Prevention of Bacterial Endocarditis: Antibiotic Prophylaxis -- Printable Tables

TITLE:	PREVENTION OF BACTERIAL ENDOCARDITIS: ANTIBIOTIC PROPHYLAXIS
AUTHOR:	ROBIN K. AVERY, MD -- Department of Infectious Diseases and Transplant Center
PUBLISHED:	JUNE 19, 2002

Table 1:

Cardiac Conditions and Endocarditis Prophylaxis

Endocarditis Prophylaxis Recommended

High-Risk Category
- Prosthetic cardiac valves, including bioprosthetic and homograft valves
- Previous bacterial endocarditis
- Complex cyanotic congenital heart disease (eg, single ventricle states, transposition of the great arteries, tetralogy of Fallot)
- Surgically constructed systemic-pulmonary shunts or conduits
Moderate-Risk Category
- Congenital cardiac malformations other than those listed in the high-risk and negligible-risk categories
- Acquired valvular dysfunction (eg, rheumatic heart disease)
- Hypertrophic cardiomyopathy
- Mitral valve prolapse with valvular regurgitation and/or thickened leaflets¹

Endocarditis Prophylaxis Not Recommended

Negligible-risk category (no greater risk than the general population)
- Isolated secundum atrial septal defect
- Surgical repair of atrial septal defect, ventricular septal defect or patent ductus arteriosus (without residua beyond six months)
- Previous coronary artery bypass graft surgery
- Mitral valve prolapse without valvular regurgitation or thickened leaflets¹
- Physiologic, functional or innocent heart murmur
- Previous Kawasaki disease without valvular dysfunction
- Previous rheumatic fever without valvular dysfunction
- Cardiac pacemakers (intravascular and epicardial) and implanted defibrillators

1. Some experts feel that the presence of an audible nonejection click even without a murmur warrants prophylaxis. A detailed discussion is found in reference 1.

Adapted from Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis. Recommendations by the American Heart Association. JAMA. 1997; 277:1794-1801. Copyrighted 1997, American Medical Association.

Table 2:

Dental Procedures and Endocarditis Prophylaxis

Endocarditis Prophylaxis Recommended¹

Dental extractions
Periodontal procedures including surgery, scaling, root planing, probing and recall maintenance
Dental implant placement and reimplantation of avulsed teeth
Endodontic (root canal) instrumentation or surgery only beyond the apex
Subgingival placement of antibiotic fibers or strips
Initial placement of orthodontic bands (but not brackets)
Intraligamentary local anesthetic injections
Prophylactic cleaning of teeth or implants, where bleeding is anticipated

Endocarditis Prophylaxis Not Recommended

Restorative dentistry (operative and prosthodontic)² with or without retraction cord³
Local anesthetic injections (nonintraligamentary)
Intracanal endodontic treatment (post placement and buildup)
Placement of rubber dams
Postoperative suture removal
Placement of removable prosthodontic or orthodontic appliances
Oral impressions
Fluoride treatments
Oral radiographs
Orthodontic appliance adjustment
Shedding of primary teeth

Prophylaxis is recommended for patients with high-and moderate-risk cardiac conditions.
This includes restoration of decayed teeth (filling cavities) and replacement of missing teeth.
Clinical judgment may indicate antibiotic use in selected circumstances that may create significant bleeding.

Adapted from Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis. Recommendations by the American Heart Association. JAMA. 1997;277:1794-1801. Copyrighted 1997, American Medical Association.

Table 3:

Other Procedures and Endocarditis Prophylaxis

Endocarditis Prophylaxis Recommended

Respiratory tract
- Tonsillectomy and/or adenoidectomy
- Surgical procedures that involve respiratory mucosa
- Bronchoscopy with a rigid bronchoscope
Gastrointestinal Tract¹
- Sclerotherapy for esophageal varices
- Esophageal stricture dilation
- Endoscopic retrograde cholangiography with biliary obstruction
- Biliary tract surgery
- Surgical procedures that involve intestinal mucosa
Genitourinary tract
- Prostatic surgery
- Cystoscopy
- Urethral dilation

Endocarditis Prophylaxis Not Recommended

Respiratory Tract
- Endotracheal intubation
- Bronchoscopy using a flexible bronchoscope, with or without biopsy²
- Tympanostomy tube insertion
Gastrointestinal Tract¹
- Transesophageal echocardiography²
- Endoscopy with or without gastrointestinal biopsy²
Genitourinary Tract
- Vaginal hysterectomy²
- Vaginal delivery²
- Caesarean section
In uninfected tissue:
- Urethral catheterization
- Uterine dilatation and curettage
- Therapeutic abortion
- Sterilization procedures
- Insertion or removal of intrauterine devices
Other procedures
- Cardiac catheterization, including balloon angioplasty
- Implanted cardiac pacemakers, implanted defibillators, and coronary stents
- Incision or biopsy of surgically scrubbed skin
- Circumcision

Prophylaxis is recommended for high-risk patients and is optional for medium-risk patients.
Prophylaxis is optional for high-risk patients.

Adapted from Danjani AS, Taubert KA, Wilson W, et al. Prevention of Bacterial Endocarditis. Recommendations by the American Heart Association. JAMA. 1997;277:1794-1801. Copyright 1997, American Medical Association.

Table 4:
Endocarditis Prophylactic Regimens for Dental, Oral, Respiratory Tract, and Esophageal Procedures
Situation	Agent	Regimen¹
Standard general prophylaxis	Amoxicillin	Adults: 2.0 g; children 50 mg/kg, orally 1 h before procedure
Unable to take oral medications	Ampicillin	Adults: 2.0 g IM or IV; children 50 mg/kg IM or IV within 30 min before procedure
Patient is allergic to penicillin	Clindamycin or	Adults: 600 mg; children 20 mg/kg orally 1 h before procedure
	or Cefadroxil² or cephalexin²	Adults: 2 g; children 50 mg/kg orally 1 h before procedure
	or Azithromycin or clarithromycin	Adults: 500 mg; children 15 mg/kg orally 1 h before procedure
Allergic to penicillin and unable to take oral medications	Clindamycin	Adults: 600 mg; children 20 mg/kg IV within 30 minutes before procedure
Allergic to penicillin and unable to take oral medications	or Cefazolin²	Adults: 1.0 g; children 25 mg/kg IM or IV within 30 min before procedure
1. The total pediatric dose should not exceed the adult dose. 2. Cephalosporins should not be used in patients with an immediate-type hypersensitivity reaction (urticaria, angioedema or anaphylaxis) to penicillins. Adapted from Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis. Recommendations by the American Heart Association. JAMA. 1997; 277:1794-1801. Copyright 1997, American Medical Association.

Table 5:
Endocarditis Prophylactic Regimens for Genitourinary and Gastrointestinal Procedures¹
Situation	Agent	Regimen¹
High risk patients	Ampicillin plus gentamicin	Adults: ampicillin 2.0 g IM or IV, plus gentamicin, 1.5 mg/kg IM or IV (gentamicin dose should not exceed 120 mg), given within 30 min of starting procedure; 6 h later, ampicillin, 1 g IM or IV, or amoxicillin, 1 g orally³ Children: ampicillin, 50 mg/kg IM or IV (not to exceed 2.0 g), plus gentamicin, 1.5 mg/kg, within 30 min of starting procedure; 6 h later, ampicillin, 25 mg/kg IM or IV, or amoxicillin, 25 mg/kg orally³
High risk patients allergic to ampicillin/amoxicillin	Vancomycin plus gentamicin	Adults: vancomycin, 1.0 g IV over 1-2 h, plus gentamicin, 1.5 mg/kg IV or IM (gentamicin dose ampicillin/amoxicillin not to exceed 120 mg); injection or infusion should be completed within 30 min of starting procedure³ Children: vancomycin 20 mg/kg IV over 1-2 h, plus gentamicin, 1.5 mg/kg IV or IM; injection or infusion should be completed within 30 min of starting procedure³
Moderate-risk patients	Amoxicillin or ampicillin	Adults: amoxicillin 2.0 g orally 1 h before procedure, or ampicillin 2.0 g IM or IV within 30 min of starting procedure Children: amoxicillin, 50 mg/kg orally 1 h before procedure, or ampicillin, 50 mg/kg IM or IV within 30 min of starting procedure
Moderate-risk patients allergic to ampicillin/amoxicillin	Vancomycin	Adults: vancomycin 1.0 g IV over 1-2 h; infusion should be completed within 30 min of starting procedure³ Children: vancomycin 20 mg/kg IV over 1-2 h; infusion should be completed within 30 min of starting procedure³
Adapted from Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis. Recommendations by the American Heart Association. JAMA. 1997; 277:1794-1801. Copyright 1997, American Medical Association. Abbreviations: IM = intramuscular; IV = intravenous Excluding esophageal procedures The total pediatric dose should not exceed the adult dose A second dose of gentamicin or vancomycin is not recommended

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