicin

Adults: ampicillin 2.0 g IM or IV plus gentamicin 1.5 mg/kg (not to exceed 120 mg) within 30 min of starting procedure; 6 h later, ampicillin 1 g IM/IV or amoxicillin 1 g orally
Children: ampicillin 50 mg/kg IM or IV (not to exceed 2.0 g) plus gentamicin 1.5 mg/kg within 30 min of starting the procedure; 6 h later, ampicillin 25 mg/kg IM/IV or amoxicillin 25 mg/kg orally

High-risk patients allergic to ampicillin/amoxicillin Vancomycin plus gentamicin

Adults: vancomycin 1.0 g IV over 1-2 h plus gentamicin 1.5 mg/kg IV/IM (not to exceed 120 mg); complete injection/infusion within 30 min of starting procedure
Children: vancomycin 20 mg/kg IV over 1-2 h plus gentamicin 1.5 mg/kg IV/IM; complete injection/infusion within 30 min of starting procedure

Moderate-risk patients Amoxicillin or ampicillin

Adults: amoxicillin 2.0 g orally 1 h before procedure, or ampicillin 2.0 g IM/IV within 30 min of starting procedure
Children: amoxicillin 50 mg/kg orally 1 h before procedure, or ampicillin 50 mg/kg IM/IV within 30 min of starting procedure

Moderate-risk patients allergic to ampicillin/amoxicillin Vancomycin

Adults: vancomycin 1.0 g IV over 1-2 h complete infusion within 30 min of starting procedure
Children: vancomycin 20 mg/kg IV over 1-2 h; complete infusion within 30 min of starting procedure

¹ Total children's dose should not exceed adult dose
² No second dose of vancomycin or gentamicin is recommended.

Table 5: Prophylactic Regimens for Genitourinary/Gastrointestinal (Excluding Esophageal) Procedures
Situation	Agents	Regimen¹,²
High-risk patients	Ampicillin plus gentamicin	Adults: ampicillin 2.0 g IM or IV plus gentamicin 1.5 mg/kg (not to exceed 120 mg) within 30 min of starting procedure; 6 h later, ampicillin 1 g IM/IV or amoxicillin 1 g orally Children: ampicillin 50 mg/kg IM or IV (not to exceed 2.0 g) plus gentamicin 1.5 mg/kg within 30 min of starting the procedure; 6 h later, ampicillin 25 mg/kg IM/IV or amoxicillin 25 mg/kg orally
High-risk patients allergic to ampicillin/amoxicillin	Vancomycin plus gentamicin	Adults: vancomycin 1.0 g IV over 1-2 h plus gentamicin 1.5 mg/kg IV/IM (not to exceed 120 mg); complete injection/infusion within 30 min of starting procedure Children: vancomycin 20 mg/kg IV over 1-2 h plus gentamicin 1.5 mg/kg IV/IM; complete injection/infusion within 30 min of starting procedure
Moderate-risk patients	Amoxicillin or ampicillin	Adults: amoxicillin 2.0 g orally 1 h before procedure, or ampicillin 2.0 g IM/IV within 30 min of starting procedure Children: amoxicillin 50 mg/kg orally 1 h before procedure, or ampicillin 50 mg/kg IM/IV within 30 min of starting procedure
Moderate-risk patients allergic to ampicillin/amoxicillin	Vancomycin	Adults: vancomycin 1.0 g IV over 1-2 h complete infusion within 30 min of starting procedure Children: vancomycin 20 mg/kg IV over 1-2 h; complete infusion within 30 min of starting procedure

APC Home

Physicians' Recommendations to Patients for Use of Antibiotic Prophylaxis to Prevent Endocarditis
Todd B. Seto, etc.
JAMA. July 5, 2000;284:68-71

Guidelines updated for infective endocarditis prophylaxis in valvular heart disease

The American College of Cardiology and American Heart Association have updated their joint guidelines for preventing infective endocarditis (IE) in valvular heart disease.

The update, published in the Aug. 19, 2008 Journal of the American College of Cardiology, is based on new evidence that has emerged since the 2006 ACC/AHA Guidelines for the Management of Valvular Heart Disease were published. Major changes include:

* There are now no Class I recommendations for IE prophylaxis in patients with valvular heart disease;

* Antibiotic IE prophylaxis is no longer indicated in patients with aortic stenosis, mitral stenosis, or symptomatic or asymptomatic mitral valve prolapse. It is also not indicated in adolescents and young adults with native heart valve disease;

* It's not recommended to administer antibiotics solely to prevent IE in patients undergoing a genitourinary (GU) and gastrointestinal (GI) tract procedure. Nor is it recommended solely on the basis of an increased lifetime risk of IE; and

* IE prophylaxis for dental procedures should only be used in patients with underlying cardiac conditions associated with the highest risk for adverse outcomes, such as prosthetic valves or prior IE. In those cases, prophylaxis is reasonable for procedures that involve manipulating gingival tissue or the periapical region of teeth, or perforating oral mucosa.

The guidelines were revised for several reasons. IE is more likely to result from frequent exposure to random bacteremias associated with daily activities than from bacteremia caused by a dental, GI tract or GU procedure. As well, the number of IE cases preventable by prophylaxis in patients undergoing those procedures is "exceedingly small," the article said. Also, the risk of adverse effects caused by antibiotics exceeds any benefit from prophylactic antibiotics.

Physicians should be prepared to discuss the updated guidelines with patients as the changes may cause some concern, the article said. Some doctors and patients may still be more comfortable continuing with prophylaxis for IE in certain circumstances; in those cases, the doctor should ensure that the risks associated with antibiotics are minor before prescribing them.

2009