Prophylaxis For Bacterial Endocarditis

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Introduction

• Guidelines 2007 recommend prophylaxis only in patients at highest risk for an adverse outcome from endocarditis. These include:
• patients with prosthetic cardiac valves

• bioprosthetic valves
• mechanical valves

• heart transplant recipients who develop cardiac valvulopathy
• history of infective endocarditis
• some patients with congenital heart disease ( CHD)

• unrepaired cyanotic CHD
• up to 6 months after a repair with prosthetic material or device
• repaired CHD with residual defects
  

• In these patients, the guidelines recommend prophylaxis before:

• dental procedures involving the gingival tissue or the periapical region of the teeth or that perforate the oral mucosa
• procedures on the respiratory tract

• tonsillectomy &/or adenoidectomy
• surgical operations that involve the respiratory mucosa
• bronchoscopy with a rigid bronchoscope

• procedures on infected skin, skin structures, or musculoskeletal tissue.
  

• Antibiotic prophylaxis is NOT recommended for:

• genitourinary procedures
• gastrointestinal tract procedures
• intubation or bronchoscopy
• cardiac catheterization
• incision of clean skin
• the following cardiac conditions

• isolated secundum atrial septal defect
• repaired atrial septal defect
• repaired ventricular septal defect
• repaired persistent patent ductus arteriosus
• previous CABG
• mitral valve prolase without regurgitation or lealet thickening [2]; mitral valve prolapse. [3,4]
• cardiac pacemakers & implanted defibrillators

• cosmetic implants [5]
  

• Implementation of 2007 guidelines have not increased incidence of endocarditis [6]
  
• Prior evidence supporting prophylaxis was anecdotal; consensus was that it seemed like a good idea. New emphasis on oral hygiene.
  
• It is the primary care responsibility to determine if patient has one of above 4 qualifying conditions for antibiotic prophylaxis. It is the dentist's responsibility, not the primary care physician's responsibility to determine whether the upcoming dental procedure warrants prophylaxis [4].
  
• Antibiotics 1 hour prior to procedure (one dose)

• amoxicillin 2 g PO
• clarithromycin 500 PO
• azithromycin 500 mg PO
• Ceftriaxone 1 g IM or IV
• Cefazolin 1 g IM or IV
• clindamycin 600 mg PO or IV
  

• recommends a single dose of antibiotic for skin surgery patients at high risk for severe adverse endocarditis events, only if the tissue is clearly infected at the time of surgery. Coverage for:

• Staphylococcus aureus
• beta-hemolytic streptococcus
  

• Antibiotics given once 30-60 minutes prior to the procedure

• dicloxacillin 500 mg PO
• clindamycin 600 mg PO or IV

More General Terms

• antibiotic prophylaxis

References

1. Dajani AS et al Prevention of bacterial endocarditis. Recommendations by the American Heart Association. JAMA 1990, 264:2919 PMID: [1]
2. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, American College of Physicians, Philadelphia 1998, 2006
3. Wilson W et al, Prevention of Infective Endocarditis. Guidelines From the American Heart Association... Circulation 2007, April 19 published online <PubMed> PMID: [2] <Internet> [3]
   - J Am Dent Assoc. 2007 Jun;138(6):739-60. PMID: [4]
   - Prescriber's Letter 14(5): 2007 Patient Handout: Do I still need an antibiotic before I visit the dentist? Chart: summary of AHA guidelines for endocarditis prophylaxis AHA statement Detail-Document#: [5] (subscription needed) [6]
4. Wilson W et al, Prevention of infective endocardititis: guidelines from the American Heart Association Rheumatic Fever, Endocarditis and Kawasaki Disease Committe, Council on Cardiovascular Disease in the Young, and Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. J AM Dent Assoc 2008, 139:3S PMID: [7]
5. Prescriber's Letter 18(4): 2011 COMMENTARY: Do Patients with Cosmetic Implants Need Antibiotic Prophylaxis for Dental Procedures? PATIENT HANDOUT: Do I Need an Antibiotic Before a Dental Visit? Detail-Document#: [8] (subscription needed) [9]
6. Thornhill MH et al. Impact of the NICE guideline recommending cessation of antibiotic prophylaxis for prevention of infective endocarditis: Before and after study. BMJ 2011 May 3; 342:d2392. PMID: [10]
7. National Guideline Clearinghouse
   - Guideline on antibiotic prophylaxis for dental patients at risk for infection. American Academy of Pediatric Dentistry ngc-guideline: [11]
   - Prophylaxis against infective endocarditis. Antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures. National Institute for Health and Clinical Excellence (NICE) ngc-guideline: [12]

antibiotic prophylaxis for bacterial endocarditis