What is the recommended antibiotic prophylaxis regimen for the prevention of infectious endocarditis before dental procedures?

Antibiotic Prophylaxis for Infectious Endocarditis Prevention Before Dental Procedures

For patients at highest risk of infective endocarditis, amoxicillin 2g orally 1 hour before dental procedures involving manipulation of gingival tissue, periapical region of teeth, or perforation of oral mucosa is the recommended prophylactic regimen. 1

High-Risk Patient Categories Requiring Prophylaxis

Antibiotic prophylaxis should only be considered for patients at highest risk for endocarditis, which includes:

• Patients with prosthetic cardiac valves or prosthetic material used for cardiac valve repair 2, 1
• Patients with previous infective endocarditis 2, 1
• Patients with congenital heart disease (CHD), specifically:
  • Unrepaired cyanotic CHD 2
  • Completely repaired congenital heart defects with prosthetic material during the first 6 months after the procedure 2
  • Repaired CHD with residual defects at or adjacent to the site of a prosthetic patch or device 2, 1

Dental Procedures Requiring Prophylaxis

Prophylaxis should only be administered for dental procedures that involve:

• Manipulation of gingival tissue 2
• Manipulation of the periapical region of teeth 2
• Perforation of the oral mucosa 2, 1

Prophylaxis is NOT recommended for:

• Local anesthetic injections in non-infected tissues 2
• Treatment of superficial caries 2
• Removal of sutures 2
• Dental X-rays 2
• Placement or adjustment of removable prosthodontic or orthodontic appliances 2
• Following the shedding of deciduous teeth 2
• Trauma to the lips and oral mucosa 2

Recommended Antibiotic Regimens

For patients NOT allergic to penicillin:

• Standard regimen: Amoxicillin 2g orally 1 hour before procedure 2, 1

For patients allergic to penicillin:

• If no history of anaphylaxis, angioedema, or urticaria:

  • Cephalexin 2g orally 1 hour before procedure 2, 1
  • OR Cefazolin or Ceftriaxone 1g IV for adults (50 mg/kg IV for children) 2

• If history of anaphylaxis, angioedema, or urticaria:

  • Clindamycin 600mg orally 1 hour before procedure 1

Rationale and Evidence for Recommendations

Recent evidence supports the association between invasive dental procedures and infective endocarditis in high-risk patients, particularly with dental extractions (OR: 11.08) and oral surgical procedures (OR: 50.77) 3. A 2024 study demonstrated that antibiotic prophylaxis significantly reduced endocarditis incidence following invasive dental procedures (OR 0.20,95% CI 0.06-0.53) 4.

The number of invasive procedures, extractions, or surgical procedures needing antibiotic prophylaxis to prevent one endocarditis case was 244,143, and 71, respectively 4. This supports the current guideline recommendations for targeted prophylaxis in high-risk patients.

Important Considerations

• Potential sources of dental sepsis should be eliminated at least 2 weeks before implantation of a prosthetic valve or other intracardiac/intravascular foreign material, unless the latter procedure is urgent 2, 1
• Maintenance of optimal oral health and hygiene is more important than prophylactic antibiotics for reducing the risk of infective endocarditis 2, 1
• Fluoroquinolones and glycopeptides are not recommended due to their unclear efficacy and potential for inducing resistance 2

Common Pitfalls to Avoid

• Administering prophylaxis to patients with lower-risk cardiac conditions (e.g., isolated mitral valve prolapse, bicuspid aortic valve without regurgitation) 2
• Prescribing prophylaxis for non-dental procedures in the absence of active infection 2, 1
• Using inappropriate antibiotic regimens or timing 1
• Neglecting the importance of regular dental care and good oral hygiene, which may be more important than prophylactic antibiotics 2, 1
• Using cephalosporins in patients with history of anaphylaxis, angioedema, or urticaria after penicillin or ampicillin intake due to cross-sensitivity 2