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Prevention of Bacterial Endocarditis 1997           See UW SBE Prophylaxis
The American Heart Association has issued new guidelines for the prevention of bacterial endocarditis.
http://circ.ahajournals.org/cgi/content/full/96/1/358  
June 11, 1997 JAMA Vol. 277, pp 1797-1801 and the July 1, 1997 issue of Circulation.

Major changes in the updated recommendations include the following:

• emphasis that most cases of endocarditis are not attributable to an invasive procedure;
• cardiac conditions are stratified into high, moderate, and negligible risk categories based on potential outcome if endocarditis develops;
• procedures that may cause bacteremia and for which prophylaxis is recommended are more clearly specified;
• an algorithm was developed to more clearly define when prophylaxis is recommended for patients with mitral valve prolapse;
• for oral/dental procedures the initial amoxicillin dose is reduced to 2 g, a follow-up antibiotic dose is no longer recommended, erythromycin is no longer recommended for penicillin-allergic individuals but clindamycin and other alternatives are offered;
• for GI/GU procedures, the prophylactic regimens have been simplified. These changes were instituted to more clearly define when prophylaxis is/is not recommended, improve practitioner and patient compliance, reduce cost and potential GI side-effects, and approach more uniform world-wide recommendations.

Key Points   REF:  ACP Online PIER  4-2003

• Be aware that patients at highest risk for IE  (Infective Endocarditis) include those with prosthetic heart valves, previous IE and cyanotic congenital heart malformations, and surgically constructed systemic pulmonary shunts or conduits.
• Recognize that patients at moderate risk for IE include those with noncyanotic congenital heart disease, hypertrophic obstructive cardiomyopathy, MVP with regurgitation or thickened leaflets, and acquired valvular dysfunction.
• Be aware that procedures associated with high rates of bacteremia include most dental procedures; some upper gastrointestinal, biliary tree, and upper respiratory tract procedures; and many genitourinary tract procedures.
• Understand that although IE occurs rarely, its high mortality prompts experts to recommend antibiotic prophylaxis among high-risk patients and to consider prophylaxis among moderate-risk patients before undergoing procedures that may cause bacteremia with organisms known to cause IE.
• Recognize that population-based, case-control studies of the efficacy of antibiotic prophylaxis for prevention of IE suggest that the current approach and/or its practical application are ineffective.
• Be aware that patients without identifiable risk factors for the development of IE are unlikely to benefit from antibiotic prophylaxis.
• Be aware that nosocomial IE accounts for 10% to 20% of all IE cases; there have been no controlled studies that examine specifically the prevention of nosocomial IE.
• Understand that cost-effectiveness studies suggest benefit from antibiotic prophylaxis, but the assumptions inherent to these studies are unrealistic, making their conclusions difficult to interpret.

Standard general prophylaxis:

• Amoxicillin  Adults: 2.0 g; Children: 50 mg/kg PO 1hour before procedure

Unable to take medications:

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

Penicillin-allergic:

• Clindamycin  Adults: 600 mg; Children: 20 mg/kg PO 1 hour before procedure.   OR
• Cephalexin* or Cefadroxil*   Adults: 2.0 g; Children: 50 mg/kg PO 1 hour before procedure,   OR
• Azithromycin or Clarithromycin   Adults: 500 mg; Children: 15 mg/kg PO 1 hour before procedure

Penicillin-allergic and unable to take medications:

• Clindamycin  Adults: 600 mg; Children: 20 mg/kg IV within 30 minutes oral,   before procedure ,   OR
• Cefazolin*   Adults: 1.0 g; Children: 25 mg/kg IM or IV within 30 minutes before procedure
  
  # Total children's dose should not exceed adult dose.

* Cephalosporins should not be used in individuals with immediate type hypersensitivity reaction (urticaria, angioedema, or anaphylaxis) to penicillins.

Adults: ampicillin 2.0 g IM/IV plus gentamicin 1.5 mg/kg (not to exceed 120 mg) within 30 min of starting the procedure.
Six hours later, ampicillin 1 g IM/IV or amoxicillin 1 g PO.
Children: ampicillin 50 mg/kg IM or IV (not to exceed 2.0 gm)   plus gentamicin 1.5 mg/kg within 30 minutes of starting the procedure.
Six hours later, ampicillin 25 mg/kg IM/IV or amoxicillin 25 mg/kg PO.

High-risk patients allergic to ampicillin/amoxicillin:   Vancomycin plus Gentamicin

Adults: vancomycin 1.0 g IV over 1-2 hours plus gentamicin 1.5 mg/kg IV/IM (not to exceed 120 mg). Complete injection/infusion within 30 minutes of starting the procedure. Children: vancomycin 20 mg/kg IV over 1-2 hours plus gentamicin 1.5 mg/kg IV/IM. Complete injection/infusion within 30 minutes of starting the procedure.

Moderate-risk patients:

Adults: amoxicillin 2.0 gm PO 1 hour before procedure, OR Ampicillin 2.0 gm IM/IV within 30 minutes of starting the procedure. Children: amoxicillin 50 mg/kg PO 1 hour before procedure, OR Ampicillin 50 mg/kg IM/IV within 30 minutes of starting the procedure.

Moderate-risk patients allergic to ampicillin/amoxicillin: Vancomycin

Adults: vancomycin 1.0 gm IV over 1-2 hours. Complete infusion within 30 minutes of starting the procedure. Children: vancomycin 20 mg/kg IV over 1-2 hours. Complete infusion within 30 minutes of starting the procedure.
# Total children's dose should not exceed adult dose.

* No second dose of vancomycin or gentamicin is recommended.

High Risk Category

• Prosthetic cardiac valves, including bioprosthetic and homograft valves
• Previous bacterial endocarditis
• Complex cyanotic congenital heart disease (e.g. 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 (e.g., rheumatic heart disease)
• Hypertrophic cardiomyopathy
• Mitral valve prolapse with valvar regurgitation and/or thickened leaflets
  

Endocarditis Prophylaxis Not Recommended

• Negligible Risk Category (No Greater Risk than the General Population)
• 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 regurgitation
• Physiologic, functional, or innocent heart murmurs
• Previous Kawasaki disease without valvar dysfunction
• Previous rheumatic fever without valvar dysfunction
• Cardiac pacemakers (intravascular and epicardial) and implanted defibrillators
  

Endocarditis Prophylaxis Recommended*

• Dental extractions
• Periodontal procedures including surgery, scaling and root planing, probing, 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/strips
• Initial placement of orthodontic bands but not brackets
• Intraligamentary local anesthetic injections
• Prophylactic cleaning of teeth or implants where bleeding is anticipated
  

Endocarditis Prophylaxis Not Recommended

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

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

Respiratory Tract

• Tonsillectomy and/or adenoidectomy
• Surgical operations that involve respiratory mucosa
• Bronchoscopy with a rigid bronchoscope

Gastrointestinal Tract*

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

Genitourinary Tract

• Prostatic surgery
• Cystoscopy
• Urethral dilation

Endocarditis Prophylaxis Not Recommended

Respiratory Tract

• Endotracheal intubation
• Bronchoscopy with a flexible bronchoscope, with or without biopsy#
• Tympanostomy tube insertion

Gastrointestinal Tract

• Transesophageal echocardiography#
• Endoscopy with or without gastrointestinal biopsy#

Genitourinary Tract

• Vaginal hysterectomy#
• Vaginal delivery#
• 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
• Implantation of cardiac pacemakers, implanted defibrillators, and coronary stents
• Incision or biopsy of surgically scrubbed skin
• Circumcision

* Prophylaxis is recommended for high-risk patients; optional for medium-risk patients.
# Prophylaxis is optional for high-risk patients.

     

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

07102000