What antibiotic prophylaxis is recommended for patients with high-risk conditions, such as prosthetic heart valves, congenital heart disease, or a history of endocarditis, undergoing dental procedures that may cause bleeding?

Endocarditis Prophylaxis During Dental Procedures

Antibiotic prophylaxis should be considered (Class IIa recommendation) for patients with prosthetic heart valves, previous infective endocarditis, unrepaired cyanotic congenital heart disease, or cardiac transplant valvulopathy who undergo dental procedures involving manipulation of gingival tissue or perforation of the oral mucosa. 1

High-Risk Cardiac Conditions Requiring Prophylaxis

The following patients warrant antibiotic prophylaxis before high-risk dental procedures:

• Prosthetic cardiac valves or prosthetic material used for valve repair (including transcatheter valves and annuloplasty rings) 1, 2
• Previous history of infective endocarditis 1, 2
• Unrepaired cyanotic congenital heart disease, including palliative shunts and conduits 1, 2
• Completely repaired congenital heart defects with prosthetic material or device during the first 6 months after the procedure 1, 2
• Repaired congenital heart disease with residual defects at or adjacent to prosthetic patches or devices (which inhibit endothelialization) 1, 2
• Cardiac transplant recipients with valve regurgitation due to structurally abnormal valves 1

Important Exclusions

Prophylaxis is not recommended for patients with innocent murmurs, mitral valve prolapse (even with regurgitation), bicuspid aortic valves without stenosis, acquired valvular dysfunction, hypertrophic cardiomyopathy, or secundum atrial septal defects. 1 These conditions were removed from prophylaxis recommendations in 2007 because the risk of adverse antibiotic effects exceeds any potential benefit. 1

Dental Procedures Requiring Prophylaxis

Prophylaxis should be considered for dental procedures that involve:

• Manipulation of gingival tissue 1, 2
• Manipulation of the periapical region of teeth (including root canal procedures) 1, 2
• Perforation of the oral mucosa (including scaling) 1, 2

Dental Procedures NOT Requiring Prophylaxis

The following procedures do not require prophylaxis:

• Local anesthetic injections in non-infected tissue 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
• Shedding of deciduous teeth 1, 2
• Trauma to lips and oral mucosa 1, 2

Recommended Antibiotic Regimens

Standard Regimen (No Penicillin Allergy)

Amoxicillin 2 g orally (adults) or 50 mg/kg orally (children, not to exceed adult dose), given 30-60 minutes before the procedure 1, 2, 3

Unable to Take Oral Medication (No Penicillin Allergy)

• Ampicillin 2 g IV/IM (adults) or 50 mg/kg IV/IM (children) 1, 2, 3
• Alternative: Cefazolin or ceftriaxone 1 g IV/IM (adults) or 50 mg/kg IV/IM (children) 1, 2

Penicillin Allergy (Oral Administration)

• Cephalexin 2 g orally (adults) or 50 mg/kg orally (children) 1, 2
• Clindamycin 600 mg orally (adults) or 20 mg/kg orally (children) 1, 2, 3
• Azithromycin or clarithromycin 500 mg orally (adults) or 15 mg/kg orally (children) 1, 2

Penicillin Allergy (Unable to Take Oral Medication)

Clindamycin 600 mg IV (adults) or 20 mg/kg IV (children) 1, 3

Critical Caveat for Cephalosporins

Cephalosporins should NOT be used in patients with a history of anaphylaxis, angioedema, or urticaria after penicillin or ampicillin due to cross-reactivity. 1, 2 In these cases, use clindamycin instead.

Non-Dental Procedures: Prophylaxis NOT Recommended

Antibiotic prophylaxis is NOT recommended for the following procedures, even in high-risk patients:

• Gastrointestinal procedures (gastroscopy, colonoscopy, esophagogastroduodenoscopy) 1, 4, 3
• Genitourinary procedures (cystoscopy, vaginal or caesarean delivery) 1, 3
• Respiratory tract procedures (bronchoscopy, laryngoscopy, transnasal or endotracheal intubation) 1, 3
• Transesophageal echocardiography 1, 3
• Diagnostic cardiac catheterization 2, 3

The rationale is that infective endocarditis from these procedures is exceedingly rare, and the risk of antibiotic-associated adverse effects exceeds any potential benefit. 4, 3 The exception is when an active infection is present at the time of the procedure, in which case antibiotics are given to treat the infection, not to prevent endocarditis. 4

Rationale for Restrictive Guidelines

The 2007-2008 shift to more restrictive prophylaxis guidelines was based on several key principles:

• Infective endocarditis is more likely to result from daily activities (eating, tooth brushing) causing random bacteremias than from dental procedures 1, 3
• Prophylaxis may prevent an exceedingly small number of cases, even if 100% effective 2, 3
• Optimal oral hygiene and regular dental care are more important than single-dose prophylaxis in reducing endocarditis risk 1, 2, 3
• The risk of antibiotic-associated adverse effects (including anaphylaxis and promotion of resistant organisms) may exceed the benefit 3

Studies following implementation of the 2007 guidelines documented no increase in infective endocarditis rates in children, supporting the safety of the more restrictive approach. 2

Common Pitfalls to Avoid

• Do not continue prophylaxis indefinitely after device closure. After 6 months post-device closure, prophylaxis is only needed if residual defects persist at or adjacent to the device. 2
• Do not give prophylaxis for non-dental procedures unless there is an active infection requiring treatment. 1, 4, 3
• Do not use fluoroquinolones or glycopeptides for routine prophylaxis due to unclear efficacy and potential for inducing resistance. 1
• Ensure good dental hygiene is emphasized as the primary prevention strategy, not just antibiotic prophylaxis. 1