What antibiotic prophylaxis is recommended for patients who have undergone Transcatheter Aortic Valve Replacement (TAVR) before a dental procedure?

Antibiotic Prophylaxis for Dental Procedures After TAVR

For patients who have undergone Transcatheter Aortic Valve Replacement (TAVR), antibiotic prophylaxis with amoxicillin 2g orally (or clindamycin 600mg orally if penicillin-allergic) is recommended before dental procedures that involve manipulation of gingival tissue, manipulation of the periapical region of teeth, or perforation of the oral mucosa. 1

Rationale for Prophylaxis in TAVR Patients

TAVR patients fall into the highest risk category for infective endocarditis (IE) requiring prophylaxis for several important reasons:

1. The 2017 AHA/ACC guidelines specifically identify patients with "prosthetic cardiac valves, including transcatheter-implanted prostheses" as being at high risk for IE and adverse outcomes 1

2. IE has been reported to occur after TAVR at rates equal to or exceeding those associated with surgical aortic valve replacement and is associated with a high 1-year mortality rate of 75% 1

3. The main targets for antibiotic prophylaxis in these high-risk patients are oral streptococci, which commonly enter the bloodstream during dental procedures 1

Recommended Antibiotic Regimens

For dental procedures requiring prophylaxis:

Standard regimen (no penicillin allergy):

• Amoxicillin 2g orally 30-60 minutes before procedure 1

For patients allergic to penicillin:

• Clindamycin 600mg orally 30-60 minutes before procedure 1

Alternative regimens (if needed):

• Cephalexin 2g orally (if no history of anaphylaxis, angioedema, or urticaria with penicillin)
• IV options are available if oral administration is not possible 1

Dental Procedures Requiring Prophylaxis

Prophylaxis should be administered for procedures that involve:

• Manipulation of gingival tissue
• Manipulation of the periapical region of teeth
• Perforation of oral mucosa 1

Dental Procedures NOT Requiring Prophylaxis

Antibiotic prophylaxis is NOT recommended for:

• Local anesthetic injections in non-infected tissues
• Treatment of superficial caries
• Removal of sutures
• Dental X-rays
• Placement or adjustment of removable prosthodontic/orthodontic appliances
• Following shedding of deciduous teeth
• Trauma to lips or oral mucosa 1

Important Clinical Considerations

1. Evidence limitations: Despite widespread recommendations for prophylaxis in high-risk patients, a 2022 Cochrane review found no clear evidence about whether antibiotic prophylaxis is effective or ineffective against bacterial endocarditis 2

2. Risk vs. benefit: The consensus among experts is that antibiotic prophylaxis is reasonable for the subset of patients at highest risk of developing IE and experiencing adverse outcomes from IE, which includes TAVR patients 1

3. Timing: Administer prophylactic antibiotics 30-60 minutes before the dental procedure 1

4. Duration: Single-dose prophylaxis is sufficient; extended courses are not recommended 1

5. Antibiotic resistance concerns: Fluoroquinolones and glycopeptides are not recommended due to unclear efficacy and potential induction of resistance 1

Special Situations

1. Recent antibiotic use: If the patient has received antibiotics for other purposes, consider using an alternative antibiotic class for prophylaxis to avoid potential resistance issues 1

2. Patients on anticoagulants: Avoid intramuscular injections; use oral or IV routes 1

3. Multiple dental visits: For patients requiring multiple dental visits, it is preferable to allow at least 10 days between appointments requiring prophylaxis to allow normal oral flora to be reestablished 1

By following these guidelines, clinicians can provide appropriate antibiotic prophylaxis for TAVR patients undergoing dental procedures to minimize the risk of potentially life-threatening infective endocarditis.