Antibiotic Prophylaxis for the Prevention of Infective Endocarditis

March 20, 2013


By Antonio Del Valle DMD, MD and Shahin Shahgoli DDS

Antibiotic prophylaxis is the administration of antibiotics to a dental patient for the prevention of the potential harmful consequences of bacterermia, which may be caused by invasion of the oral bacterial flora into an injured gingival or peri-apical vessel during dental treatment.  This issue remains a subject under constant revision, with the intention of providing recommendations based on sound scientific evidence.  currently there are official guidelines for dental antibiotic prophylaxis for the prevention of infective endocarditis.  The following are the most current guidelines as recommended by the American Heart Association (AHA) and American Dental Association (ADA).

Antibiotic prophylaxis is recommended only for patients with underlining cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis.  Prophylaxis is recommended for all dental procedures that  involve manipulation of gingival tissue or the periapical region of the teeth, or perforation of oral mucosa.

The current recommendations include the use of antibiotic prophylaxis for patients with the following:

~ artificial heart valves

~ history of infective endocarditis

~ a cardiac transplant that develops a heart valve problem

The current recommendations also include the use of antibiotic prophylaxis for patients with the following congenital (present from birth) heart conditions.  Patients should check with their cardiologist if there is any question as to whether they fall into on of these categories:

~ unrepaired or incompletely repaired cyanotic congenial heart disease, including those      with palliative shunts and conduits

~ a completely repaired congenital heart defect with prosthetic material of device, whether placed by surgery or by catheter intervention, during the first six months after the procedure

~ any repaired congenital heart defect with residual defect at the site or adjacent to the    site of a prosthetic patch or a prosthetic device

Patients who took prophylactic antibiotics in the past but no longer need them include those with:

~ mitral valve prolapse

~ rheumatic heart disease

~ bicuspid valve disease

~ calcified aortic stenosis

~ congenital heart conditions such as ventricular septal defect, atrial septal defect and hypertrophic cardiomyopathy

Prophylaxis regimens included below are administered once as a single dose 30-60 minutes before the procedure:

1.  Amoxicillin 2 g PO, pediatric dose:50 mg/kg PO; does not exceed 2 g/dose

If allergic to penicillin

  1.  Cephalexin 2g PO, pediatric dose: 50 mg/kg PO; not to exceed 2g/dose
  2.  Azithromycin or Clarithromycin: 500 mg PO, pediatric dose: 15 mg/kg PO; not to exceed 500 mg/dose
  3. Clindamycin 600 mg PO, pediatric dose: 20 mg/kg PO; not to exceed 600 mg/dose

The recommendation is that the antibiotic be given before the procedure.  This is important, because it allows the antibiotic to reach adequate blood levels. However, sometimes patients forget to premeditate prior to their appointment.  In such cases, the recommendations to prevent infective endocarditis state:

“If the dosage of antibiotic is inadvertently not administered before the procedure, the dosage may be administered up to two hours after the procedure.”

Another area of concern for dentists involves patients who require prophylaxis but are already taking antibiotics for another condition.  In these cases, the guidelines for infective endocardocarditis recommended that the dentist select an antibiotic from a different class than the ont the patient is already taking.  For example, if the patient is taking amoxicillin, the dentist should select clindamycin, azithromycin, or clarithrom for prophylaxis.

It should be understood that these guidelines are subject to change and may be revisited in the future.  In cases where any doubts exist consulting with the patients cardiologist is recommended.

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