What is the recommended pre-dental procedure prophylaxis (preventative antibiotic regimen)?

From the Guidelines

Antibiotic prophylaxis is recommended for certain high-risk patients before dental procedures to prevent infective endocarditis, including those with prosthetic cardiac valves, previous infective endocarditis, unrepaired cyanotic congenital heart disease, completely repaired congenital heart defects with prosthetic material during the first six months after the procedure, repaired congenital heart disease with residual defects, or cardiac transplantation recipients who develop cardiac valvulopathy. The standard regimen is amoxicillin 2g orally taken 30-60 minutes before the dental procedure 1. For patients allergic to penicillin, alternatives include clindamycin 600mg, azithromycin or clarithromycin 500mg, or cephalexin 2g (if no history of anaphylaxis to penicillins) 1. For patients unable to take oral medications, ampicillin 2g IM/IV or clindamycin 600mg IV can be administered 1. Prophylaxis is specifically indicated for procedures involving manipulation of gingival tissue, periapical region of teeth, or perforation of oral mucosa.

Some key points to consider:

• The American Heart Association (AHA) recommends antibiotic prophylaxis for high-risk patients before dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa 1.
• The AHA guidelines emphasize the importance of focusing on the risk of adverse outcomes after infective endocarditis rather than the lifetime risk of acquisition of infective endocarditis 1.
• The guidelines also highlight the need for strict attention to sterile technique at the wound entry site during cardiac catheterization to prevent infective endocarditis 1.
• Antibiotic prophylaxis is not recommended for non-dental procedures that do not penetrate the mucosa, such as transesophageal echocardiography, diagnostic bronchoscopy, esophagogastroscopy, or colonoscopy, in the absence of active infection 1.

Overall, the goal of antibiotic prophylaxis is to prevent infective endocarditis in high-risk patients undergoing dental procedures, and the guidelines provide a framework for determining which patients should receive prophylaxis and what regimens should be used.

From the Research

Predental Procedure Prophylaxis

• The American Heart Association (AHA) has guidelines for the prevention of infective endocarditis through antibiotic prophylaxis protocol 2.
• However, the actual guidelines for antibiotic prophylaxis should be revised according to recent evidence of bacterial resistance 2.
• Amoxicillin/clavulanic acid and moxifloxacin should be considered due to their effectiveness against bacteria associated with oral, GU, and GI infections and the low rates of antibiotic resistance associated with these antibiotics 2.
• A systematic review found that there is no clear evidence about whether antibiotic prophylaxis is effective or ineffective against bacterial endocarditis in at-risk people who are about to undergo an invasive dental procedure 3.
• Another systematic review found that evidence to support or discourage the use of antibiotic prophylaxis prior to dental procedures as a prevention for infective endocarditis is very low 4.

Antibiotic Prophylaxis for Preventing Bacterial Endocarditis

• Guidelines in many countries have recommended that antibiotics be administered to people at high risk of endocarditis prior to invasive dental procedures 3.
• However, guidance by the National Institute for Health and Care Excellence (NICE) in England and Wales states that antibiotic prophylaxis against infective endocarditis is not recommended routinely for people undergoing dental procedures 3.
• A study found that prophylactic antibacterial therapy is recommended for procedures thought to be associated with the occurrence of bacteraemia involving organisms commonly associated with endocarditis, including dental extractions and oral, respiratory tract, genitourinary, gastrointestinal or oesophageal procedures 5.
• The American Heart Association recommends ampicillin + gentamicin or vancomycin + gentamicin for prophylaxis of bacterial endocarditis in high-risk patients undergoing genitourinary and gastrointestinal surgical procedures 5.

Pharmacokinetic Observations

• A study reported the serum concentrations and side effects of oral amoxycillin, clindamycin, and erythromycin, which are recommended for antibiotic prophylaxis of bacterial endocarditis 6.
• The study found that peak serum concentrations of amoxycillin and clindamycin were 27 mg/l and 5.5 mg/l respectively, and that amoxycillin was eliminated more rapidly than clindamycin 6.
• The study also found that serum concentrations of erythromycin were below the sensitivity limit of the assay in some volunteers, and that peak levels were associated with gastrointestinal side effects such as nausea, abdominal cramps, and vomiting 6.