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Prevention of infective endocarditis:

Guidelines from the American Heart

Association

Itsaranuwat Yongpisanphop (DDS.,B.Sc,B.Pol.Sc)

Dental Health Department

Watphleng Hospital, Ratchaburi

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Primary reasons for revision of the infective

endocarditis prophylaxis guidelines

IE is much more likely to result from frequent exposure to random bacteremias associated with daily activities than from bacteremia

caused by a dental, GI or GU tract procedure

Prophylaxis may prevent an exceedingly small number of cases of IE,

if any, in people who undergo a dental, GI tract or GU tract procedure

The risk of antibiotic-associated adverse events exceeds the benefit, if

any, from prophylactic antibiotic therapy

Maintenance of optimal oral health and hygiene may reduce theincidence of bacteremia from daily activities and is more important

than prophylactic antibiotics for a dental procedure to reduce the risk

of IE

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Pathogenesis of Infective Endocarditis

Formation of NBTE

Transient bacteremia

Bacterial adherence

Proliferation of bacteria within a vegetation

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Cardiac conditions and Endocarditis

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Cardiac conditions associated with the highest risk of adverse

outcome from endocarditis for which prophylaxis with dental

procedures is recommended

Prosthetic cardiac valve

Previous infective endocarditis

Congenital heart disease (CHD)*

Unrepaired cyanotic CHD, including palliative shunts and conduits

Completely repaired congenital heart defect with prosthetic material or

device, whether placed by surgery or by catheter intervention, during the first

six months after the procedure

Repaired CHD with residual defects at the site or adjacent to the site of a

prosthetic patch or prosthetic device (which inhibit endothelialization)

Cardiac transplantation recipients who develop cardiac valvulopathy

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Regimens Recommended

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General principles

Should be administered in a single dose before the procedure

The dosage may be administered up to 2 hrs after the procedure

when the patient did not receive the pre-procedure dose The presence of fever or other manifestations of systemic

infection should alert be IE

It is important to obtain blood cultures and other relevant tests

before administration of antibiotics intended to prevent IE

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Regimens for Dental Procedures

Antibiotic prophylaxis is recommended for patients

with the conditions listed who undergo any dental

procedure that involves the gingival tissues or

periapical region of a tooth and for those

procedures that perforate the oral mucosa

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The following procedures do not need

prophylaxis Routine anesthetic injection through noninfected tissue

Taking dental radiographs

Placement of removable prosthodontics or orthodonticappliances

Adjustment of orthodontic appliances

Placement of orthodontic brackets

Shedding of deciduous teeth

Bleeding from trauma to the lips or oral mucosa

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Regimens for a dental procedureRegimen: Single dose 30 to 60 min beforeprocedure

Situation Agent Adults Children

Oral Amoxicillin 2 g 50 mg/kg

Unable to take oralmedication

AmpicillinOR

Cefazolin or Ceftriaxone

2 g IM or IV

1 g IM or IV

50 mg/kg IM or IV

50 mg/kg IM or IV

Allergic to penicillinsor ampicillin - oral

CephalexinOR

ClindamycinOR

Azithromycin or Clarithromycin

2 g

600 mg

500 mg

50 mg/kg

20 mg/kg

15 mg/kg

Allergic to penicillinsor ampicillin andunable to take oralmedication

Cefazolin or CeftriaxoneOR

Clindamycin

1 g IM or IV

600 mg IM or IV

50 mg/kg IM or IV

20 mg/kg IM or IV

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Summary of Major Changes in Updated

Document Bacteremia resulting from daily activities is much more likely to cause

IE than bacteremia associated with a dental procedure

Only an extremely small number of cases of IE might be prevented by

antibiotic prophylaxis even if prophylaxis is 100% effective

Antibiotic prophylaxis is not recommended based solely on an

increased lifetime risk of acquisition of IE

Limit recommendations for IE prophylaxis only to those conditions

listed

Antibiotic prophylaxis is no longer recommended for any other form of

CHD, except for the conditions listed

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Summary of Major Changes in Updated

Document

Antibiotic prophylaxis is recommended for all dental

procedures that involve manipulation of gingival tissues or

periapical region of teeth or perforation of oral mucosa only for

patient in conditions listed

Antibiotic prophylaxis is recommended for procedures on

respiratory tract or infected skin, or musculoskeletal tissue onlyfor patient in conditions listed

Antibiotic prophylaxis is NOT recommended for GI or GU

tract procedures

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Specific Situations and Circumstances

Patients already receiving antibiotics

It is prudent to select an antibiotic from a different class rather than

to increase the doses of the current antibitotic

Patients who receive anticoagulants

IM injection should be avoided

Patients who undergo cardiac surgery

Dental treatment may be completed whenever possible before

cardiac valve surgery or replacement or repair of CHD

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Reference Wilson W, et al. Prevention of infective endocarditis: Guidelines from the American Heart

Association A guideline from the American Heart Association Rheumatic Fever, Endocarditis

and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the

Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the

Quality of Care and Outcomes Research Interdisciplinary Working Group. JADA 2007;138(6):739-

60.