CHAPTER 221 Antibiotic Prophylaxis

Antibiotic Prophylaxis for Infective Endocarditis

The publication of new American Heart Association guidelines for the prevention of infective endocarditis by Wilson and associates (2007) in Circulation represents a major change. The American Heart Association originally published guidelines for infective endocarditis prevention in 1955. Before the 2007 update, the last changes were in 1997. Since that time, the efficacy of antimicrobial prophylaxis to prevent infective endocarditis in patients undergoing dental, gastrointestinal, and genitourinary procedures has been questioned by many groups. Those seeking further discussion beyond that presented here are referred to the American Heart Association guideline.

Major changes in the guidelines include the following:

• Emphasizes that most cases of infective endocarditis are caused by random bacteremia related to daily exposures, such as chewing, tooth brushing, flossing, and use of toothpicks.

• Review of the literature shows that prophylaxis prevents a very small number of cases of infective endocarditis.

• The risk of antibiotic-associated adverse events appears to exceed the benefit of prophylactic antibiotic therapy, which seems to be very small.

• Current recommendations are based on consideration of those conditions that are most likely to have an adverse outcome from infective endocarditis, not necessarily those with the highest lifetime risk of acquiring infective endocarditis.

• Although the committee acknowledges that there is no convincing evidence that prophylaxis is effective, prophylaxis is considered reasonable for those with the highest risk of adverse outcomes from infective endocarditis.

• Mitral valve prolapse, which is the most common underlying condition that might predispose to infective endocarditis, is not on the list of recommended conditions for prophylactic antibiotic use because the absolute incidence of infective endocarditis in this population is very low, and poor outcomes are extremely uncommon.

Box 221-1 lists the conditions that are at highest risk for poor outcomes with infective endocarditis and should therefore be considered for prophylaxis with antibiotics for some procedures. No other cardiac conditions should be considered for prophylaxis for any dental, gastrointestinal, or genitourinary procedures.

Box 221-1 Cardiac Conditions with High Risk of Adverse Outcome

Adapted from Wilson W, Taubert KA, Gewitz M, 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. Circulation 116:1736–1754, 2007.

Prosthetic cardiac valve

Previous infectious endocarditis

Congenital heart disease including only the following:

• Unrepaired cyanotic congenital heart disease

• Palliative shunts and conduits

• Completely repaired congenital heart defect with prosthetic material or device (placed surgically or by catheter) during first 6 months after procedure (until endothelialization of prosthetic material occurs)

• Repaired congenital heart disease with residual defects at site of prosthetic patch or device (because endothelialization may be inhibited)

Cardiac transplant recipients with cardiac valvulopathy

Prior recommendations separated dental procedures into those for which prophylaxis was or was not recommended, based on risk of bacteremia and subsequent development of infective endocarditis. The updated recommendations indicate prophylaxis for any dental procedure that might involve manipulation of the gingival tissues or apical region of the teeth or perforation of the oral mucosa, including teeth cleaning, only for those at high risk (see Box 221-1). Box 221-2 lists dental procedures for which antibiotic prophylaxis is not recommended for anyone.

Box 221-2 Dental Procedures for Which Antibiotic Prophylaxis Is Not Recommended

Adjustment of orthodontic appliances

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