IE Prophylaxis for Tooth Extraction in Patients with Prosthetic Heart Valves
For patients with prosthetic heart valves (DVR) undergoing tooth extraction, antibiotic prophylaxis with amoxicillin 2g orally 30-60 minutes before the procedure is recommended to prevent infective endocarditis. 1, 2
High-Risk Patients Requiring Prophylaxis
Antibiotic prophylaxis should be administered to patients in the following highest-risk categories undergoing tooth extraction: 1
- Prosthetic cardiac valve or prosthetic material used for cardiac valve repair (including your DVR patient) 1, 2
- Previous infective endocarditis 1, 2
- Unrepaired cyanotic congenital heart disease 1, 2
- Completely repaired congenital heart disease with prosthetic material during the first 6 months after procedure 1, 2
- Repaired congenital heart disease with residual defects at or adjacent to prosthetic patch/device 1, 2
- Cardiac transplant recipients who develop cardiac valvulopathy 1, 3
Prophylaxis is NOT recommended for other forms of valvular or congenital heart disease. 1
Standard Antibiotic Regimen
For patients who can tolerate penicillin:
- Amoxicillin 2g orally as a single dose, 30-60 minutes before the procedure 1, 2
- For children: Amoxicillin 50 mg/kg orally (maximum 2g) 2
- Only a single pre-procedure dose is indicated; post-procedure antibiotics are NOT recommended 2
For penicillin-allergic patients:
- First choice: Clindamycin 600mg orally, 30-60 minutes before the procedure 1, 3, 2
- Alternative: Azithromycin or clarithromycin 500mg orally 3, 2
- Alternative: Cephalexin 2g orally or IV ONLY if no history of anaphylaxis, angioedema, or urticaria with penicillin 1, 3, 2
Critical caveat: Cephalosporins must NEVER be used in patients with history of anaphylaxis, angioedema, or urticaria after penicillin/ampicillin due to cross-sensitivity. 1, 3
Dental Procedures Requiring Prophylaxis
Prophylaxis is indicated for: 1, 2
- Tooth extraction (your specific scenario)
- Manipulation of gingival tissue
- Manipulation of periapical region of teeth
- Perforation of oral mucosa
- Periodontal surgery
Procedures NOT requiring prophylaxis:
- Local anesthetic injections in non-infected tissue 1
- Removal of sutures 1
- Dental X-rays 1
- Placement/adjustment of removable prosthodontic or orthodontic appliances 1
- Treatment of superficial caries 1
- Shedding of deciduous teeth 1
Evidence Supporting This Approach
The most recent high-quality evidence from a 2022 case-crossover study of nearly 8 million U.S. subjects demonstrated a significant temporal association between invasive dental procedures and subsequent IE in high-risk individuals (OR: 2.00), with this relationship strongest for dental extractions (OR: 11.08). 4 Critically, antibiotic prophylaxis was associated with a significant reduction in IE incidence following invasive dental procedures (OR: 0.49), particularly for extractions (OR: 0.13). 4 This provides the strongest contemporary evidence supporting prophylaxis recommendations.
However, a 2022 Cochrane review found only very low certainty evidence from one case-control study showing no significant effect of penicillin prophylaxis, highlighting the ongoing controversy. 5 Despite this, the consistent guideline recommendations from the European Society of Cardiology (2015) 1 and American Heart Association (2007) 1 support prophylaxis in highest-risk patients, prioritizing the potential mortality and morbidity reduction even with limited direct evidence.
Important Clinical Considerations
- Eliminate potential sources of dental sepsis at least 2 weeks before implantation of prosthetic valve or intracardiac/intravascular foreign material, unless urgent. 1, 3
- For patients already on long-term antibiotic therapy, select an antibiotic from a different class rather than increasing the current antibiotic dosage. 2
- Maintaining optimal oral hygiene and regular dental review is critically important for IE prevention, potentially more so than single-dose prophylaxis. 1, 3
- Fluoroquinolones and glycopeptides are NOT recommended due to unclear efficacy and potential resistance induction. 1