What is the recommended dose of amoxicillin (Amoxicillin) for patients after Transcatheter Aortic Valve Replacement (TAVR) prior to dental treatment?

Amoxicillin Dosing for TAVR Patients Before Dental Procedures

For patients with transcatheter aortic valve replacement (TAVR) undergoing dental procedures that involve manipulation of gingival tissue, periapical region, or oral mucosa perforation, administer a single dose of 2 grams of amoxicillin orally 30-60 minutes before the procedure. 1

Rationale for Prophylaxis in TAVR Patients

TAVR patients are at the highest risk for infective endocarditis (IE) and require antibiotic prophylaxis. The 2017 AHA/ACC guidelines specifically identify prosthetic cardiac valves, including transcatheter-implanted prostheses, as conditions warranting prophylaxis due to the high mortality risk (75% at 1 year) associated with IE after TAVR. 1

The 2017 ACC Expert Consensus explicitly recommends that TAVR patients follow AHA/ACC guidelines for antibiotic prophylaxis and maintain optimal dental hygiene as part of long-term management. 1

Standard Dosing Regimen

For Patients Who Can Take Oral Medications:

• Amoxicillin 2 grams orally as a single dose, administered 30-60 minutes before the dental procedure 2, 3
• This is the preferred first-line regimen for patients without penicillin allergy 3

For Patients Unable to Take Oral Medications:

• Ampicillin 2 grams IM or IV within 30 minutes before the procedure 2, 3
• Note: Avoid IM injections in anticoagulated patients (common in TAVR population); use IV route instead 2, 3

For Patients with Penicillin Allergy:

• Clindamycin 600 mg orally 1 hour before the procedure 2, 3, 4
• Alternative options: Azithromycin or clarithromycin 500 mg orally 3
• Do not use cephalosporins in patients with immediate-type hypersensitivity reactions to penicillin 3

Critical Implementation Points

A single preoperative dose is sufficient—do not prescribe postoperative antibiotics. Postoperative doses provide no additional benefit and only increase the risk of adverse events, including allergic reactions. 2, 3, 5

For Patients Already on Chronic Antibiotic Therapy:

• Select an antibiotic from a different class rather than increasing the dose of the current antibiotic 2, 3
• This prevents development of resistant organisms at the prophylaxis site

Special Considerations for TAVR Patients:

• Many TAVR patients are on anticoagulation (aspirin, clopidogrel, or warfarin per ACC guidelines) 1
• For anticoagulated patients, use oral regimens whenever possible; avoid IM injections 2, 3
• The standard 2-gram amoxicillin dose does not require adjustment for renal function, even in dialysis patients 4

Dental Procedures Requiring Prophylaxis

Prophylaxis is indicated for procedures involving: 2, 3

• Manipulation of gingival tissue (scaling, root planing)
• Manipulation of periapical region (endodontic treatment)
• Perforation of oral mucosa
• Dental extractions
• Dental implant placement

Prophylaxis is NOT required for: 2, 3

• Routine anesthetic injections through noninfected tissue
• Taking dental radiographs
• Placement of orthodontic brackets

Common Pitfalls to Avoid

• Do not prescribe prophylaxis for all dental patients—restrict to highest-risk cardiac conditions only (TAVR qualifies) 3
• Do not prescribe prolonged antibiotic courses—a single preoperative dose is sufficient and safer 3, 5
• Do not forget that maintaining good oral hygiene is more important than prophylaxis for preventing endocarditis in the long term 2, 3
• Remember that most IE cases result from random bacteremia from daily activities (brushing teeth, chewing) rather than dental procedures, making optimal daily oral care paramount 3