Infective endocarditis prophylaxis

1. Prevention of Infective
Endocarditis
Guidelines From the American Heart
Association
Circulation: April 19, 2007
http://ahajournals.org

2. Summary of AHA-Recommended Antibiotic Regimens From 1955 to
1997 for Dental/Respiratory Tract Procedures
•Year Primary Regimens for Dental Procedures
•1955 Aqueous penicillin 600 000 U and procaine penicillin
600 000 U in oil containing 2% aluminum monostearate
administered IM 30 minutes before the operative procedure
•1957 For 2 days before surgery, penicillin 200 000 to
250000 U by mouth 4 times per day. On day of surgery,
aqueous penicillin 600 000 U with procaine penicillin
600000 U IM 30 to 60 minutes before surgery. For 2 days
after, 200000 to 250000 U by mouth 4 times per day.
•1960 Step I: prophylaxis 2 days before surgery with procaine
penicillin 600 000 U IM on each day
Step II: day of surgery: procaine penicillin 600 000 U
IM supplemented by crystalline penicillin 600 000 U
IM 1 hour before surgical procedure
Step III: for 2 days after surgery: procaine penicillin
600000 U IM each day

3. Continued….
•1965 Day of procedure: procaine penicillin 600 000 U,
supplemented by crystalline penicillin 600 000 U IM 1
to 2 hours before the procedure For 2 days after
procedure: procaine penicillin 600 000 U IM each day
•1972 Procaine penicillin G 600 000 U mixed with crystalline
penicillin G 200 000 U IM 1 hour before procedure and
once daily for the 2 days after the procedure
•1977 Aqueous crystalline penicillin G (1 000 000 U IM)
mixed with procaine penicillin G (600 000 U IM) 30
minutes to 1 hour before procedure and then penicillin
V 500 mg orally every 6 hours for 8 doses.
•1984 Penicillin V 2 g orally 1 hour before, then 1 g 6 hours
after initial dose
•1990 Amoxicillin 3 g orally 1 hour before procedure, then
1.5 g 6 hours after initial dose
•1997 Amoxicillin 2 g orally 1 hour before procedure

4. Reasons for Revision of the IE
Prophylaxis Guidelines
•IE is much more likely to results from frequent exposure to
random bacteremias associated with daily activities than
from bacteremia caused by a dental, GI tract, or GU tract
procedure.
•Prophylaxis may prevent an exceedingly small number of
cases of IE, if any, in individuals who undergo a dental, GI
tract, or GU tract procedure.
•The risk of antibiotic-associated adverse events exceeds
the benefit, if any, from prophylactic antibiotic therapy.
•Maintenance of optimal oral health and hygiene may
reduce the incidence of bacteremia from daily activities
and is more important than prophylactic antibiotics for a
dental procedure to reduce the risk of IE.

5. Summary of Changes From
the 1997 Guidelines
•A significant reduction in the numbers and types
of cardiac conditions for which antibiotic
prophylaxis is recommended (only those with the
most serious adverse outcomes of IE)
•A significant increase in the types of dental
procedures recommended for prophylaxis in at-
risk individuals (almost all dental procedures)
•A minor modification in the timing of antibiotic
administration (30-60 minutes prior)

6. Continued..
•Respiratory tract procedures
•Antibiotic prophylaxis may be considered for patients
who undergo an invasive procedure of the respiratory
tract that involves incision or biopsy of the respiratory
mucosa, such as tonsillectomy and adenoidectomy
•GI or GU procedures:
•The administration of prophylactic antibiotics solely to
prevent endocarditis is not recommended for patients
who undergo GU or GI tract procedures, including
diagnostic esophagogastroduodenoscopy or
colonoscopy

7. Cardiac Conditions for Which Prophylaxis of IE is
Recommended
•Prosthetic cardiac valve
•Previous infective endocarditis
•Congenital heart disease (CHD) [except for the conditions listed below,
Antibiotic prophylaxis is no longer recommended for any other form of CHD]
•Unrepaired cyanotic CHD, including those with palliative shunts and
conduits
•Completely repaired CHD with prosthetic material or device either by
surgery or catheter intervention during first 6 months after procedure
(to allow time for endothelial covering of the material)
•Repaired CHD with residual defects at the site or adjacent to the site of
a prosthetic patch or prosthetic device which inhibits endothelialization
•Cardiac transplantation recipients who develop cardiac
valvulopathy

8. Conditions for which prophylaxis is no longer
recommended
(1997 moderate risk conditions)
•Mitral valve prolapse with regurgitation
•Rheumatic heart disease and other types of
acquired valvular heart disease (e.g. SLE)
•Ventricular septal defect
•Atrial septal defect
•Hypertrophic cardiomyopathy

9. Dental Procedures for Which Endocarditis
Prophylaxis is Recommended
•All dental procedures that involve
manipulation of gingival tissue or the
periapical region of teeth or perforation of the
oral mucosa
•Except the following:
•Routine anesthetic injections through non-infected tissue
•Taking dental radiographs
•Placement of removable prosthodontic or orthodontic appliances
•Adjustment of orthodontic appliances
•Shedding of deciduous teeth and bleeding from trauma to the lips
or oral mucosa

10. Regimens for a Dental Procedure
50 mg/kg IM or IV2 gm IM or IV
1 gm IM or IV
Ampicillin or cephazolin or
cephtriaxone
Unable to take oral
medication
50 mg/kg IM or IV
20 mg/kg IM or IV
1 gm IM or IV
600 mg IM or IV
Cephazolinn or
cephtriaxone
Clindamycin phosphate
Allergic to
penicillins or
ampicillin and
unable to take oral
medication
50 mg/kg
20 mg/kg
15 mg/kg
15 mg/kg
2 gm
600 mg
500 mg
500 mg
Cephalexin or
Clindamycin or
Azithromycin or
Clarithromycin
Allergic to
penicillin or
ampicillin
Oral
50 mg/kg2 gm
ChildrenAdultsAmoxicillinOral
Regimen-Single dose 30-60
minutes before procedure
AgentSituation

11. Forgot to give antibiotics to the
patient
•If the dosage of antibiotic is inadvertently
not administered before the procedure, the
dosage may be administered up to 2 hours
after the procedure. However, the
administration of the dosage after the
procedure should be considered only when
the patient did not receive the pre-procedure
dose

12. For patients already taking penicillin or
amoxicillin (e.g. prevention of acute
Rheumatic fever, treatment of sinusitis)
•In such cases , due to the likelihood of the
presence of penicillin-resistant bacteria in the oral
flora, the provider should select either
clindamycin, azithromycin, or clarithromycin for
IE prophylaxis for a dental procedure

13. Summary
•Bacteremia resulting from daily activities is much more likely
to cause IE than bacteremia associated with a dental
procedure.
•Only an extremely small number of cases of IE might be
prevented by antibiotic prophylaxis even if prophylaxis is
100% effective.
•Antibiotic prophylaxis is not recommended based solely on an
increased lifetime risk of acquisition of IE.
•Antibiotic prophylaxis is no longer recommended for any
other form of CHD and other Valvular heart disease except as
mentioned above

14. •Antibiotic prophylaxis is reasonable for all dental
procedures that involve manipulation of gingival
tissues or periapical region of teeth or perforation of
oral mucosa only for patients with underlying high
risk cardiac conditions.
•Antibiotic prophylaxis is reasonable for procedures
on respiratory tract or infected skin, skin structures,
or musculoskeletal tissue only for patients with
underlying high risk cardiac conditions.
•Antibiotic prophylaxis solely to prevent IE is not
recommended for GU or GI tract procedures.

15. Thank You