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8/13/2019 (69621703) Circulation-2007-Wilson-1736-54
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Prevention of Infective Endocarditis: Guidelines From the American Heart Association: AGuideline From the American Heart Association Rheumatic Fever, Endocarditis, and
Kawasaki Disease ommittee, ouncil on ardiovascular Disease in the !oun", and theouncil on linical ardiolo"#, ouncil on ardiovascular $ur"er# and Anesthesia, andthe %ualit# of are and &utcomes Research Interdisci'linar# (orkin" Grou'
Walter Wilson, Kathryn A. Taubert, Michael Gewitz, Peter B. Lockhart, Larry M. Baddour,Matthew Levison, Ann Boler, !hristo"her #. !abell, Masato Takahashi, $obert %. Balti&ore,'ane W. (ewburer, Brian L. %tro&, Lloyd ). Tani, Michael Gerber, $obert *. Bonow, Tho&as
Pallasch, %tan+ord T. %hul&an, Anne #. $owley, 'ane !. Burns, Patricia errieri, Ti&othyGardner, -avid Go++, -avid T. -urack and The !ouncil on %cienti+ic A++airs o+ the A&erican
-ental Association has a""roved the uideline as it relates to dentistry. n addition, thisuideline has been endorsed by the A&erican Acade&y o+ Pediatrics, n+ectious -iseases
%ociety o+ A&erica, the nternational %ociety o+ !he&othera"y +or n+ection and !ancer, andthe Pediatric n+ectious -iseases %ociety.
Circulation. /001233453164731892 oriinally "ublished online A"ril 3:, /0012doi5 30.3343;!$!<LAT*(A#A.304.3=60:8Circulation is "ublished by the A&erican #eart Association, 1/1/ Greenville Avenue,
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(ilson et al Prevention of Infective Endocarditis 1737
evidence +or "ractice uidelines were used. The "a"er was subseuently reviewed by outside
e"erts not a++iliated with the writin rou" and by the A#A %cience Advisory and !oordinatin
!o&&ittee.
Conclusions FThe &a@or chanes in the u"dated reco&&endations include the +ollowin5 D3E The
!o&&ittee concluded that only an etre&ely s&all nu&ber o+ cases o+ in+ective endocarditis &iht
be "revented by antibiotic "ro"hylais +or dental "rocedures even i+ such "ro"hylactic thera"y were300 e++ective. D/E n+ective endocarditis "ro"hylais +or dental "rocedures is reasonable only +or
"atients with underlyin cardiac conditions associated with the hihest risk o+ adverse outco&e
+ro& in+ective endocarditis. D6E or "atients with these underlyin cardiac conditions, "ro"hylais is
reasonable +or all dental "rocedures that involve &ani"ulation o+ inival tissue or the "eria"ical
reion o+ teeth or "er+oration o+ the oral &ucosa. D9E Pro"hylais is not reco&&ended based solely
on an increased li+eti&e risk o+ acuisition o+ in+ective endocarditis. D8E Ad&inistration o+
antibiotics solely to "revent endocarditis is not reco&&ended +or "atients who undero a
enitourinary or astrointestinal tract "rocedure. These chanes are intended to de+ine &ore clearly
when in+ective endocarditis "ro"hylais is or is not reco&&ended and to "rovide &ore uni+or& and
consistent lobal reco&&endations. 8Circulation+ 9..;--/:-5/<-7=+>Ke# (ords: A#A %cienti+ic %tate&ents cardiovascular diseases
endocarditis "revention antibiotic
"ro"hylais
n+ective endocarditis DE is an unco&&on
but li+e7 threatenin in+ection. -es"ite advancesin dianosis, anti&i7 crobial thera"y, surical
techniues, and &anae&ent o+ co&7 "lications,
"atients with still have hih &orbidity
and &ortality rates related to this condition.
%ince the last A&erican #eart Association
DA#AE "ublication on "revention o+ in
3::1,3 &any authorities and societies, as well as
the conclusions o+ "ublished studies, have
uestioned the e++icacy o+ anti&icro7 bial
"ro"hylais to "revent in "atients who
undero a dental, astrointestinal DGE, or
enitourinary DG<E tract "rocedure and have
suested that the A#A uidelines should be
revised./N8
Me&bers o+ the $heu&atic ever, ndocarditis,
and Kawasaki -isease !o&&ittee o+ the A#A
!ouncil on !ardiovascular -isease in the )oun
Dthe !o&&itteeE and a national and
international rou" o+ e"erts on etensively
reviewed data "ublished on the "revention o+ .
The !o&&ittee is es"ecially rate+ul to a rou"
o+ international e"erts on who "rovided
content review and in"ut on this docu&ent DseeAcknowled7 &entsE. The revised uidelines +or
"ro"hylais are the sub@ect o+ this re"ort.
The writin rou" was chared with the task
o+ "er+or&7 in an assess&ent o+ the evidence
and ivin a classi+ica7 tion o+ reco&&endations
and a level o+ evidence DL*E to each
reco&&endation. The A&erican !ollee o+
!ardiol7 oy DA!!E;A#A classi+ication syste&
was used as +ollows.
lassification of
Recommendations:lass I: !onditions +or which there isevidence and;or eneral aree&ent that a iven "rocedure or treat&ent is bene+icial, use+ul,and e++ective.lass II: !onditions +or which there iscon+lictin evi7 dence and;or a diverence o+o"inion about the use+ulness; e++icacy o+ a "rocedure or treat&ent.
lass IIa: Weiht o+ evidence;o"inion is in+avor o+ use+ulness;e++icacy.
lass II): <se+ulness;e++icacy is less well-ownloaded +ro& htt"5;;circ.aha@ournals.or; by uest on Auust 60, /036
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reco&&endations were
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1738 Circulation &cto)er 6, 9..
Table 1. Summary of 9 Iterations of AHA-Recommended Antibiotic Regimens From 1955 to 1997 forental!Res"iratoryTract #rocedures$
Year (Reference) Primary Regimens for DentalProcedures
1955 (6) Aqueous penicillin 600 000 and procaine penicillin 600 000 in oil containing !"aluminum monostearate administered #$ %0 minutes &efore t'e operatie procedure
195 () *or ! days &efore surgery+ penicillin !00 000 to !50 000 &y mout' , times per day- .nday of surgery+ penicillin !00 000 to
!50 000 &y mout' , times per day and aqueous penicillin 600 000 /it' procaine penicillin600 000 #$ %0 to 60 minutes &efore surgery- *or ! days after+ !00 000 to !50 000 &y
mout' , times per day-
1960 () tep #2 prop'yla3is ! days &efore surgery /it' procaine penicillin 600 000 #$ on eac'day
tep ##2 day of surgery2 procaine penicillin 600 000 #$ supplemented &y crystallinepenicillin 600 000 #$ 1 'our &efore surgical procedure
tep ###2 for ! days after surgery2 procaine penicillin 600 000 #$ eac' day
1965 (9) Day of procedure2 procaine penicillin 600 000 + supplemented &y crystalline penicillin600 000 #$ 1 to ! 'ours &efore t'e procedure
*or ! days after procedure2 procaine penicillin 600 000 #$ eac' day
19! (10) Procaine penicillin 4 600 000 mi3ed /it' crystalline penicillin 4 !00 000 #$ 1
'our &efore procedure and once daily for t'e ! days after t'e procedure
19 (11) Aqueous crystalline penicillin 4 (1 000 000 #$) mi3ed /it' procaine penicillin 4 (600
000 #$) %0 minutes to 1 'our &efore procedure and t'en penicillin 500 mg orally eery 6'ours for doses-
19, (1!) Penicillin ! g orally 1 'our &efore+ t'en 1 g 6 'ours after initial dose
1990 (1%) Amo3icillin % g orally 1 'our &efore procedure+ t'en 1-5 g 6 'ours after initial dose
199 (1) Amo3icillin ! g orally 1 'our &efore procedure
#$ indicates intramuscularly-
7'ese regimens /ere for adults and represented t'e initial regimen listed in eac' ersion of t'erecommendations- #n some ersions+ 1 regimen /as included-
intended to serve as a uideline, not asestablished standard o+ care. The &ost recent
A#A docu&ent on "ro"hylais was
"ublished in 3::1.3 The 3::1 docu&ent
strati+ied cardiac conditions into hih7,
&oderate7, and low7risk Dneliible riskE
cateories, with "ro"hylais not reco&&ended
+or the low7risk rou".3 An even &ore detailed
list o+ dental, res"i7 ratory, G, and G< tract
"rocedures +or which "ro"hylais was and was
not reco&&ended was "rovided. The 3::1docu&ent was notable +or its
acknowled&ent that &ost cases o+ are not
attributable to an invasive "rocedure but ratherare the result o+ rando&ly occurrin bactere&ias
+ro& routine daily activities and +or its
acknowled&ent o+ "ossi7 ble "ro"hylais
+ailures.
Rationale for Revisin" the -66 Documentt is clear +ro& the above chronoloy that theA#A uidelines
+or "ro"hylais have been in a "rocess o+
evolution &ore than 80 years. The rationale +or
"ro"hylais was based larely on e"ert o"inionand what see&ed to be a rational and "rudent
atte&"t to "revent a li+e7threatenin in+ection.
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*n the basis o+ the A!! and A#A Task orce on
Practice Guide7 linesO evidence7based radin
syste& +or rankin reco&&en7 dations, the
reco&&endations in the A#A docu&ents "ub7
lished durin the "ast 80 years would be !lass
b, L* !. Accordinly, the basis +or
reco&&endations +or "ro"hy7 lais was not
well established, and the uality o+ evidence was
li&ited to a +ew case7control studies or was
based on e"ert o"inion, clinical e"erience, and
descri"tive studies that utilized surroate
&easures o+ risk.
*ver the years, other international societies
have "ublished reco&&endations and uidelines
+or the "revention o+ .39,38
$ecently, the British %ociety +or Anti&icrobial
!he&other7 a"y issued new "ro"hylais
reco&&endations.38 This
rou" now reco&&ends "ro"hylais be+ore
dental "rocedures only +or "atients who have a
history o+ "revious or who have had cardiac
valve re"lace&ent or surically constructed
"ul&onary shunts or conduits.
The +unda&ental underlyin "rinci"les that
drove the +or&ulation o+ the A#A uidelines and
the : "revious A#A docu&ents were that D3E
is an unco&&on but li+e7 threatenin disease,
and "revention is "re+erable to treat&ent o+
established in+ection2 D/E certain underlyin
cardiac con7 ditions "redis"ose to 2 D6E
bactere&ia with oranis&s known to cause
occurs co&&only in association with invasive
dental, G, or G< tract "rocedures2 D9E
anti&icrobial "ro"hylais was "roven to be
e++ective +or "revention o+ e"eri&ental in
ani&als2 and D8E anti&icrobial "ro"hylais wasthouht to be e++ective in hu&ans +or "revention
o+ associated with dental, G, or G< tract
"rocedures. The !o&&ittee believes that o+
these 8 underlyin "rinci"les, the +irst 9 are valid
and have not chaned durin the "ast 60 years.
(u&erous "ublications have uestioned the
validity o+ the +i+th "rinci"le and suested
revision o+ the uidelines, "ri&arily +or reasons
as shown in Table /.
Another reason that led the !o&&ittee torevise the 3::1 docu&ent was that over the "ast
80 years, the A#A uide7 lines on "revention o+
beca&e overly co&"licated, &akin it
di++icult +or "atients and healthcare "roviders to
inter"ret or re&e&ber s"eci+ic details, and they
contained a&biuities and so&e inconsistencies
in the reco&&endations. The deci7 sion to
substantially revise the 3::1 docu&ent was not
taken lihtly. The "resent revised docu&ent was
not based on the results o+ a sinle study butrather on the collective body o+ evidence
"ublished in nu&erous studies over the "ast /
decades. The !o&&ittee souht to construct the
"resent reco&&endations such that they would
be in the best interest
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(ilson et al Prevention of Infective Endocarditis 1739
Table %. #rimary Reasons forRe&ision of t'e I( #ro"'yla)is*uidelines
#8 is muc' more liely to result from frequente3posure to random &acteremias associated /it'
daily actiities t'an from &acteremia caused &y adental+ 4# tract+ or 4 tract procedure-
Prop'yla3is may preent an e3ceedingly smallnum&er of cases of #8+ if any+ in indiiduals /'oundergo a dental+ 4# tract+ or 4 tract procedure-
7'e ris of anti&iotic:associated aderse eentse3ceeds t'e &enefit+ if any+ from prop'ylacticanti&iotic t'erapy-
$aintenance of optimal oral 'ealt' and 'ygiene
may reduce t'e incidence of &acteremia from dailyactiities and is more important t'an prop'ylacticanti&iotics for a dental procedure to reduce t'e risof #8-
o+ "atients and "roviders, would be reasonable
and "rudent, and would re"resent the
conclusions o+ "ublished studies and the
collective wisdo& o+ &any e"erts on and
relevant national and international societies.
Potential onse@uences of
$u)stantivehan"es in
Recommendations%ubstantive chanes in reco&&endations couldD3E violate
lon7standin e"ectations and "ractice "atterns2
D/E &ake +ewer "atients eliible +or
"ro"hylais2 D6E reduce &al7 "ractice clai&s
related to "ro"hylais2 and D9E sti&ulate
"ros"ective studies on "ro"hylais. The!o&&ittee and others34 reconize that
substantive chanes in "ro"hylais uidelines
&ay violate lon7standin e"ectations and
"rac7 tice "atterns by "atients and healthcare
"roviders. The !o&7 &ittee reconizes that
these new reco&&endations &ay cause concern
a&on "atients who have "reviously received
anti7 biotic "ro"hylais to "revent be+ore
dental or other "rocedures and are now advised
that such "ro"hylais is unnecessary. Table /
includes the &ain talkin "oints that &ay be
hel"+ul +or clinicians in reeducatin their
"atients about these chanes. To reco&&end
such chanes de&ands due dilience and critical
analysis. or 80 years, since the "ublication o+
the +irst A#A uidelines on the "revention o+
,4
"atients and healthcare "roviders assu&edthat antibiotics ad&inistered in association with
a bactere&ia7"roducin "rocedure e++ectively
"revented in "atients with underly7 in
cardiac risk +actors. Patients were educated
about bactere&ia7"roducin "rocedures and risk
+actors +or , and they e"ected to receive
antibiotic "ro"hylais2 healthcare "roviders,
es"ecially dentists, were e"ected to ad&inister
the&. Patients with underlyin cardiac
conditions that carry a li+eti&e risk o+acuisition o+ , such as &itral valve
"rola"se DMPE, had a sense o+ reassurance and
co&+ort that antibiotics ad&inistered in
association with a dental "roce7 dure were
e++ective and usually sa+e to "revent .
#ealthcare "roviders, es"ecially dentists, +elt a
sense o+ obliation and "ro+essional and leal
res"onsibility to "rotect their "atients +ro&
that &iht result +ro& a "rocedure. *n the basis
o+ reco&&endations in this revised docu&ent,substantially +ewer "atients will be
reco&&ended +or "ro"hylais.
!ases o+ either te&"orally or re&otely
associated with an invasive "rocedure, es"ecially
a dental "rocedure, have +reuently been the
basis +or &al"ractice clai&s aainst healthcare
"roviders. <nlike &any other in+ections +or
which
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there is conclusive evidence +or the e++icacy o+
"reventive thera"y, the "revention o+ is not a
"recise science. Because "reviously "ublished
A#A uidelines +or the "revention o+
contained a&biuities and inconsistencies and
were o+ten based on &ini&al "ublished data or
e"ert o"inion, they were sub@ect to con+lictin
inter"retations a&on "atients, health7 care
"roviders, and the leal syste& about "atient
eliibility +or "ro"hylais and whether there was
strict adherence by healthcare "roviders to A#A
reco&&endations +or "ro"hy7 lais. This
docu&ent is intended to identi+y which, i+ any,
"atients &ay "ossibly bene+it +ro&
"ro"hylais and to de+ine, to the etent "ossible,
which dental "rocedures should have
"ro"hylais in this select rou" o+ "atients.
Accord7 inly, the !o&&ittee ho"es that this
docu&ent will result in reater clarity +or
"atients, healthcare "roviders, and consult7 in
"ro+essionals.
The !o&&ittee believes that
reco&&endations +or "ro"hylais &ust be
evidence based. A "lacebo7controlled,
&ulticenter, rando&ized, double7blinded study
to evaluate the e++icacy o+ "ro"hylais in
"atients who undero a dental, G, or G< tract
"rocedure has not been done. %uch a study
would reuire a lare nu&ber o+ "atients "er
treat&ent rou" and standardization o+ the
s"eci+ic invasive "rocedures and the "atient
"o"ulations. This ty"e o+ study would be
necessary to de+initively answer lon7standin
unresolved uestions reardin the e++icacy o+
"ro"hylais. The !o&&ittee ho"es that this
revised docu&ent will sti&ulate additional
studies on the "revention o+ . uture "ublished
data will be reviewed care+ully by the A#A, the
!o&&ittee on $heu&atic ever, ndocarditis,
and Kawasaki -isease, and other societies, and
+urther revisions to the "resent docu&ent will be
based on relevant studies.
Patho"enesis of IEThe develo"&ent o+ is the net result o+the co&"le
interaction between the bloodstrea& "athoen
with &atri &olecules and "latelets at sites o+
endocardial cell da&ae. n addition, &any o+
the clinical &ani+estations o+ e&anate +ro&
the hostOs i&&une res"onse to the in+ectin
&icroor7 anis&. The +ollowin seuence o+
events is thouht to result in 5 +or&ation o+
nonbacterial thro&botic endocarditis D(BTE on
the sur+ace o+ a cardiac valve or elsewhere that
endothelial da&ae occurs, bactere&ia,
adherence o+ the bacteria in the bloodstrea& to
(BT, and "roli+eration o+ bacteria within a
veetation.
Formation of
3?2ETurbulent blood +low "roduced by certain ty"eso+ conenital
or acuired heart disease, such as +low +ro& a
hih7 to a low7"ressure cha&ber or across a
narrowed ori+ice, trau&a7 tizes the endotheliu&.
This creates a "redis"osition +or de"osition o+
"latelets and +ibrin on the sur+ace o+ the
endotheliu&, which results in (BT. nvasion
o+ the blood7 strea& with a &icrobial s"ecies
that has the "athoenic "otential to colonize this
site can then result in .
2ransient
?acteremiaMucosal sur+aces are "o"ulated by a denseendoenous
&icro+lora. Trau&a to a &ucosal sur+ace, "articularly the
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1740 Circulation &cto)er 6, 9..
inival crevice around teeth, oro"haryn, G
tract, urethra, and vaina, releases &any
di++erent &icrobial s"ecies tran7 siently into the
bloodstrea&. Transient bactere&ia caused by
viridans rou" stre"tococci and other oral
&icro+lora occurs co&&only in association withdental etractions or other dental "rocedures or
with routine daily activities. Althouh
controversial, the +reuency and intensity o+ the
resultin bactere&ias are believed to be related
to the nature and &anitude o+ the tissue trau&a,
the density o+ the &icrobial +lora, and the deree
o+ in+la&&ation or in+ection at the site o+
trau&a. The &icrobial s"ecies enterin the
circulation de"ends on the uniue endoenous
&icro+lora that colonizes the "articulartrau&atized site.
?acterial
Adherence
The ability o+ various &icrobial s"ecies to
adhere to s"eci+ic sites deter&ines the anato&ic
localization o+ in+ection caused by these
&icrooranis&s. Mediators o+ bacterial
adherence serve as virulence +actors in the
"athoenesis o+ . (u&er7 ous bacterial sur+aceco&"onents "resent in stre"tococci,
sta"hylococci, and enterococci have been shown
in ani&al &odels o+ e"eri&ental endocarditis to
+unction as critical adhesins. %o&e viridans
rou" stre"tococci contain a i&A "rotein that is
a li"o"rotein rece"tor antien DLraE that serves
as a &a@or adhesin to the +ibrin "latelet &atri o+
(BT.31 %ta"hylococcal adhesins +unction in at
least / ways. n one, &icrobial sur+ace
co&"onents reconizin adhesive &atri&olecules +acilitate the attach&ent o+
sta"hylococci to hu&an etracellular &atri
"roteins and to &edical devices that beco&e
coated with &atri "roteins a+ter i&"lantation.
n the other, bacterial etracellular structures
contribute to the +or&ation o+ bio+il& that +or&s
on the sur+ace o+ i&"lanted &edical devices. n
both cases, sta"hylococcal adhesins are
i&"ortant virulence +actors.
Both i&A and sta"hylococcal adhesins arei&&unoenic in e"eri&ental in+ections.
accines "re"ared aainst i&A and
sta"hylococcal adhesins "rovide so&e "rotective
e++ect in e"eri&ental endocarditis caused by
viridans rou" stre"to7 cocci and
sta"hylococci. 3=,3: The results o+ these
e"eri&en7 tal studies are hihly intriuin,
because the develo"&ent o+ an e++ective vaccine+or use in hu&ans to "revent viridans rou"
stre"tococcal or sta"hylococcal would be o+
&a@or i&"ortance.
Proliferation of ?acteria (ithin a e"etation
Microoranis&s adherent to the veetation
sti&ulate +urther de"osition o+ +ibrin and
"latelets on their sur+ace. Within this secluded
+ocus, the buried &icrooranis&s &ulti"ly as
ra"7 idly as bacteria in broth cultures to reach&ai&al &icrobial densities o+ 30= to 3033
colony7+or&in units "er ra& o+ veetation
within a short ti&e on the le+t side o+ the heart,
a""arently uninhibited by host de+enses in le+t7
sided lesions. $iht7sided veetations have
lower bacterial densities, which &ay be the
conseuence o+ host de+ense &echanis&s active
at this site, such as "oly&or"honuclear
activity or "latelet7 derived antibacterial
"roteins. More than :0 o+ the &icro7oranis&s in &ature le+t7 or riht7sided valvular
veetations are &etabolically inactive rather
than in an active rowth
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"hase and are there+ore less res"onsive to the
bactericidal e++ects o+ antibiotics./0
Rationale for or A"ainst Pro'h#laBis of IE
Historical
?ack"round
iridans rou" stre"tococci are "art o+ the
nor&al skin, oral, res"iratory, and G tract +lora,and they cause at least 80 o+ cases o+
co&&unity7acuired native valve not
associated with intravenous dru use./3 More
than a century ao, the oral cavity was
reconized as a "otential source o+ the
bactere&ia that caused viridans rou"
stre"tococcal . n 3==8, *sler // noted an
association between bactere&ia +ro& surery
and . *kell and lliott/6 in 3:68 re"orted that
33 o+ "atients with "oor oral hyiene had "ositive blood cultures with viridans rou"
stre"tococci and that 43 o+ "atients had
viridans rou" stre"tococcal bactere&ia with
dental etraction.
As a result o+ these early studies and
subseuent studies, durin the "ast 80 years, the
A#A uidelines reco&&ended anti&icrobial
"ro"hylais to "revent in "atients with
underlyin cardiac conditions who underwent
bactere&ia7 "roducin "rocedures on the basiso+ the +ollowin +actors5 D3E bactere&ia causes
endocarditis2 D/E viridans rou" stre"7 tococci
are "art o+ the nor&al oral +lora, and enterococci
are "art o+ the nor&al G and G< tract +lora2 D6E
these &icroor7 anis&s were usually susce"tible
to antibiotics reco&&ended +or "ro"hylais2 D9E
antibiotic "ro"hylais "revents viridans rou"
stre"tococcal or enterococcal e"eri&ental
endocardi7 tis in ani&als2 D8E a lare nu&ber o+
"oorly docu&ented case re"orts i&"licated a
dental "rocedure as a cause o+ 2 D4E in so&e
cases, there was a te&"oral relationshi" between
a dental "rocedure and the onset o+ sy&"to&s o+
2 D1E an awareness o+ bactere&ia caused by
viridans rou" stre"to7 cocci associated with a
dental "rocedure eists2 D=E the risk o+
sini+icant adverse reactions to an antibiotic is
low in an individual "atient2 and D:E &orbidity
and &ortality +ro& are hih. Most o+ these
+actors re&ain valid, but collectively, they do not
co&"ensate +or the lack o+ "ublished data that
de&onstrate a bene+it +ro& "ro"hylais.
?acteremia<Producin" Dental
Procedures
The lare &a@ority o+ "ublished studies have
+ocused on dental "rocedures as a cause o+ and the use o+ "ro"hylactic antibiotics to "revent
in "atients at risk. ew data eist on the risk
o+ or "revention o+ associated with a G or
G< tract "rocedure. Accordinly, the !o&&ittee
undertook a critical analysis o+ "ublished data in
the contet o+ the historical rationale +or
reco&&endin antibiotic "ro"hylais +or
be+ore a dental "rocedure. The +ollowin +actors
were considered5 D3E +reuency, nature,
&anitude, and duration o+ bactere&ia
associated with dental "rocedures2 D/E i&"act o+
dental disease, oral hyiene, and ty"e o+ dental
"rocedure on bactere&ia2 D6E i&"act o+
antibiotic "ro"hylais on bactere7 &ia +ro& a
dental "rocedure2 and D9E the e"osure over ti&e
o+ +reuently occurrin bactere&ia +ro& routine
daily activ7 ities co&"ared with bactere&ia +ro&
various dental "rocedures.
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174- Circulation &cto)er 6, 9..
These +actors co&"licated reco&&endations
in "revious A#A uidelines on "revention o+
that suested antibiotic "ro"hylais +or so&e
dental "rocedures but not +or others. The
collective "ublished data suest that the vast
&a@ority o+ dental o++ice visits result in so&ederee o+ bactere&ia2 however, there is no
evidence7based ðod to decide which
"rocedures should reuire "ro"hylais, because
no data show that the incidence, &anitude, or
duration o+ bactere&ia +ro& any dental
"rocedure increase the risk o+ . Accordinly, it
is not clear which dental "rocedures are &ore or
less likely to cause a transient bactere&ia or
result in a reater &anitude o+ bactere&ia than
that which results +ro& routine dailyactivities such as chewin +ood, tooth brushin,
or +lossin. n "atients with underlyin
cardiac conditions, li+elon antibiotic thera"y
is not reco&&ended to "revent that &iht
result +ro& bactere&ias associated with routine
daily activities.8 n "atients with dental disease,
the +ocus on the +reuency o+ bactere&ia
associated with a s"eci+ic dental "rocedure
and the A#A uidelines +or "revention o+
have resulted in an overe&"hasis on antibiotic "ro"hylais and an undere&"hasis on
&aintenance o+ ood oral hyiene and access
to routine dental care, which are likely &ore
i&"ortant in reducin the li+eti&e risk o+ than
the ad&inistration o+ antibiotic "ro"hylais +or a
dental "rocedure. #owever, no
observational or controlled studies su""ort thiscontention.
($)act o# %nti.iotic ,hera)y on
Bactere$ia Fro$ a "ental 'rocedureThe ability o+ antibiotic thera"y to "revent orreduce the
+reuency, &anitude, or duration o+ bactere&ia
associated with a dental "rocedure is
controversial. /9,19 %o&e studies re"orted that
antibiotics ad&inistered be+ore a dental "roce7
dure reduced the +reuency, nature, and;or
duration o+ bac7 tere&ia,86,18,14 whereas others did
not./9,44,11,1= $ecent studies suest thata&oicillin thera"y has a statistically sini+icant
i&"act on reducin the incidence, nature, and
duration o+ bactere&ia +ro& dental "rocedures,
but it does not eli&inate bactere&ia.8/,86,14
#owever, no data show that such a reduc7 tion as
a result o+ a&oicillin thera"y reduces the risk o+
or "revents . #all et al1= re"orted that neither
"enicillin nor a&oicillin thera"y wase++ective in reducin the +reuency o+ bactere&ia
co&"ared with untreated control sub@ects. n
"atients who underwent a dental etraction,
"enicillin or a&"icillin thera"y co&"ared with
"lacebo di&inished the "ercentae o+ viridans
rou" stre"tococci and anaerobes in culture, but
there was no sini+icant di++erence in the
"ercent7 ae o+ "atients with "ositive cultures 30
&inutes a+ter tooth eGtraction./9,44 n a se"arate
study, #all et al11
re"orted that ce+aclor7treated "atients did not have a reduction o+ "ost"ro7
cedure bactere&ia co&"ared with untreated
control sub@ects. !ontradictory "ublished results
+ro& / studies showed reduc7 tion o+
"ost"rocedure bactere&ia by erythro&ycin in
one18 but lack o+ e++icacy +or erythro&ycin or
clinda&ycin in another.1= inally, results are
contradictory with reard to the e++icacy o+ the
use o+ to"ical antise"tics in reducin the
+reuency o+ bactere&ia associated with dental "rocedures, but the "re"onderance o+ evidence
suests that there is no clear bene+it. *ne study
re"orted that chlorheidine and "ovidone iodine
&outh rinse were e++ective,1: whereas others
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showed no statistically sini+icant bene+it.8/,=0
To"ical anti7 se"tic rinses do not "enetrate
beyond 6 && into the "eriodon7 tal "ocket and
there+ore do not reach areas o+ ulcerated tissue
where bacteria &ost o+ten ain entrance to the
circulation. *n the basis o+ these data, it is
unlikely that to"ical antise"tics are e++ective to
sini+icantly reduce the +reuency, &anitude,
and duration o+ bactere&ia associated with a
dental "rocedure.
umulative Risk &ver 2ime of?acteremias From Routine Dail#Activities om'ared (ith the?acteremia From a Dental Procedure
Guntheroth=3 esti&ated a cu&ulative e"osure o+
8610 &in7 utes o+ bactere&ia over a 37&onth
"eriod in dentulous "atients resultin +ro&
rando& bactere&ia +ro& chewin +ood and
+ro& oral hyiene &easures, such as tooth
brushin and +lossin, and co&"ared that with a
duration o+ bactere&ia lastin 4 to 60 &inutes
associated with a sinle tooth etraction.
$oberts4/ esti&ated that tooth brushin / ti&es
daily +or 3 year had a 389 000 ti&es reater risk
o+ e"osure to bactere&ia than that resultin
+ro& a sinle tooth etrac7 tion. The cu&ulative
e"osure durin 3 year to bactere&ia +ro&
routine daily activities &ay be as hih as 8.4&illion ti&es reater than that resultin +ro& a
sinle tooth etrac7 tion, the dental "rocedure
re"orted to be &ost likely to cause a
bactere&ia.4/
-ata eist +or the duration o+ bactere&ia +ro&
a sinle tooth etraction, and it is "ossible to
esti&ate the annual cu&ulative e"osure +ro&
dental "rocedures +or the averae individual.
#owever, calculations +or the incidence, nature,
and duration o+ bactere&ia +ro& routine daily
activities are at best rouh esti&ates, and it is
there+ore not "ossible to co&"are "recisely the
cu&ulative &onthly or annual duration o+
e"osure +or bactere&ia +ro& dental "rocedures
co&"ared with routine daily activities.
(evertheless, even i+ the esti7 &ates o+
bactere&ia +ro& routine daily activities are o++
by a +actor o+ 3000, it is likely that the +reuency
and cu&ulative duration o+ e"osure to
bactere&ia +ro& routine daily events over 3 year
are &uch hiher than those that result +ro&
dental "rocedures.
Results of linical $tudies of IE
Pro'h#laBis forDentalProcedures
(o "ros"ective, rando&ized, "lacebo7controlledstudies eist on the e++icacy o+ antibiotic
"ro"hylais to "revent in "atients who
undero a dental "rocedure. -ata +ro& "ub7
lished retros"ective or "ros"ective case7control
studies are li&ited by the +ollowin +actors5 D3E
the low incidence o+ , which reuires a lare
nu&ber o+ "atients "er cohort +or statistical
sini+icance2 D/E the wide variation in the ty"es
and severity o+ underlyin cardiac conditions,
which would re7 uire a lare nu&ber o+ "atientswith s"eci+ic &atched control sub@ects +or each
cardiac condition2 and D6E the lare variety o+
invasive dental "rocedures and dental disease
states, which would be di++icult to standardize
+or control rou"s. These and other li&itations
co&"licate the inter"retation o+ the results o+
"ublished studies o+ the e++icacy o+
"ro"hylais in "atients who undero dental
"rocedures.
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(ilson et al Prevention of Infective Endocarditis 1743
Althouh so&e retros"ective studies suested
that there was a bene+it +ro& "ro"hylais, these
studies were s&all in size and re"orted
insu++icient clinical data. urther&ore, in a
nu&ber o+ cases, the incubation "eriod between
the dental "rocedure and the onset o+ sy&"to&so+ was "roloned.=0,=/N =9
van der Meer and colleaues=8 "ublished a
study o+ dental "rocedures in the (etherlands
and the e++icacy o+ antibiotic "ro"hylais to
"revent in "atients with native or "rosthetic
cardiac valves. They concluded that dental or
other "roce7 dures "robably caused only a s&all
+raction o+ cases o+ and that "ro"hylais
would "revent only a s&all nu&ber o+ cases
even i+ it were 300 e++ective. These sa&eauthors=4 "er+or&ed a /7year case7control study.
A&on "atients +or who& "ro"hy7 lais was
reco&&ended, 8 o+ /0 cases o+ occurred
des"ite receivin antibiotic "ro"hylais. The
authors concluded that "ro"hylais was not
e++ective. n a se"arate study,=1 these authors
re"orted "oor awareness o+ reco&&endations +or
"ro7 "hylais a&on both "atients and
healthcare "roviders.
%tro& and colleaues
/
evaluated dental "ro"hylais and cardiac risk +actors in a
&ulticenter case7control study. These authors
re"orted that MP, conenital heart disease
D!#-E, rheu&atic heart disease D$#-E, and
"revious cardiac valve surery were risk +actors
+or the develo"&ent o+ . n that study, control
sub@ects without were &ore likely to have
underone a dental "rocedure than were those
with cases o+ D P 0.06E. The authors
concluded that dental treat&ent was not a risk
+actor +or even in "atients with valvular heart
disease and that +ew cases o+ could be
"revented with "ro"hylais even i+ it were 300
e++ective.
These studies are in aree&ent with a recently
"ublished rench study o+ the esti&ated risk o+
in adults with "redis7 "osin cardiac
conditions who underwent dental "rocedures
with or without antibiotic "ro"hylais.== These
authors con7 cluded that a hue nu&ber o+
"ro"hylais doses would be necessary to "revent
a very low nu&ber o+ cases.
A)solute Risk of IE Resultin" From a
DentalProcedure (o "ublished data accurately deter&ine theabsolute risk o+
that results +ro& a dental "rocedure. *nestudy re"orted that 30 to /0 o+ "atients with
caused by oral +lora underwent a "recedin
dental "rocedure Dwithin 60 or 3=0 days o+
onsetE.=8 The evidence linkin bactere&ia
associated with a dental "rocedure with is
larely circu&stantial, and the nu&ber o+ cases
related to a dental "rocedure is overes7 ti&ated
+or a nu&ber o+ reasons. or 40 years, noted
o"inion leaders in &edicine suested a link
between bactere&ia7 causin dental "roceduresand ,/6 and +or 80 years, the A#A "ublished
reularly u"dated uidelines that e&"hasized the
association between dental "rocedures and
and reco&7 &ended antibiotic "ro"hylais.3
Additionally, bactere&ia7 "roducin dental
"rocedures are co&&on2 it is esti&ated that at
least 80 o+ the "o"ulation in the <nited %tates
visits a dentist at least once a year. urther&ore,
there are nu&erous "oorly docu&ented case
re"orts that i&"licate dental "roce7 duresassociated with the develo"&ent o+ , but these
re"orts did not "rove a direct causal relationshi".
ven in the event o+ a close te&"oral
relationshi" between a dental "rocedure and
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, it is not "ossible to deter&ine with certainty
whether the bactere&ia that caused oriinated
+ro& a dental "rocedure or +ro& a rando&ly
occurrin bactere&ia as a result o+ routine daily
activities durin the sa&e ti&e "eriod. Many
case re"orts and reviews have included cases
with a re&ote "recedin dental "rocedure, o+ten
6 to 4 &onths be+ore the dianosis o+ . %tudies
suest that the ti&e +ra&e between bactere&ia
and the onset o+ sy&"to&s o+ is usually 1 to
39 days +or viridans rou" stre"tococci or
enterococci. $e"ortedly,
1= o+ such cases o+ occur within 1 days o+ bactere&ia and
=8 within 39 days.=: Althouh the u""er ti&e
li&it is not known, it is likely that &any cases o+
with incubation "eriods loner than / weeks
a+ter a dental "rocedure were incorrectly
attributed to the "rocedure. These and other+actors have led to a heihtened awareness
a&on "atients and healthcare "roviders o+ the
"ossible association between dental "rocedures
and , which likely has led to substantial
overre"ortin o+ cases attributable to dental
"rocedures.
Althouh the absolute risk +or +ro& a dental
"rocedure is i&"ossible to &easure "recisely,
the best available esti7 &ates are as +ollows5 +
dental treat&ent causes 3 o+ all cases o+viridans rou" stre"tococcal annually in the
<nited %tates, the overall risk in the eneral
"o"ulation is esti&ated to be as low as 3 case o+
"er 39 &illion dental "rocedures.93,:0,:3 The
esti&ated absolute risk rates +or +ro& a dental
"rocedure in "atients with underlyin cardiac
conditions are as +ollows5 MP, 3 "er 3.3
&illion "rocedures2 !#-, 3 "er 918 0002 $#-,
3 "er 39/ 0002 "resence o+ a "rosthetic cardiac
valve, 3 "er 339 0002 and "revious , 3 "er
:8 000 dental "rocedures.93,:3 Althouh these
calculations o+ risk are esti&ates, it is likely that
the nu&ber o+ cases o+ that result +ro& a
dental "rocedure is eceedinly s&all.
There+ore, the nu&ber o+ cases that could be
"revented by antibiotic "ro"hylais, even i+
300 e++ective, is si&ilarly s&all. *ne would
not e"ect antibiotic "ro"hylais to be near
300 e++ective, however, because o+ the nature
o+ the oranis&s and choice o+ antibiotics.
Risk of Adverse Reactions and ost<Effectiveness of Pro'h#lactic 2hera'# (on+atal adverse reactions, such as rash,diarrhea, and G
u"set, occur co&&only with the use o+
anti&icrobials2 however, only sinle7dose
thera"y is reco&&ended +or dental "ro"hylais,
and these co&&on adverse reactions are usually
not severe and are sel+7li&ited. atalana"hylactic reactions were esti&ated to occur
in 38 to /8 individuals "er 3 &illion "atients
who receive a dose o+ "enicillin.:/,:6 A&on
"atients with a "rior "enicillin use, 64 o+
+atalities +ro& ana"hylais occurred in those
with a known allery to "enicillin co&"ared
with 49 o+ +atalities a&on those with no
history o+ "enicillin allery.:9 These calculations
are at best rouh esti&ates and &ay overesti&ate
the true risk o+ death caused by +atal ana"hylais+ro& ad&inistration o+ a "enicillin. They are
based on retros"ective reviews or surveys o+
"atients or on healthcare "rovidersO recall o+
events. A "ros"ective study is necessary to
accurately deter&ine the risk o+ +atal ana"hy7
lais resultin +ro& ad&inistration o+ a
"enicillin.
or 80 years, the A#A has reco&&ended a
"enicillin as the "re+erred choice +or dental
"ro"hylais +or . -urin these
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1744 Circulation &cto)er 6, 9..
80 years, the !o&&ittee is unaware o+ any cases
re"orted to the A#A o+ +atal ana"hylais
resultin +ro& the ad&inistra7 tion o+ a "enicillin
reco&&ended in the A#A uidelines +or
"ro"hylais. The !o&&ittee believes that a
sinle dose o+ a&oicillin or a&"icillin is sa+eand is the "re+erred "ro"hy7 lactic aent +or
individuals who do not have a history o+ ty"e
hy"ersensitivity reaction to a "enicillin, such as
ana"hy7 lais, urticaria, or anioede&a. atal
ana"hylais +ro& a ce"halos"orin is esti&ated to
be less co&&on than +ro& "enicillin, at
a""roi&ately 3 case "er 3 &illion "atients.:8
atal reactions to a sinle dose o+ a &acrolide or
clinda&ycin are etre&ely rare.:4,:1 There has
been only 3 case re"ort o+ docu&entedClostridium difficile colitis a+ter a sinle dose o+
"ro"hylactic clinda&ycin.:=
$ummar
#Althouh it has lon been assu&ed that dental "rocedures
&ay cause in "atients with underlyin cardiac
risk +actors and that antibiotic "ro"hylais is
e++ective, scienti+ic "roo+ is lackin to su""ort
these assu&"tions. The collective "ub7 lishedevidence suests that o+ the total nu&ber o+
cases o+ that occur annually, it is likely that
an eceedinly s&all nu&ber are caused by
bactere&ia7"roducin dental "roce7 dures.
Accordinly, only an etre&ely s&all nu&ber o+
cases o+ &iht be "revented by antibiotic
"ro"hylais even i+ it were 300 e++ective. The
vast &a@ority o+ cases o+ caused by oral
&icro+lora &ost likely result +ro& rando&
bactere7 &ias caused by routine daily activities,such as chewin +ood, tooth brushin, +lossin,
use o+ tooth"icks, use o+ water irriation
devices, and other activities. The "resence o+
dental disease &ay increase the risk o+
bactere&ia associated with these routine
activities. There should be a shi+t in e&"hasis
away +ro& a +ocus on a dental "rocedure and
antibiotic "ro"hylais toward a reater e&"hasis
on i&"roved access to dental care and oral
health in "atients with underlyin cardiacconditions associated with the hihest risk o+
adverse out7 co&e +ro& and those conditions
that "redis"ose to the acuisition o+ .
ardiac onditions and Endocarditis
Previous A#A uidelines cateorized
underlyin cardiac conditions associated with
the risk o+ as those with hih risk, &oderate
risk, and neliible risk and reco&&ended
"ro"hylais +or "atients in the hih7 and
&oderate7risk cateories.3 or the "resent
uidelines on "revention o+ , the !o&&ittee
considered 6 distinct issues5 D3E What under7
lyin cardiac conditions over a li+eti&e have
the hihest "redis"osition to the acuisition o+
endocarditisJ D/E What underlyin cardiac
conditions are associated with the hihest risk
o+ adverse outco&e +ro& endocarditisJ D6E
%hould reco&&endations +or "ro"hylais be
based on either or both o+ these / conditionsJ
0nderl#in" onditions &ver a 1ifetime 2hatHave the Hi"hest Predis'osition to theAc@uisitionofEndocarditisn *l&sted !ounty, Minnesota, the incidence o+ in adults
raned +ro& 8 to 1 cases "er 300 000 "erson7
years.:: This incidence has re&ained stable
durin the "ast 9 decades and
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is si&ilar to that re"orted in other studies. 300 N306
Previously, $#- was the &ost co&&on
underlyin condition "redis"os7 in to
endocarditis, and $#- is still co&&on in
develo"in countries.:: n develo"ed countries,
the +reuency o+ $#- has declined, and MP is
now the &ost co&&on underlyin condition in
"atients with endocarditis.309
ew "ublished data uantitate the li+eti&e risk
o+ acuisi7 tion o+ associated with a s"eci+ic
underlyin cardiac condition. %teckelber and
Wilson:0 re"orted the li+eti&e risk o+ acuisition
o+ , which raned +ro& 8 "er 300 000
"atient7years in the eneral "o"ulation with no
known cardiac conditions to /340 "er 300 000
"atient7years in "atients who underwent
re"lace&ent o+ an in+ected "rosthetic cardiac
valve. n that study,:0 the risk o+ "er 300 000
"atient7years was 9.4 in "atients with MPwithout an audible cardiac &ur&ur and 8/ in
"atients with MP with an audible &ur&ur o+
&itral reuritation. Per 300 000 "atient7years,
the li+eti&e risk D6=0 to 990E +or $#- was
si&ilar to that D60= to 6=6E +or "atients with a
&echanical or bio"rosthetic cardiac valve. The
hihest li+eti&e risks "er 300 000 "atient7
years were as +ollows5 cardiac valve
re"lace&ent surery +or native valve , 4602
"revious , 1902 and "rosthetic valvere"lace&ent done in "atients with "rosthetic
valve endocarditis, /340. n a se"arate study, the
risk o+ "er 300 000 "atient7years was
/13 in "atients with conenital aortic stenosis
and 398 in "atients with ventricular se"tal
de+ect.308 n that sa&e study, the risk o+ be+ore
closure o+ a ventricular se"tal de+ect was &ore
than twice that a+ter closure. Althouh these data
"rovide use+ul ranes o+ risk in lare
"o"ulations, it is di++icult to utilize the& to
de+ine accurately the li+eti&e risk o+ acuisition
o+ in an individual "atient with a s"eci+ic
underlyin cardiac risk +actor. This di++iculty is
based in "art on the +act that each individual
cardiac condition, such as $#- or MP,
re"resents a broad s"ectru& o+ "atholoy +ro&
&ini&al to severe, and the risk o+ would
likely be in+luenced by the severity o+ valvular
disease.
!#- is another underlyin condition with
&ulti"le di++er7 ent cardiac abnor&alities that
rane +ro& relatively &inor to severe, co&"le
cyanotic heart disease. -urin the "ast /8 years,
there has been an increasin use o+ various
intracardiac valvular "rostheses and
intravascular shunts, ra+ts, and other devices
+or re"air o+ valvular heart disease and !#-.
The diversity and nature o+ these "rostheses and
"rocedures likely "resent di++erent levels o+ risk+or acuisition o+ . These +actors co&"licate
an accurate assess&ent o+ the true li+eti&e risk
o+ acuisition o+ in "atients with a s"eci+ic
underlyin cardiac condition.
*n the basis o+ the data +ro& %teckelber and
Wilson:3 and others,/ it is clear that the
underlyin conditions discussed above re"resent
a li+eti&e increased risk o+ acuisition o+
co&"ared with individuals with no known
underlyin cardiac condition. Accordinly, whenutilizin "revious A#A uide7 lines in the
decision to reco&&end "ro"hylais +or a
"atient scheduled to undero a dental, G tract,
or G< tract "rocedure, healthcare "roviders were
reuired to base their decision on "o"ulation7
based studies o+ risk o+ acuisition o+ that
&ay or &ay not be relevant to their s"eci+ic
"atient. urther&ore, "ractitioners had to weih
the "otential e++icacy o+ "ro"hylais in a
"atient who &ay neither need nor
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(ilson et al Prevention of Infective Endocarditis 174/
Table +. ,ardiac ,onditions Associated it't'e Hig'est Ris. of Ad&erse /utcome From(ndocarditis for 'ic' #ro"'yla)is it' ental#rocedures Is Reasonable
Prost'etic cardiac ale or prost'etic material used
for cardiac ale repair Pre(ious #8
;ongenital 'eart disease (;<D)
nrepaired cyanotic ;<D+ including palliaties'unts and conduits
;ompletely repaired congenital 'eart defect /it'prost'etic material or deice+ /'et'er placed &ysurgery or &y cat'eter interention+ during t'e first6 mont's after t'e procedure=
Repaired ;<D /it' residual defects at t'e site orad>acent to t'e site of a prost'etic patc' orprost'etic deice (/'ic' in'i&it endot'eliali?ation)
;ardiac transplantation recipients /'o deelopcardiac alulopat'y
83cept for t'e conditions listed a&oe+ anti&ioticprop'yla3is is no longer recommended for any ot'erform of ;<D-
=Prop'yla3is is reasona&le &ecause
endot'eliali?ation of prost'etic material occurs
/it'in 6 mont's after t'e procedure-
bene+it +ro& such thera"y aainst the risk o+
adverse reaction to the antibiotic "rescribed.
inally, healthcare "roviders had to consider the
"otential &edicoleal risk o+ not "rescribin
"ro"hylais. or dental "rocedures, there is a
rowin body o+ evidence that suests that
"ro"hylais &ay "revent only an eceedinly
s&all nu&ber o+ cases o+ , as discussed in
detail above.
ardiac onditions Associated (ith the
Hi"hest Risk of Adverse &utcome From
Endocarditis ndocarditis, irres"ective o+ the
underlyin cardiac condition, is a serious, li+e7
threatenin disease that was always +atal in the
"reantibiotic era. Advances in anti&icrobial
thera"y, early reconition and &anae&ent o+
co&"lications o+ , and i&"roved surical
technoloy have reduced the &orbidity and
&ortality o+ . (u&erous co&orbid +actors,
such as older ae, diabetes &ellitus,
i&&unosu""ressive conditions or thera"y, and
dialysis, &ay co&"licate . ach o+ these
co&orbid conditions inde"endently increases
the risk o+ adverse outco&e +ro& , and they
o+ten occur in co&bina7 tion, which +urther
increases &orbidity and &ortality rates.Additionally, there &ay be lon7ter&
conseuences o+ . *ver ti&e, the cardiac valve
da&aed by &ay undero "roressive
+unctional deterioration that &ay result in the
need +or cardiac valve re"lace&ent.
n native valve viridans rou" stre"tococcal or
enterococcal , the s"ectru& o+ disease &ay
rane +ro& a relatively benin in+ection to
severe valvular dys+unction, dehiscence,
conestive heart +ailure, &ulti"le e&bolicevents, and death2 however, the underlyin
conditions shown in Table 6 virtually always
have an increased risk o+ adverse outco&e. or
ea&"le, "atients with viridans rou"
stre"tococcal "rosthetic valve endocarditis have
a &ortality rate o+ /0 or reater,304 N30: whereas
the &ortality +ro& "atients with viridans rou"
stre"tococcal native valve is 8 or less.30=,330 N
334 %i&ilarly, the &ortality o+ enterococcal
"rosthetic valve endocarditis is hiher than thato+ native valve enterococcal B.301,30=,339,331
Moreover, "atients with "rosthetic valve
endocarditis are &ore likely than those with
native valve endocarditis to develo" heart
+ailure, the need +or cardiac valve re"lace&ent
surery, "erivalvular etension o+ in+ection, and
other co&"lications.
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1746 Circulation &cto)er 6, 9..
dures is reasonable, even thouh we
acknowlede that its e++ectiveness is unknown
8Class ((a * B>.
!o&"ared with "revious A#A uidelines,
under these revised uidelines, &any +ewer
"atients would be candidates to receive "ro"hylais. We believe that these revised
uidelines are in the best interest o+ "atients and
healthcare "roviders and are based on the best
available "ublished data and e"ert o"inion.
Additionally, the chane in e&"hasis to restrict
"ro"hylais +or only those "atients with the
hihest risk o+ adverse outco&e should reduce
the uncertainties a&on "atients and "roviders
about who should receive "ro"hylais. MP is
the &ost co&&on underlyin condition that "redis"oses to acuisition o+ in the Western
world2 however, the absolute incidence o+
endocarditis is etre&ely low +or the entire
"o"ulation with MP, and it is not usually
associated with the rave outco&e associated
with the con7 ditions identi+ied in Table 6.
Thus, "ro"hylais is no loner
reco&&ended +or this rou" o+ individuals.
inally, the ad&inistration o+ "ro"hylactic
antibiotics is not risk +ree, as discussed above.Additionally, the wides"read use o+ antibiotic
thera"y "ro&otes the e&erence o+ resistant
&icrooranis&s &ost likely to cause
endocarditis, such as viridans rou" stre"tococci
and enterococci. The +reuency o+ &ultidru7
resistant viridans rou" stre"tococci and entero7
cocci has increased dra&atically durin the "ast
/ decades. This increased resistance has reduced
the e++icacy and nu&7 ber o+ antibiotics available
+or the treat&ent o+ .
Anti)iotic Re"imens
General
Princi'lesAn antibiotic +or "ro"hylais should bead&inistered in a
sinle dose be+ore the "rocedure. + the dosae
o+ antibiotic is inadvertently not ad&inistered
be+ore the "rocedure, the dosae &ay be
ad&inistered u" to / hours a+ter the "rocedure.
#owever, ad&inistration o+ the dosae a+ter the "rocedure should be considered only when the
"atient did not receive the "re7"rocedure dose.
%o&e "atients who are scheduled +or an invasive
"rocedure &ay have a coincidental endocarditis.
The "resence o+ +ever or other &ani+estations o+
syste&ic in+ection should alert the "rovider to
the "ossibility o+ . n these circu&stances, it is
i&"ortant to obtain blood cultures and otherrelevant tests be+ore ad&inistration o+ antibiotics
intended to "revent . ailure to do so &ay
result in delay in dianosis or treat&ent o+ a
conco&itant case o+ .
Re"imens for Dental
ProceduresPrevious A#A uidelines on "ro"hylais listed asubstantial
nu&ber o+ dental "rocedures and events +or
which antibiotic "ro"hylais was reco&&endedand those "rocedures +or which "ro"hylais was
not reco&&ended. *n the basis o+ a critical
review o+ the "ublished data, it is clear that
transient viridans rou" stre"tococcal bactere&ia
&ay result +ro& any dental "rocedure that
involves &ani"ulation o+ the inival or
"eria"ical reion o+ teeth or "er+oration o+ the
oral &ucosa. t cannot be assu&ed that
&ani"ulation o+ a healthy7a""earin &outh or a
&ini&ally invasive dental "rocedure reduces thelikelihood o+ a bactere&ia. There+ore, antibiotic
"ro"hylais is reasonable +or "atients with the
conditions listed in Table 6 who undero any
dental "rocedure that involves the inival
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Table 0. ental #rocedures for 'ic'(ndocarditis#ro"'yla)is Is Reasonable for#atients in Table +
All dental procedures t'at inole manipulation of
gingial tissue or t'e periapical region of teet' orperforation of t'e oral mucosa
7'e follo/ing procedures and eents do notneed prop'yla3is2 routine anest'etic in>ections
t'roug' noninfected tissue+ taing dental
radiograp's+ placement of remoa&le prost'odontic
or ort'odontic appliances+ ad>ustment of ort'odontic
appliances+ placement of ort'odontic &racets+
s'edding of deciduous teet'+ and &leeding from
trauma to t'e lips or oral mucosa-
tissues or "eria"ical reion o+ a tooth and +orthose "rocedures that "er+orate the oral &ucosa
DTable 9E. Althouh "ro7 "hylais is
reasonable +or these "atients, its e++ectiveness is
unknown 8Class ((a * C >. This includes
"rocedures such as bio"sies, suture re&oval, and
"lace&ent o+ orthodontic bands, but it does not
include routine anesthetic in@ections throuh
nonin+ected tissue, the takin o+ dental
radiora"hs, "lace&ent o+ re&ovable
"rosthodontic or orthodontic a""li7 ances, "lace&ent o+ orthodontic brackets, or
ad@ust&ent o+ orthodontic a""liances. inally,
there are other events that are not dental
"rocedures and +or which "ro"hylais is not
reco&&ended, such as sheddin o+ deciduous
teeth and trau&a to the li"s and oral &ucosa.
n this li&ited "atient "o"ulation, "ro"hylactic
anti&icro7 bial thera"y should be directed
aainst viridans rou" stre"7 tococci. -urin the
"ast / decades, there has been a sini+i7 cantincrease in the "ercentae o+ strains o+ viridans
rou" stre"tococci resistant to antibiotics
reco&&ended in "revious A#A uidelines +or
the "revention o+ . Prabhu et al368 studied
susce"tibility "atterns o+ viridans rou"
stre"tococci recovered +ro& "atients with
dianosed durin a "eriod +ro& 3:13 to 3:=4
and co&"ared these susce"tibilities with those o+
viridans rou" stre"tococci +ro& "atients with
dianosed +ro& 3::9 to /00/. n that study,
none o+ the strains o+ viridans rou" stre"tococci
were "enicillin resistant in the early ti&e "eriod
co&"ared with 36 o+ strains that were
inter&ediately or +ully "enicillin resistant durin
the later ti&e "eriod. n that study, &acrolide
resistance increased +ro& 33 to /4 and
clinda&ycin resistance +ro& 0 to 9. A&on
68/ blood culture isolates o+ viridans rou"
stre"7 tococci, resistance rates were 36 +or
"enicillin, 38 +or a&oicillin, 31 +or
ce+triaone, 6= +or erythro&ycin, and
:4 +or ce"halein.364 The rank order o+
decreasin level o+ activity o+ ce"halos"orins inthat study was ce+"odoi&e eual to ce+triaone,
reater than ce+"rozil, and eual to ce+uroi&e,
and ce"halein was the least active. n other
studies, resistance o+ viridans rou" stre"tococci
to "enicillin raned +ro& 31 to 80M361N39/ and
resistance to ce+triaone raned +ro& // to
9/M.363,390 !e+triaone was / to 9 ti&es &ore
active in vitro than ce+azolin.363,390 %i&ilarly hih
rates o+ resistance were re"orted +or &acrolides,
ranin +ro& // to 8=M361,393,396,3992 resistanceto clinda&ycin raned +ro&
36 to
/1.3/=,3/:,363,361,
36=,390
Most o+ the strains o+ viridans rou"
stre"tococci in the above7cited studies were
recovered +ro& "atients with serious underlyin
illnesses, includin &alinancies and +ebrile
neu7 tro"enia. These "atients are at increased
risk o+ in+ection and colonization by &ulti"le7
druNresistant &icrooranis&s, in7 cludin
viridans rou" stre"tococci. Accordinly,
these
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(ilson et al Prevention of Infective Endocarditis 1747
Table 5. Regimens for a ental#rocedure
Regimen2 ingle Dose %0to 60 min
@efore Procedure
ituation Ag Adults ;'ildren
.ral Amo3icillin
50 mg9g
na&le to tae oral medication Ampici
llin/
! g #$ or #5
1 g #$ or #5
50 mgg #$ or
#
Allergic to penicillins or ampicillinBoral ;ep'ale3i
n= /R;lindamy
cin /R A?it'rom ycin or
!g
600mg
50 mg9g
!0 mg9g
15 mg9g
Allergic to penicillins or ampicillin and una&le to
tae oral medication;efa?olin orceftria3one=
/
1 g #$ or#5
#
50 mgg #$ or#
#$ indicates intramuscularC #+ intraenous-.r ot'er first: or second:generation oral cep'alosporin in equialent adult or pediatric dosage-
=;ep'alosporins s'ould not &e used in an indiidual /it' a 'istory of anap'yla3is+ angioedema+ or urticaria /it' penicillins or ampicillin-
strains &ay not be re"resentative o+
susce"tibility "atterns o+ viridans rou"
stre"tococci recovered +ro& "resu&ably nor7
&al individuals who undero a dental "rocedure.
-ieke&a et al361 re"orted that 6/ o+ strains o+
viridans rou" stre"to7 cocci were resistant to
"enicillin in "atients without cancer. Kin et al399
re"orted erythro&ycin resistance in 93 o+
stre"tococci recovered +ro& throat cultures in
otherwise healthy individuals who "resentedwith &ild res"iratory tract in+ections. n that
study, a+ter treat&ent with either azithro7 &ycin
or clinda&ycin, the "ercentae o+ resistant
stre"tococci increased to =/ and 13,
res"ectively. Accordinly, the resistance rates o+
viridans rou" stre"tococci are si&ilarly hih in
otherwise healthy individuals and in "atients
with serious underlyin diseases.
The i&"act o+ viridans rou" stre"tococcal
resistance on antibiotic "revention o+ isunknown. + resistance in vitro is "redictive o+
lack o+ clinical e++icacy, the hih resistance rates
o+ viridans rou" stre"tococci "rovide additional
su""ort +or the assertion that "ro"hylactic
thera"y +or a dental "rocedure is o+ little, i+ any,
value. t is i&"ractical to reco&&end
"ro"hylais with only those antibiotics, such as
vanco&ycin or a +luorouin7 olone, that are
hihly active in vitro aainst viridans rou"
stre"tococci. There is no evidence that suchthera"y is e++ective +or "ro"hylais o+ , and
their use &iht result in the develo"7 &ent o+
resistance o+ viridans rou" stre"tococci and
other &icrooranis&s to these and other
antibiotics.
n Table 8, a&oicillin is the "re+erred choice
+or oral thera"y because it is well absorbed in the
G tract and "rovides hih and sustained seru&
concentrations. or indi7 viduals who are alleric
to "enicillins or a&oicillin, the use o+
ce"halein or another +irst7eneration oral
ce"halos"orin, clinda&ycin, azithro&ycin, orclarithro&ycin is reco&7 &ended. ven thouh
ce"halein was less active aainst viridans rou"
stre"tococci than other +irst7eneration oral
ce"halos"orins in 3 study,364 ce"halein is
included in Table
8. (o data show su"eriority o+ 3 oral
ce"halos"orin over another +or "revention o+ ,
and eneric ce"halein is widely available and
relatively ine"ensive. Because o+ "ossible
cross7reactions, a ce"halos"orin should not bead&inistered
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1748 Circulation &cto)er 6, 9..
tract in+ections, "articularly in older &ales with
"rostatic hy"ertro7 "hy and obstructive uro"athy
or "rostatitis.
The ad&inistration o+ "ro"hylactic antibiotics
solely to "re7 vent endocarditis is not
reco&&ended +or "atients who undero G< orG tract "rocedures, includin dianostic
eso"ha7 oastroduodenosco"y or colonosco"y
8Class ((( * B>. This is in contrast to
"revious A#A uidelines that listed G or G<
tract "rocedures +or which "ro"hylais was
reco&&ended and those +or which "ro"hylais
was not reco&&ended.3 A lare nu&ber o+
dianostic and thera"eutic "rocedures that
involve the G, he"atobiliary, or G< tract &ay
cause transient enterococcal bactere&ia. The
"ossible association between G or G< tract
"roce7 dures and has not been studied as
etensively as the "ossible association with
dental "rocedures.398 The cases o+ te&"orally
associated with a G or G< tract "roce7 dure are
anecdotal, with either a sinle or very s&all
nu&ber o+ cases re"orted.=6 (o "ublished data
de&onstrate a conclusive link between
"rocedures o+ the G or G< tract and the
develo"&ent o+ .398 Moreover, no studies eist
that de&onstrate that the ad&inistration o+
anti&icrobial "ro"hylais "revents in
association with "rocedures "er+or&ed on the G
or G< tract.
There has been a dra&atic increase in the
+reuency o+ anti&icrobial7resistant strains o+
enterococci to "enicillins, vanco7 &ycin, and
a&inolycosides.394 N383 These antibiotics were
reco&7 &ended +or "ro"hylais in "reviousA#A uidelines.3 The sini+icance o+ the
increased +reuency o+ &ultiresistant strains o+
enterococci on "revention o+ in "atients who
undero G or G< tract "rocedures is unknown.
The hih "revalence o+ resistant strains o+
enterococci adds +urther doubt about the e++icacy
o+ "ro"hylactic thera"y +or G or G< tract
"rocedures.
Patients with in+ections o+ the G or G< tract
&ay have inter&ittent or sustained enterococcal bactere&ia. or "atients with the conditions
listed in Table 6 who have an established G or
G< tract in+ection or +or those who receive
antibiotic thera"y to "revent wound in+ection or
se"sis associated with a G or G< tract
"rocedure, it &ay be reasonable that the
antibiotic rei&en include an aent active
aainst enterococci, such as "enicillin,a&"icillin, "i"eracillin, or vanco&ycin 8Class
((. * B>2 however, no "ublished studies
de&onstrate that such thera"y would "revent
enterococcal .
or "atients with the conditions listed in Table
6 scheduled +or an elective cystosco"y or other
urinary tract &ani"ulation who have an
enterococcal urinary tract in+ection or coloniza7
tion, antibiotic thera"y to eradicate enterococci
+ro& the urine be+ore the "rocedure &ay be
reasonable 8Class ((. * B>. + the urinary
tract "rocedure is not elective, it &ay be
reasonable that the e&"iric or s"eci+ic
anti&icrobial rei&en ad&inistered to the
"atient contain an aent active aainst
enterococci 8Class ((. * B>.
A&oicillin or a&"icillin is the "re+erred
aent +or entero7 coccal coverae +or these
"atients. anco&ycin &ay be ad&inistered to
"atients unable to tolerate a&"icillin. + in+ection
is caused by a known or sus"ected strain o+
resistant enterococcus, consultation with an
in+ectious diseases e"ert is reco&&ended.
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Table . Summary of 2a3or ,'anges in 4"datedocument
e concluded t'at &acteremia resulting from dailyactiities is muc' more liely to cause #8 t'an&acteremia associated /it' a dental procedure-
e concluded t'at only an e3tremely small num&erof cases of #8 mig't &e preented &y anti&iotic
prop'yla3is een if prop'yla3is is 100" effecti(e- Anti&iotic prop'yla3is is not recommended &asedsolely on an increased lifetime ris of acquisitionof #8-
Eimit recommendations for #8 prop'yla3is only tot'ose conditions listed in
7a&le %-
Anti&iotic prop'yla3is is no longer recommended forany ot'er form of ;<D+ e3cept for t'e conditions
listed in 7a&le %- Anti&iotic prop'yla3is is reasona&le for all dentalprocedures t'at inole manipulation of gingialtissues or periapical region of teet' or perforation of
oral mucosa only for patients /it' underlying cardiacconditions associated /it' t'e 'ig'est ris of
aderse outcome from #8 (7a&le %)-
Anti&iotic prop'yla3is is reasona&le forprocedures on respiratory tract or infected sin+sin structures+ or musculoseletal tissue only for
patients /it' underlying cardiac conditionsassociated /it' t'e 'ig'est ris of aderseoutcome from #8 (7a&le %)-
Anti&iotic prop'yla3is solely to pre(ent #8 is notrecommended for 4 or 4#tract procedures-
Alt'oug' t'ese guidelines recommend c'anges in
indications for #8 prop'yla3is /it' regard to selecteddental procedures (see te3t)+ t'e /riting group
reaffirms t'at t'ose medical procedures listed as notrequiring #8 prop'yla3is in t'e 199 statementremain unc'anged and e3tends t'is ie/ to
aginal deliery+ 'ysterectomy+ and tattooing- Additionally+ t'e committee adises against &odypiercing for patients /it' conditions listed in 7a&le %
&ecause of t'e possi&ility of &acteremia+ /'ilerecogni?ing t'at t'ere are minimal pu&lis'ed dataregarding t'e ris of &acteremia or endocarditisassociated /it' &ody piercing-
Re"imens for Procedures on Infected $kin,
$kin$tructure, or usculoskeletal 2issue
These in+ections are o+ten "oly&icrobial, but
only sta"hylococci and 7he&olytic stre"tococci
are likely to cause . or "atients with the
conditions listed in Table 6 who undero a
surical "rocedure that involves in+ected skin,
skin structure, or &usculo7 skeletal tissue, it &ay
be reasonable that the thera"eutic rei&en
ad&inistered +or treat&ent o+ the in+ection
contain an aent active aainst sta"hylococci
and 7he&olytic stre"tococci, such as an
antista"hylococcal "enicillin or a ce"halos"orin
DTable 8 +or dosae2 Class ((. * C >.
anco&ycin or clinda&ycin &ay be
ad&inistered to "atients unable to tolerate a
7lacta& or who are known or sus"ected to have
an in+ection caused by a ðicillin7 resistant
strain o+ sta"hylococcus.
A su&&ary o+ the &a@or chanes in these
u"dated reco&7 &endations +or "revention o+
co&"ared with "revious A#A reco&&endations
is shown in Table 4.
$'ecific $ituations and
ircumstances
Patients Alread# Receivin" Anti)iotics
+ a "atient is already receivin lon7ter&
antibiotic thera"y with an antibiotic that is also
reco&&ended +or "ro"hy7 lais +or a dental
"rocedure, it is "rudent to select an antibiotic
+ro& a di++erent class rather than to increase the
dosae o+ the current antibiotic. or ea&"le,antibiotic rei&ens used to "revent the
recurrence o+ acute rheu&atic +ever are
ad&inistered in dosaes lower than those reco&7
&ended +or the "revention o+ . ndividuals
who take an oral
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(ilson et al Prevention of Infective Endocarditis 1749
"enicillin +or secondary "revention o+ rheu&atic
+ever or +or other "ur"oses are likely to have
viridans rou" stre"tococci in their oral cavity
that are relatively resistant to "enicillin or
a&oicillin. n such cases, the "rovider should
select either clinda&ycin, azithro&ycin, orclarithro&ycin +or "ro"hy7 lais +or a dental
"rocedure, but only +or "atients shown in Table
6. Because o+ "ossible cross7resistance o+
viridans rou" stre"tococci with ce"halos"orins,
this class o+ antibi7 otics should be avoided. +
"ossible, it would be "re+erable to delay a dental
"rocedure until at least 30 days a+ter co&"le7
tion o+ the antibiotic thera"y. This &ay allow
ti&e +or the usual oral +lora to be reestablished.
Patients receivin "arenteral antibiotic thera"y+or &ay reuire dental "rocedures durin
anti&icrobial thera"y, "articu7 larly i+
subseuent cardiac valve re"lace&ent surery is
antici7 "ated. n these cases, the "arenteral
antibiotic thera"y +or should be continued
and the ti&in o+ the dosae ad@usted to be
ad&inistered 60 to 40 &inutes be+ore the dental
"rocedure. This "arenteral anti&icrobial thera"y
is ad&inistered in such hih doses that the hih
concentration would overco&e any "ossiblelow7level resistance develo"ed a&on &outh
+lora Dunlike the concentration that would occur
a+ter oral ad&inistrationE.
Patients (ho Receive
Anticoa"ulantsntra&uscular in@ections +or "ro"hylaisshould be avoided
in "atients who are receivin anticoaulant
thera"y 8Class ( * %>. n these
circu&stances, orally ad&inistered rei7 &ensshould be iven whenever "ossible.
ntravenously ad&inistered antibiotics should be
used +or "atients who are unable to tolerate or
absorb oral &edications.
Patients (ho 0nder"o ardiac
$ur"er#A care+ul "reo"erative dental evaluation isreco&&ended so that
reuired dental treat&ent &ay be co&"leted
whenever "ossible be+ore cardiac valve sureryor re"lace&ent or re"air o+ !#-. %uch &easures
&ay decrease the incidence o+ late "rosthetic
valve endocarditis caused by viridans rou"
stre"tococci.
Patients who undero surery +or "lace&ent o+
"rosthetic heart valves or "rosthetic intravascular
or intracardiac &ate7 rials are at risk +or the
develo"&ent o+ in+ection.38/
Because the&orbidity and &ortality o+ in+ection in these
"atients are hih, "erio"erative "ro"hylactic
antibiotics are reco&&ended 8Class ( * B>.
arly7onset "rosthetic valve endocarditis is &ost
o+ten caused by S aureus, coaulase7neative
sta"hylo7 cocci, or di"htheroids. (o sinle
antibiotic rei&en is e++ec7 tive aainst all these
&icrooranis&s. Pro"hylais at the ti&e o+
cardiac surery should be directed "ri&arily
aainst sta"hylococci and should be o+ shortduration. A +irst7 eneration ce"halos"orin is
&ost o+ten used, but the choice o+ an antibiotic
should be in+luenced by the antibiotic susce"ti7
bility "atterns at each hos"ital. or ea&"le, a
hih "reva7 lence o+ in+ection by ðicillin7
resistant S aureus should "ro&"t the
consideration o+ the use o+ vanco&ycin +or
"erio"erative "ro"hylais. The &a@ority o+
nosoco&ial coaulase7neative sta"hylococci
are ðicillin7resistant. (onetheless, surical "ro"hylais with a +irst7eneration
ce"halos"orin &ay be reco&&ended +or these
"atients 8Class ( * %>.301 n hos"itals with a
hih "revalence o+ ðicillin7resistant strains o+
S epidermidis, surical "ro"hylais
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with vanco&ycin &ay be reasonable but has not
been shown to be su"erior to "ro"hylais with a
ce"halos"orin 8Class ((. * C >. Pro"hylais
should be initiated i&&ediately be+ore the
o"erative "rocedure, re"eated durin "roloned
"rocedures to &aintain seru& concentrations
intrao"eratively, and continued +or no &ore than
9= hours "osto"eratively to &ini&ize e&erence
o+ resistant &icro7 oranis&s 8Class ((a *
B>. The e++ects o+ cardio"ul&onary by"ass and
co&"ro&ised renal +unction on antibiotic
concentra7 tions in seru& should be considered
and dosaes ad@usted as necessary be+ore and
durin the "rocedure.
&ther
onsiderationsThere is no evidence that coronary artery by"assra+t surery is
associated with a lon7ter& risk +or in+ection.There+ore, antibi7 otic "ro"hylais +or dental
"rocedures is not needed +or individ7 uals who
have underone this surery. Antibiotic
"ro"hylais +or dental "rocedures is not
reco&&ended +or "atients with coronary artery
stents 8Class ((( * C >. The treat&ent and
"revention o+ in+ection +or these and other
endovascular ra+ts and "rosthetic devices are
addressed in a se"arate A#A "ubli7 cation.38/
There are insu++icient data to su""ort s"eci+icreco&7 &endations +or "atients who have
underone heart trans"lanta7 tion. %uch "atients
are at risk o+ acuired valvular dys+unction,
es"ecially durin e"isodes o+ re@ection.
ndocarditis that occurs in a heart trans"lant
"atient is associated with a hih risk o+ adverse
outco&e DTable 6E.386 Accordinly, the use o+
"ro"hylais +or dental "rocedures in cardiac
trans"lant reci"ients who develo" cardiac
valvulo"athy is reasonable, but the use+ul7 nessis not well established 8Class ((a * C 2 Table
9E. The use o+ "ro"hylactic antibiotics to "revent
in+ection o+ @oint "rosthe7 ses durin "otentially
bactere&ia7inducin "rocedures is not within the
sco"e o+ this docu&ent.
Future onsiderationsPros"ective "lacebo7controlled, double7blindedstudies o+ anti7
biotic "ro"hylais o+ in "atients who undero
a bactere&ia7 "roducin "rocedure would benecessary to evaluate accurately the e++icacy o+
"ro"hylais. Additional "ros"ective case7
control studies are needed. The A#A has
&ade substantial revisions to "reviously
"ublished uidelines on "ro"hylais. Given
our current reco&&endations, we antici"ate that
sini+i7 cantly +ewer "atients will receive
"ro"hylais +or a dental "rocedure. %tudies are
necessary to &onitor the e++ects, i+ any, o+ these
reco&&ended chanes in "ro"hylais. Theincidence o+ could chane or stay the sa&e.
Because the incidence o+ is low, s&all
chanes in incidence &ay take years to detect.
Accordinly, we ure that such studies be
desined and insti7 tuted "ro&"tly so that any
chane in incidence &ay be detected sooner
rather than later. %ubseuent revisions o+ the
A#A uidelines on the "reven7tion o+ will be
based on the results o+ these studies and other
"ublished data.
Acknowled"ment
sThe writin rou" thanks the +ollowininternational e"erts on in+ec7 tive endocarditis+or their valuable co&&ents5 -rs !hristaGohlke7 BaRrwol+, $oer #all, 'ae7#oon %on,!atherine Kil&artin, !atherine Le"ort, 'oseS M.MiroS , !hristo"h (aber, Graha& $oberts, and'an T.M. van der Meer. The writin rou" alsothanks -r Geore Meyer +or his hel"+ulco&&ents reardin astroenteroloy. inally,the writin rou" would like to thank Lori
#inrichs +or her su"erb assistance with the "re"aration o+ this &anuscri"t.
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17/0 Circulation &cto)er 6, 9..
Disclosures
riting *rou" isclosures
Researc'.t'er Researc'
peaersF
@ureau ./ners'ip;onsultant
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riting 4roup 8mploym 4r upport <onor #nter Adisory @oard .t
alter ilson $ayo G G Gon Go G G
Earry $- @addour $ayo G G Gon Go G G
Ro&ert 1- @altimore Yale niersity c'ool of $edicine G G Gon Go G G
Ann @olger niersity of ;alifornia+ an *rancisco G G Gon Go G G
Ro&ert .- @ono/ Gort'/estern niersity *ein&erg c'ool of G G Gon Go G G
Hane ;- @urns niersity of ;alifornia+ an Diego G G Gon Go G G
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of <ealt'=
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7'omas Pallasc' niersity of out'ern ;alifornia Gone
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;onsultationand e3pert
/itnesstestimony on
records ofpatients /it'
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Anne < - Ro/ley ;'ildrenFs $emorial <ospital+ ;'icago G G Gon Go G G
tanford 7- 'ulman ;'ildrenFs $emorial <ospital+ ;'icago G G Gon Go G G
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7'is ta&le represents t'e relations'ips of /riting group mem&ers t'at may &e perceied as actual or reasona&ly perceied conflicts of interest as reported on t'eDisclosure Kuestionnaire+ /'ic' all mem&ers of t'e /riting group are required to complete and su&mit- A relations'ip is considered to &e LignificantM if (1) t'e person
receies N10 000 or more during any 1!:mont' period+ or 5" or more of t'e personFs gross incomeC or (!) t'e person o/ns 5" or more of t'e oting stoc or s'ar e oft'e entity or o/ns N10 000 or more of t'e fair maret alue of t'e entity- A relations'ip is considered to &e L$odestM if it is less t'an LignificantM under t'epreceding definition-
$odest-
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(ilson et al Prevention of Infective Endocarditis 17/1
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.t
7'omas @as'ore Due niersity $edical ;enter Gone Gone Gone G Gone Gone G
Arnold @ayer niersity of ;alifornia+ Eos
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$ic'ael *reed @oston ;'ildrenFs <ospital Gone Gone Gone G Gone Gone G
elton 4ersony ;'ildrenFs <ospital of Ge/ Yor Gone Gone Gone G Gone Gone G
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=ignificant-
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Ton -!, %teckelber 'M, Balti&ore $%,
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ever, ndocarditis, and Kawasaki -isease2
!ouncil on !ardiovascular -isease in the
)oun2 !ouncils on !linical !ardioloy,
%troke, and !ardiovascular %urery and
Anesthesia2 A&erican #eart Association2
n+ectious -iseases %ociety o+ A&erica.
n+ective endo7 carditis5 dianosis,
anti&icrobial thera"y, and &anae&ent o+co&"li7 cations5 a state&ent +or healthcare
"ro+essionals +ro& the !o&&ittee on
$heu&atic ever, ndocarditis, and
Kawasaki -isease, !ouncil on !ar7
diovascular -isease in the )oun, and the
!ouncils on !linical !ar7 dioloy, %troke,
and !ardiovascular %urery and Anesthesia,
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n+ectious -iseases %ociety o+ A&erica
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30:. Wilson W$, -anielson GK, Giuliani $,
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#oen B, Miro 'M, ykyn %, Abrutyn ,
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338. %eton -', Tenenbau& M', Wilson W$,
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ndocarditis Treat&ent !onsortiu& Grou".
!e+triaone once daily +or +our weeks
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ce+triaone sodiu& +or 9 weeks5 e++icacy and
out"atient treat&ent +easibility. A!A. 3::/2
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331. Wilson W$, Wilkowske !', Wriht A',%ande MA, Geraci '.
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33=. Mansur A', -al Bo !M, ukushi&a 'T,
ssa %, Grinber M, Po&er7 antze++ PM.
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and &ortality
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"atients with and without the dianosis o+
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resistance in intensive care units.
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39:. %ou+ir L, Ti&sit ', Mahe !, !arlet ',
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anco&ycin7resistant and vanco&ycin7
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Partici"ants Grou". %urvey o+ blood strea&
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in 3::1 in the <nited %tates, !anada, and
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Anti&icrobial %ur7 veillance Prora&.
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38/. Baddour LM, Bett&ann MA, Boler A,
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/063.386. %her&an7Weber %, Aelrod P, %uh B,
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orrection
n the A#A Guideline by Wilson et al, Prevention o+ n+ective ndocarditis5
Guidelines ro& the A&erican #eart Association5 A Guideline ro& the
A&erican #eart Association $heu&atic ever, ndocarditis, and Kawasaki
-isease !o&&ittee, !ouncil on !ardiovascular -isease in the )oun, and the!ouncil on !linical !ardioloy, !ouncil on !ardiovascular %urery and
Anesthesia, and the Cuality o+ !are and *utco&es $esearch nterdisci"linary
Workin Grou", that "ublished online on A"ril 3:, /001 D-*5
30.3343;!$!<LAT*(A#A.304.3=60:8E, several chanes are needed.
A+ter online "ublication o+ these uidelines, the writin rou" was &ade
aware that there was con+usion a&on the readershi" reardin the use o+ the
lanuae $eco&&ended in the title o+ Tables 6 and 9 and &ay be
reasonable or &ay be considered in the tet when re+errin to our !lass
b reco&&endations. The writin rou" has clari+ied this by revisin the
wordin in the tables and chanin the lanuae in the tet to isreasonable. Accordin to eistin A&erican #eart Association "olicy +or
wordin o+ classes o+ reco&&en7 dations, this chane in lanuae is
acco&"anied by a shi+t in the class o+ reco&&endation +ro& b to a as
detailed in the errata.
3. %ince the online "ublication o+ this article, the A&erican Acade&y o+
Pediatrics and the nternational %ociety o+ !he&othera"y +or n+ection
and !ancerH have added their endorse&ents.
/. *n "ae 3164, in the +ootnotes section, the +ollowin +ootnote a""lies to
the endorse&ent by the nternational %ociety o+ !he&othera"y +orn+ection and !ancer5 H+ these uidelines are a""lied outside o+ the
<nited %tates o+ A&erica, ada"tation o+ the reco&&ended antibiotic
aents &ay be considered with res"ect to the reional situation.
6. *n "ae 3161, in the !onclusions "art o+ the abstract, the
+ollowin ite&s have been &odi+ied5 D/E n+ective endocarditis
"ro"hylais +or dental "rocedures is reasonable only +or "atients with
underlyin cardiac conditions associated with the hihest risk o+ adverse
outco&e +ro& in+ective endocarditis. D6E or "atients with these
underlyin cardiac condi7 tions, "ro"hylais is reasonable +or all dental
"rocedures that involve &ani"ulation o+ inival tissue or the "eria"icalreion o+ teeth or "er+oration o+ the oral &ucosa.
9. n Table 6 on "ae 3198, the +ollowin ite&s have been &odi+ied5
a. The title now reads5 !ardiac !onditions Associated With the #ihest
$isk o+ Adverse *utco&e ro& ndocarditis +or Which Pro"hylais
With -ental Procedures s $easonable
b. The +irst entry now reads5 Prosthetic cardiac valve or "rosthetic
&aterial used +or cardiac valve re"air
c. The second +ootnote now reads5 QPro"hylais is reasonable because
endothelialization o+ "rosthetic &aterial occurs within 4 &onths a+terthe "rocedure.
8. *n "ae 3198, second colu&n, second "arara"h, the +i+th sentence has
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orrection e377
:. *n "ae 3194, +irst colu&n, +ourth "arara"h, the +ourth and +i+th
sentences have been &odi+ied to read5 There+ore, antibiotic "ro"hylais
is reasonable +or "atients with the conditions listed in Table 6 who
undero any dental "rocedure that involves the inival tissues or
"eria"ical reion o+ a tooth and +or those "rocedures that "er+orate the
oral &ucosa DTable 9E. Althouh "ro"hylais is reasonable +or these "atients, its e++ectiveness is unknown 8Class ((a * C E.
30. or Table 9 on "ae 3194, the title has been chaned to5 -ental Procedures +orWhich
ndocarditis Pro"hylais s $easonable +or Patients in Table 6.
33. *n "ae 3191, second colu&n, under the $ei&ens +or $es"iratory
Tract Procedures headin, the second sentence has been &odi+ied to
read5 Antibiotic "ro"hylais with a rei&en listed in Table 8 is
reasonable 8Class ((a * C E +or "atients with the conditions listed in
Table 6 who undero an invasive "rocedure o+ the res"iratory tract that
involves incision or bio"sy o+ the res"iratory &ucosa, such astonsillecto&y and adenoidecto&y.
3/. n Table 4 on "ae 319=, the +ollowin ite&s have been u"dated5
a. The sith entry should read5 Antibiotic "ro"hylais is
reasonable +or all dental "rocedures that involve &ani"ulation o+
inival tissues. . . .
b. The seventh entry should read5 Antibiotic "ro"hylais is reasonable
+or "rocedures on res"iratory tract or in+ected skin, skin structures, or
&usculoskeletal. . ..
c. The last entry should read5 Althouh these uidelines reco&&end
chanes in indications +or "ro"hylais with reard to selected dental
"rocedures Dsee tetE, the writin rou" rea++ir&s that those &edical
"rocedures listed as not reuirin "ro"hylais in the 3::1 state&ent
re&ain unchaned and etends this view to vainal delivery and
hysterecto&y and tattooin. Additionally, the co&&ittee advises
aainst body "iercin +or "atients in Table 6 because o+ the "ossibility
o+ bactere&ia, while reconizin there are &ini&al "ublished data
reardin the risk o+ bactere&ia or endocarditis associated with body
"iercin.
36. *n "ae 319=, second colu&n, the headin at the to" o+ the colu&n has
been &odi+ied to read5 $ei&ens +or Procedures on n+ected %kin, %kin
%tructure, or Musculoskeletal Tissue.
39. *n "ae 319=, second colu&n, +irst "arara"h, the second sentence has
been &odi+ied to read5 or "atients with the conditions listed in Table 6
who undero a surical "rocedure that involves in+ected skin, skin
structure, or &usculoskeletal tissue, it &ay be reasonable that the
thera"eutic rei&en ad&inistered +or treat&ent o+ the in+ection contain an
aent active aainst sta"hylococci. . . .
38. *n "ae 319:, +irst colu&n, last "arara"h, the last sentence has been
&odi+ied to read5 n hos"itals with a hih "revalence o+ ðicillin7
resistant strains o+ S epidermidis, surical "ro"hylais with vanco&ycin
&ay be reasonable but has not been shown to be su"erior to "ro"hylais. .
..
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34. *n "ae 319:, second colu&n, under the headin *ther
!onsiderations, the "enulti&ate sentence has been &odi+ied to read5
Accordinly, the use o+ "ro"hylais +or dental "rocedures in cardiac
trans"lant reci"ients who develo" cardiac valvulo"athy is reasonable, but
the use+ulness is not well established DClass ((a * C 2 Table 9E.
These chanes have been &ade in the current "rint DCirculation.
/001233453164 N3189E and online versions o+ the article.
D&I: -.+--/-*IR01A2I&3AHA+-.+-47766
-ownloaded +ro& htt"5;;circ.aha@ournals.or; by uest on Auust 60, /036