Which invasive procedures require antibiotic prophylaxis for a patient with a prosthetic heart valve?

Antibiotic Prophylaxis for Prosthetic Heart Valves

Patients with prosthetic heart valves require antibiotic prophylaxis only for dental procedures that manipulate gingival tissue, manipulate the periapical region of teeth, or perforate the oral mucosa—prophylaxis is NOT recommended for gastrointestinal, genitourinary, or respiratory procedures. 1, 2

High-Risk Dental Procedures Requiring Prophylaxis

Antibiotic prophylaxis is indicated for the following dental procedures in prosthetic valve patients:

• Dental extractions 1, 2
• Periodontal surgery and scaling that induces bleeding 2, 3
• Root canal procedures involving manipulation of the periapical region 1, 2
• Subgingival placement of antibiotic fibers or strips 1
• Initial placement of orthodontic bands (not brackets) 1
• Intraligamentary local anesthetic injections 1
• Prophylactic cleaning of teeth or implants where bleeding is anticipated 1, 2

The rationale is that these procedures cause predictable bacteremia, and prosthetic valve patients have a 75% one-year mortality rate when infective endocarditis develops. 2

Dental Procedures NOT Requiring Prophylaxis

The following dental procedures do not require antibiotic prophylaxis, even in prosthetic valve patients:

• Local anesthetic injections through non-infected tissue 1, 2
• Dental radiographs (X-rays) 1, 2
• Removal of sutures 1, 2
• Placement or adjustment of removable prosthodontic or orthodontic appliances 1, 2
• Adjustment of orthodontic brackets 1
• Shedding of deciduous teeth 1, 2
• Bleeding from trauma to lips or oral mucosa 1, 2
• Treatment of superficial caries 2

Non-Dental Procedures NOT Requiring Prophylaxis

Antibiotic prophylaxis is explicitly not recommended for the following procedures, even in high-risk prosthetic valve patients:

• Transesophageal echocardiography (TEE) 1, 2
• Esophagogastroduodenoscopy (EGD) 1, 2
• Colonoscopy 1, 2
• Cystoscopy 1, 2
• Bronchoscopy and laryngoscopy 1, 2
• Sigmoidoscopy 1
• Transnasal or endotracheal intubation 1

This represents a major shift from older guidelines: the 2007 AHA guidelines rescinded prophylaxis for gastrointestinal and genitourinary procedures that had been recommended since 1984. 1 The bacteremia rate from these procedures is only 2-5%, and the organisms involved (predominantly gram-negative bacilli) rarely cause endocarditis. 2

Recommended Antibiotic Regimens

Standard Regimen (No Penicillin Allergy)

• Amoxicillin 2 g orally, given 30-60 minutes before the procedure 2, 3
• Alternative: Ampicillin 2 g IV if oral administration is not possible 4

Penicillin Allergy Regimen

• Clindamycin 600 mg orally or IV, given 30-60 minutes before the procedure 2, 3
• Alternative: Cephalexin 2 g orally or cefazolin 1 g IV 3

Critical Contraindications

• Do NOT use cephalosporins in patients with a history of anaphylaxis, angioedema, or urticaria to penicillin 2, 3
• Do NOT use fluoroquinolones or glycopeptides for prophylaxis—their efficacy is unclear and they promote antimicrobial resistance 2
• Do NOT substitute amoxicillin-clavulanate for plain amoxicillin as first-line prophylaxis 2

Duration of Prophylaxis

Prosthetic valve patients require lifelong antibiotic prophylaxis for high-risk dental procedures—this is not time-limited to the first 6 months or 2 years after valve implantation. 2 This applies equally to mechanical valves, bioprosthetic valves, and transcatheter valves (TAVR). 1, 2

Cardiac Procedures Requiring Perioperative Prophylaxis

For patients undergoing implantation of prosthetic valves or intracardiac devices:

• Cefazolin 2 g IV as a slow infusion 30-60 minutes before incision 4
• Vancomycin is an alternative for patients with beta-lactam allergy 1
• Preoperative screening for nasal Staphylococcus aureus carriage is recommended, with treatment of carriers before elective cardiac surgery 1

Evidence Quality and Guideline Consensus

The 2013 Cochrane systematic review found no definitive evidence that antibiotic prophylaxis prevents endocarditis, as no randomized controlled trials have been performed. 1, 2 Despite this, the ACC/AHA, ESC, and AHA all recommend prophylaxis based on:

• Severe consequences of prosthetic valve endocarditis (75% one-year mortality) 2
• Observational data showing higher IE rates in prosthetic valve patients 1
• Pathophysiological rationale that bacteremia from dental procedures can seed prosthetic material 1

The guidelines emphasize that maintaining optimal oral hygiene and regular dental care is more important than antibiotic prophylaxis for preventing endocarditis. 1, 2, 3 Potential sources of dental sepsis should be eliminated at least 2 weeks before elective valve implantation. 1, 2

Common Pitfalls to Avoid

• Do NOT withhold prophylaxis for high-risk dental procedures in prosthetic valve patients—this is a documented error 2
• Do NOT provide prophylaxis for gastrointestinal or genitourinary procedures in the absence of active infection 1, 2
• Do NOT provide prophylaxis for low-risk dental procedures such as routine adjustments of orthodontic appliances 2
• Do NOT neglect the importance of regular dental care and good oral hygiene as the primary prevention strategy 2, 3