What antibiotics are recommended before dental cleaning for patients at high risk of infective endocarditis?

Antibiotic Prophylaxis Before Dental Cleaning for High-Risk Patients

For patients at highest risk of infective endocarditis undergoing dental cleaning, administer amoxicillin 2g orally as a single dose 30-60 minutes before the procedure. 1, 2, 3

Who Requires Prophylaxis

Antibiotic prophylaxis is recommended only for patients with the following high-risk cardiac conditions: 1, 2

• Prosthetic cardiac valves or prosthetic material used for cardiac valve repair (including transcatheter valves and annuloplasty rings) 1, 2, 3
• Previous infective endocarditis 1, 2
• Congenital heart disease (CHD) including:
  • Unrepaired cyanotic CHD, including palliative shunts and conduits 1
  • Completely repaired CHD with prosthetic material or device during the first 6 months after the procedure 1, 2
  • Repaired CHD with residual defects at or adjacent to the site of a prosthetic patch or device 1, 2
• Cardiac transplant recipients who develop cardiac valvulopathy 1, 2

Standard Antibiotic Regimens

For Patients Who Can Take Oral Medication (No Penicillin Allergy):

• Amoxicillin 2g orally (50 mg/kg in children, not to exceed adult dose) given as a single dose 30-60 minutes before the procedure 1, 2, 3

For Patients Unable to Take Oral Medication (No Penicillin Allergy):

• Ampicillin 2g IM or IV (50 mg/kg in children) 30-60 minutes before the procedure 1, 3
• OR Cefazolin or ceftriaxone 1g IM or IV (50 mg/kg in children) 30-60 minutes before the procedure 1

For Penicillin-Allergic Patients (Oral):

• Clindamycin 600mg orally (20 mg/kg in children) 30-60 minutes before the procedure 1, 2, 3
• OR Azithromycin or clarithromycin 500mg orally (15 mg/kg in children) 30-60 minutes before the procedure 1, 3
• OR Cephalexin 2g orally (50 mg/kg in children) if no history of anaphylaxis, angioedema, or urticaria with penicillin 1, 2

For Penicillin-Allergic Patients (Unable to Take Oral Medication):

• Clindamycin 600mg IM or IV (20 mg/kg in children) 30-60 minutes before the procedure 1, 3
• OR Cefazolin or ceftriaxone 1g IM or IV (50 mg/kg in children) only if no history of anaphylaxis, angioedema, or urticaria with penicillin 1, 2

Critical Special Situations

Patients Already on Chronic Antibiotics:

If the patient is already taking penicillin or amoxicillin chronically (e.g., for rheumatic fever prophylaxis), do not use amoxicillin for endocarditis prophylaxis because oral flora may be resistant. 1 Instead:

• Select clindamycin, azithromycin, or clarithromycin 1
• Avoid cephalosporins due to possible cross-resistance 1
• Ideally, delay the dental procedure at least 10 days after completing the chronic antibiotic to allow normal oral flora to reestablish 1

Patients on Anticoagulation:

• Avoid intramuscular injections 1
• Use oral regimens whenever possible 1
• Use intravenous antibiotics only if the patient cannot tolerate or absorb oral medications 1

Patients Receiving Parenteral Antibiotics for Active Endocarditis:

• Continue the parenteral antibiotic therapy for endocarditis and adjust timing to administer 30-60 minutes before the dental procedure 1
• The high doses used for treatment overcome any low-level resistance in oral flora 1

Important Context and Caveats

The evidence base for antibiotic prophylaxis is weak. No randomized controlled trials have demonstrated that prophylaxis prevents endocarditis, and Cochrane reviews found only very low-certainty evidence from a single case-control study showing no significant protective effect. 4, 5 However, guidelines continue to recommend prophylaxis for the highest-risk patients because the mortality and morbidity of endocarditis in these populations is so severe that even a potential benefit justifies the intervention. 1, 2

Daily oral hygiene is likely more important than prophylaxis. Most cases of oral bacteria-related endocarditis probably result from cumulative bacteremia from daily activities like tooth brushing and chewing rather than from discrete dental procedures. 1, 4, 6 Maintaining optimal oral health and regular dental care reduces overall risk more than single-dose prophylaxis. 1, 2

Routine dental cleaning qualifies as a high-risk procedure because it involves manipulation of gingival tissue, which causes bacteremia. 1, 2

Most patients do NOT need prophylaxis. The 2007 American Heart Association guidelines dramatically narrowed the indications compared to earlier recommendations, restricting prophylaxis to only the highest-risk cardiac conditions. 1 Patients with conditions like mitral valve prolapse, bicuspid aortic valve, or most other forms of valvular disease do not require prophylaxis. 1