Do you need antibiotics (abx) after a history of Coronary Artery Bypass Graft (CABG) before dental procedures?

Antibiotic Prophylaxis After CABG for Dental Procedures

Antibiotic prophylaxis is NOT routinely recommended for patients with a history of coronary artery bypass graft (CABG) before dental procedures unless they have specific high-risk cardiac conditions. 1

High-Risk Cardiac Conditions Requiring Prophylaxis

Antibiotic prophylaxis is reasonable only for dental procedures involving manipulation of gingival tissue, periapical region of teeth, or perforation of oral mucosa in patients with:

• Prosthetic cardiac valves, including transcatheter-implanted prostheses and homografts 1
• Prosthetic material used for cardiac valve repair (annuloplasty rings, chords, clips) 1
• Previous infective endocarditis 1, 2
• Unrepaired cyanotic congenital heart disease or repaired congenital heart disease with residual shunts/valvular regurgitation at or adjacent to prosthetic material 1
• Cardiac transplant recipients with valve regurgitation due to structurally abnormal valve 1

Rationale for Current Recommendations

• The risk of developing infective endocarditis from dental procedures is extremely small, even if prophylaxis were 100% effective 1, 3
• Daily activities (brushing teeth, flossing) are more likely to cause transient bacteremia than dental procedures 1, 4
• The risk of antibiotic-associated adverse effects may exceed potential benefits 1, 3
• A history of CABG alone is not considered a high-risk condition requiring prophylaxis 1

Recommended Prophylactic Regimens (if indicated)

For patients with the high-risk conditions listed above:

• Standard regimen: Amoxicillin 2g orally 1 hour before procedure 2
• Penicillin-allergic patients: Clindamycin 600mg orally 1 hour before procedure 2
• Alternative for penicillin-allergic patients (if no history of anaphylaxis, angioedema, or urticaria): Cephalexin 2g orally 1, 2

Dental Procedures Requiring Prophylaxis (for high-risk patients only)

Prophylaxis is reasonable for procedures involving:

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

Prophylaxis is NOT recommended for:

• Local anesthetic injections in non-infected tissues 1
• Treatment of superficial caries 1
• Removal of sutures 1
• Dental X-rays 1
• Placement/adjustment of removable prosthodontic/orthodontic appliances 1

Important Considerations

• Maintenance of optimal oral health is more important than antibiotic prophylaxis for reducing infective endocarditis risk 1, 2
• Recent meta-analysis showed antibiotic prophylaxis was associated with significantly lower risk of infective endocarditis after invasive dental procedures in high-risk individuals (pooled RR, 0.41; 95% CI, 0.29-0.57) 4
• Potential sources of dental sepsis should be eliminated at least 2 weeks before implantation of a prosthetic valve or other intracardiac/intravascular foreign material 1, 2
• Despite guideline recommendations, there remains inconsistency in antibiotic prophylaxis provision throughout healthcare systems 5

Common Pitfalls to Avoid

• Prescribing antibiotics for CABG patients without other high-risk conditions 1
• Administering prophylaxis for non-dental procedures (e.g., TEE, endoscopy, colonoscopy, cystoscopy) in the absence of active infection 1
• Using inappropriate antibiotic regimens or timing (should be given 30-60 minutes before procedure) 1, 2
• Neglecting the importance of regular dental care and good oral hygiene, which are more effective than prophylaxis 1, 2