What is the recommended amoxicillin (or alternative) prophylactic dose and timing for an adult undergoing a dental procedure at risk for infective endocarditis or prosthetic joint infection, including adjustments for penicillin allergy, severe renal impairment, and intravenous administration?

Amoxicillin Prophylaxis Dosing for Dental Procedures

For adults undergoing dental procedures who require infective endocarditis prophylaxis, give amoxicillin 2 g orally as a single dose 30–60 minutes before the procedure. 1, 2, 3

Standard Dosing Regimen

• Adults: Amoxicillin 2 g orally, single dose, administered 30–60 minutes before the dental procedure 1, 2, 3
• Pediatric patients: Amoxicillin 50 mg/kg orally (maximum 2 g), single dose, administered 30–60 minutes before the procedure 1
• No post-procedure dose is required—only a single pre-procedure dose is indicated 1, 2

Alternative Regimens for Penicillin Allergy

Oral Alternatives

• Clindamycin 600 mg orally 30–60 minutes before the procedure is the preferred alternative for all patients with penicillin allergy 1, 2, 3
• Cephalexin 2 g orally may be used only if there is no history of anaphylaxis, angioedema, or urticaria with penicillin 1, 3
• Azithromycin or clarithromycin 500 mg orally are additional alternatives 3

Intravenous Alternatives (When Oral Administration Is Impossible)

• Ampicillin 2 g IM or IV within 30 minutes before the procedure for non-allergic patients 2, 3
• Clindamycin 600 mg IV within 30 minutes before the procedure for penicillin-allergic patients 1
• Vancomycin 1 g IV over 1–2 hours for penicillin-allergic patients unable to take oral medications 3, 4

Special Clinical Situations

Patients Already on Chronic Antibiotic Therapy

• Select an antibiotic from a different class rather than increasing the dose of the current antibiotic 1, 2, 3
• For patients on long-term penicillin therapy, use clindamycin, azithromycin, or clarithromycin 2
• Avoid cephalosporins in patients on penicillin due to possible cross-resistance 2

Patients on Anticoagulation

• Use oral regimens exclusively—avoid intramuscular injections entirely 2, 3

Patients with Severe Renal Impairment (Including Hemodialysis)

• The standard 2 g amoxicillin dose remains appropriate if not allergic to penicillin 2
• No dose adjustment is required for single-dose prophylaxis, even in hemodialysis patients 2

Who Requires Prophylaxis

Antibiotic prophylaxis is indicated only for patients with the highest-risk cardiac conditions undergoing at-risk dental procedures:

• Prosthetic cardiac valves or prosthetic material used for cardiac valve repair 1, 2, 3
• Previous history of infective endocarditis 1, 2
• Unrepaired cyanotic congenital heart disease, or completely repaired congenital heart disease with prosthetic material during the first 6 months after the procedure 1, 2
• Cardiac transplant recipients with cardiac valvulopathy 1, 2

Patients who do NOT require prophylaxis include those with mitral valve prolapse, rheumatic heart disease without prosthetic valves, and healthy individuals without cardiac risk factors 2, 3

Dental Procedures Requiring Prophylaxis

Prophylaxis is required for procedures that:

• Manipulate gingival tissue (e.g., scaling, root planing, periodontal surgery) 1, 2
• Involve the periapical region of teeth (e.g., endodontic treatment, tooth extractions) 1, 2
• Perforate the oral mucosa 1

Prophylaxis is NOT required for routine anesthetic injections through noninfected tissue, dental radiographs, placement or adjustment of removable prosthodontic or orthodontic appliances, shedding of deciduous teeth, or treatment of superficial caries 1, 2

Prosthetic Joint Considerations

• Routine antibiotic prophylaxis is NOT recommended for most patients with prosthetic joints undergoing dental procedures 1, 3
• Prophylaxis may be appropriate only in specific high-risk patients, such as those who are immunocompromised, have inflammatory arthropathies, or have a history of previous prosthetic joint infection 1, 2

Critical Pitfalls to Avoid

• Do not prescribe post-procedure antibiotics—only a single pre-procedure dose is indicated 1, 2
• Do not prescribe prolonged antibiotic courses—this increases adverse event risk without additional benefit 3
• Do not use cephalosporins in patients with immediate-type penicillin hypersensitivity (anaphylaxis, angioedema, urticaria) 1, 3
• Do not give IM injections to anticoagulated patients—use oral or IV routes only 2, 3
• Do not increase the dose of a patient's current antibiotic—switch to a different antibiotic class instead 1, 2, 3
• Do not prescribe prophylaxis for all dental patients—only those with highest-risk cardiac conditions require it 3

Antibiotic Stewardship Considerations

• Avoiding penicillins and cephalosporins based solely on unverified allergy labels leads to increased use of broad-spectrum antibiotics, contributing to antimicrobial resistance and raising the risk of Clostridioides difficile infection 1
• Single-dose prophylaxis carries a very low risk of C. difficile colitis—only one case report has been documented after a single dose of clindamycin 1
• Maintaining good oral hygiene is more important for preventing infective endocarditis than antibiotic prophylaxis for dental procedures 2