What is the recommended long-term prophylaxis against infectious endocarditis for patients with prosthetic valves?

Long-Term Prophylaxis Against Infectious Endocarditis for Patients with Prosthetic Valves

Antibiotic prophylaxis is reasonable before dental procedures that involve manipulation of gingival tissue, manipulation of the periapical region of teeth, or perforation of the oral mucosa in patients with prosthetic cardiac valves, including transcatheter-implanted prostheses. 1, 2

High-Risk Patient Groups Requiring Prophylaxis

Patients with the following conditions are at highest risk for adverse outcomes from infective endocarditis (IE) and should receive prophylaxis:

• Patients with prosthetic cardiac valves, including transcatheter-implanted prostheses and homografts 1, 2
• Patients with prosthetic material used for cardiac valve repair, such as annuloplasty rings and chords 1, 2
• Patients with previous IE 1
• Patients with unrepaired cyanotic congenital heart disease or repaired congenital heart disease with residual shunts or valvular regurgitation at or adjacent to the site of a prosthetic patch or device 1
• Cardiac transplant recipients with valve regurgitation due to a structurally abnormal valve 1, 2

Dental Procedures Requiring Prophylaxis

Prophylaxis is recommended only for dental procedures that involve:

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

Prophylaxis is NOT recommended for:

• Local anesthetic injections in non-infected tissues 1, 2
• Treatment of superficial caries 1, 2
• Removal of sutures 1, 2
• Dental X-rays 1, 2
• Placement or adjustment of removable prosthodontic or orthodontic appliances 1, 2

Recommended Antibiotic Regimens

For patients not allergic to penicillin:

• Amoxicillin or ampicillin: 2 g orally 30-60 minutes before procedure (adults); 50 mg/kg orally for children 1

For patients allergic to penicillin:

• Clindamycin: 600 mg orally 30-60 minutes before procedure (adults); 20 mg/kg orally for children 1
• Alternative: Azithromycin or clarithromycin: 500 mg orally (adults); 15 mg/kg orally for children 1

For patients unable to take oral medications:

• Ampicillin: 2 g IV or IM 30 minutes before procedure (adults); 50 mg/kg IV or IM for children 1
• If allergic to penicillin: Clindamycin 600 mg IV (adults); 20 mg/kg IV for children 1

Non-Dental Procedures

Antibiotic prophylaxis is NOT recommended for:

• Respiratory tract procedures, including bronchoscopy or laryngoscopy 1
• Gastrointestinal procedures such as gastroscopy or colonoscopy 1
• Genitourinary procedures 1
• Dermatological or musculoskeletal procedures 1
• Transesophageal echocardiography 1

Special Considerations for Prosthetic Valve Patients

• Potential sources of dental sepsis should be eliminated at least 2 weeks before implantation of a prosthetic valve, unless the procedure is urgent 1, 2
• Perioperative antibiotic prophylaxis should be considered during valve implantation due to increased risk of infection 1
• Prophylaxis should be started immediately before the procedure, repeated if the procedure is prolonged, and terminated 48 hours afterward 1
• The most frequent microorganisms causing early (<1 year after surgery) prosthetic valve infections are coagulase-negative staphylococci and S. aureus 1, 3

Importance of Oral Hygiene

• Good oral hygiene and regular dental review are critically important for reducing IE risk 1, 2
• Poor oral hygiene and periodontal disease, rather than dental procedures, are likely responsible for the majority of IE cases originating from the mouth 1, 2
• Regular professional dental care is strongly recommended for all patients with prosthetic valves 2, 4

Common Pitfalls to Avoid

• Failing to provide prophylaxis for high-risk patients undergoing high-risk dental procedures 2
• Providing unnecessary prophylaxis for low-risk dental procedures or non-dental procedures in the absence of active infection 1, 2
• Neglecting the importance of regular dental care and good oral hygiene in preventing IE 2, 4
• Using inappropriate antibiotic regimens that don't target the most common oral pathogens 2
• Using fluoroquinolones or glycopeptides for prophylaxis due to unclear efficacy and potential induction of resistance 2

Despite the long-standing practice of antibiotic prophylaxis, it's important to note that there is limited evidence from randomized controlled trials demonstrating its efficacy in preventing IE 5. However, given the high mortality associated with prosthetic valve endocarditis, the current guidelines still recommend prophylaxis for this high-risk group 1, 2.