What is the recommended antibiotic prophylaxis for a patient with a history of heart valve problems or artificial heart valves undergoing medical procedures to prevent infective endocarditis (IE)?

Infective Endocarditis Prophylaxis

Antibiotic prophylaxis for infective endocarditis should only be given to the highest-risk cardiac patients (prosthetic valves, prior IE, specific congenital heart disease, or cardiac transplant with valvulopathy) and only before dental procedures that manipulate gingival tissue or perforate oral mucosa—prophylaxis is NOT recommended for gastrointestinal, genitourinary, or respiratory procedures. 1, 2

Who Qualifies for Prophylaxis

Prophylaxis is reasonable only for patients with these highest-risk cardiac conditions 2, 1:

• Prosthetic cardiac valves or prosthetic material used for valve repair 2, 1
• Previous history of infective endocarditis 2, 1
• Congenital heart disease including:
  • Unrepaired cyanotic CHD, including palliative shunts and conduits 2, 1
  • Completely repaired CHD with prosthetic material/device during first 6 months post-procedure 2, 1
  • Repaired CHD with residual defects at or adjacent to prosthetic patch/device 2, 1
• Cardiac transplant recipients who develop cardiac valvulopathy 2, 1

Prophylaxis is NOT recommended for patients with native valve disease (including mitral valve prolapse, bicuspid aortic valve, rheumatic heart disease), hypertrophic cardiomyopathy, or coronary artery stents. 2

Which Procedures Require Prophylaxis

Dental Procedures: Prophylaxis Indicated

Prophylaxis should be given for dental procedures involving 2, 1:

• Manipulation of gingival tissue
• Manipulation of periapical region of teeth
• Perforation of oral mucosa

Dental Procedures: NO Prophylaxis Needed

Prophylaxis is NOT needed for 2, 1:

• Local anesthetic injections in non-infected tissue
• Treatment of superficial caries
• Removal of sutures
• Dental X-rays
• Placement or adjustment of removable prosthodontic/orthodontic appliances
• Shedding of deciduous teeth
• Trauma to lips and oral mucosa

Non-Dental Procedures: NO Prophylaxis Recommended

Prophylaxis is NOT recommended for any of the following procedures, even in highest-risk patients 2, 1:

• Gastrointestinal: Esophagogastroduodenoscopy, colonoscopy, gastroscopy, transgastric biopsy 2, 1, 3
• Genitourinary: Cystoscopy, vaginal delivery, cesarean section 2, 1
• Respiratory: Bronchoscopy, laryngoscopy, transnasal/endotracheal intubation 2, 1
• Cardiac: Transesophageal echocardiography 2, 1

This represents a Class III recommendation (no benefit) for GI/GU procedures. 2, 4

Antibiotic Regimens for Dental Procedures

Standard Regimen (No Penicillin Allergy)

Amoxicillin 2g orally (adults) or 50 mg/kg orally (children), given 30-60 minutes before the procedure 2, 1

Unable to Take Oral Medication

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

Penicillin Allergy (Oral)

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

Critical caveat: Cephalosporins should NOT be used in patients with history of anaphylaxis, angioedema, or urticaria with penicillins. 2

Penicillin Allergy (Unable to Take Oral)

• Clindamycin 600mg IV/IM (adults) or 20 mg/kg IV/IM (children) 2, 1
• OR Cefazolin or ceftriaxone 1g IV/IM (adults) or 50 mg/kg IV/IM (children) if no history of anaphylaxis 2

Special Situations

Patients Already on Antibiotics

If a patient is already receiving antibiotics (e.g., for rheumatic fever prophylaxis), select an antibiotic from a different class rather than increasing the current dose. 2 Avoid cephalosporins due to possible cross-resistance with oral streptococci. 2 Ideally, delay the dental procedure until 10 days after completing antibiotic therapy to allow normal oral flora to reestablish. 2

Patients on Anticoagulation

Avoid intramuscular injections in patients receiving anticoagulant therapy (Class I recommendation). 2 Use oral regimens whenever possible, or intravenous antibiotics if unable to tolerate oral medications. 2

Patients Undergoing Cardiac Surgery

Complete required dental treatment before cardiac valve surgery whenever possible to decrease late prosthetic valve endocarditis. 2 Perioperative prophylaxis for cardiac surgery should target staphylococci (typically first-generation cephalosporin), be initiated immediately before surgery, and continue no more than 48 hours postoperatively. 2

Rationale for Restrictive Guidelines

The dramatic restriction in prophylaxis recommendations is based on 1, 2:

• Infective endocarditis is more likely from daily activities (tooth brushing, flossing, chewing) causing random bacteremias than from medical/dental procedures 1, 2
• Prophylaxis may prevent an exceedingly small number of cases, if any 1
• Risk of antibiotic-associated adverse effects exceeds benefit from prophylactic therapy for most situations 1
• Optimal oral hygiene and regular dental care are more important than procedural prophylaxis for IE prevention 1, 4

Recent data from 2022 does show a temporal association between invasive dental procedures (particularly extractions and oral surgery) and subsequent IE in high-risk individuals, with prophylaxis associated with reduced IE incidence (OR 0.49). 5 This supports current recommendations for prophylaxis in highest-risk patients undergoing high-risk dental procedures.

Common Pitfalls to Avoid

• Do not give prophylaxis for GI/GU procedures even in patients with prosthetic valves—this is unnecessary antibiotic exposure without proven benefit 1, 3, 4
• Do not use cephalosporins in patients with penicillin anaphylaxis history due to cross-reactivity risk 2
• Do not give prophylaxis to patients with native valve disease (mitral valve prolapse, bicuspid aortic valve)—they no longer qualify 2, 1
• Ensure adequate preoperative dental clearance before valve surgery to eliminate sources of dental sepsis 2, 4