Is antibiotic prophylaxis still recommended after having a history (H/O) of aortic valve replacement?

Antibiotic Prophylaxis After Aortic Valve Replacement

Antibiotic prophylaxis is recommended before dental procedures for patients with a history of aortic valve replacement, as they fall into the highest risk category for infective endocarditis with prosthetic cardiac valves. 1, 2

Indications for Antibiotic Prophylaxis

Antibiotic prophylaxis is reasonable for patients with aortic valve replacement before dental procedures that involve:

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

This recommendation applies to patients with:

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

Rationale for Recommendation

• Patients with prosthetic valves have the highest risk of developing infective endocarditis 1, 2
• Infective endocarditis after transcatheter aortic valve implantation occurs at rates equal to or exceeding those associated with surgical aortic valve replacement 1
• Prosthetic valve endocarditis is associated with a high one-year mortality rate of approximately 75% 1, 2
• Case reports have documented severe prosthetic valve-related endocarditis following dental procedures performed without antibiotic prophylaxis 3

Recommended Antibiotic Regimens

For patients not allergic to penicillin:

• Amoxicillin 2g orally 1 hour before procedure (adults) 2, 4
• Amoxicillin 50 mg/kg orally 1 hour before procedure (children) 2

For patients allergic to penicillin:

• Clindamycin 600mg orally 1 hour before procedure (adults) 2, 4
• Clindamycin 20 mg/kg orally 1 hour before procedure (children) 2
• Alternative: Cephalexin 2g orally (adults) or 50 mg/kg orally (children) for patients without history of anaphylaxis, angioedema, or urticaria 2

Non-Dental Procedures

• Antibiotic prophylaxis is NOT recommended for non-dental procedures (e.g., TEE, esophagogastroduodenoscopy, colonoscopy, or cystoscopy) in the absence of active infection 1, 5
• The rate of transient bacteremia during endoscopy is relatively low (2-5%), and the organisms typically identified are unlikely to cause infective endocarditis 1, 5
• For genitourinary procedures, there is no strong evidence correlating these procedures with the development of prosthetic valve endocarditis 6

Important Considerations

• Maintaining optimal oral health through regular professional dental care and good oral hygiene is critically important for reducing IE risk 2, 5
• Potential sources of dental sepsis should be eliminated at least 2 weeks before implantation of a prosthetic valve 2
• Daily activities such as brushing teeth and flossing cause more frequent bacteremia than many procedures 5
• The indiscriminate use of antibiotics can lead to development of resistant organisms, Clostridium difficile colitis, unnecessary expense, and drug toxicity 1, 5

Common Pitfalls to Avoid

• Failing to provide prophylaxis for patients with aortic valve replacement undergoing high-risk dental procedures 2
• Providing unnecessary prophylaxis for low-risk dental procedures or non-dental procedures in the absence of active infection 2, 5
• Neglecting the importance of regular dental care and good oral hygiene in preventing IE 2, 5
• Using fluoroquinolones or glycopeptides for prophylaxis due to unclear efficacy and potential induction of resistance 2