Guidelines for Antibiotic Prophylaxis of Bacterial Endocarditis
Excerpted from the American Heart Association, JAMA, June 11, 1997 - Vol. 277, No. 22
Prophylactic Regimens for Dental, Oral, Respiratory Tract, or Esophageal Procedures
|
Situation |
Agent |
Regimen* |
| Standard Prophylaxis | Amoxicillin | Adults: 2g; Children: 50mg/kg orally 1 h before procedure |
| Unable to take oral medications | Ampicillin | Adults: 2g; Children: 50 mg/kg IM or IV within 30 min before procedure |
| Allergic to penicillin | Clindamycin, or
Cephalexin/ Cefadroxil**, or Azithromycin/ Clarithromycin |
Adults: 600 mg; Children:
20 mg/kg orally 1 h before procedure
Adults: 2g; Children: 50 mg/kg orally 1 h before procedure Adults: 500 mg; Children: 15 mg/kg orally 1 h before procedure |
| Allergic to penicillin & unable to take oral medications | Clindamycin or
Cefazolin |
Adults: 600 mg; Children:
20 mg/kg IV within 30 min before procedure
Adults: 1 g; Children: 25 mg/kg IM/IV within 30 min before procedure |
* Total children's dose should
not exceed adult dose.
**Cephalosporins should not be used in individuals with immediate-type hypersensitivity
reaction to penicillins.
Prophylactic Regimens for Genitourinary or Gastrointestinal (Excluding Esophageal) Procedures
| Situation | Agents | Regimen* |
| High-risk patients | Ampicillin + Gentamicin |
Adults: Ampicillin 2 g IM/IV
+ gentamicin 1.5 mg/kg (not to exceed 120 mg) within 30 min of procedure;
6 h later, ampicillin 1 g IM/IV or amoxicillin 1 g orally
Children: ampicillin 50 mg/kg IM/IV (not to exceed 2 g) + gentamicin 1.5 mg/kg within 30 min of procedure; 6 h later ampicillin 25 mg/kg IM/IV or amoxicillin 25 mg/kg orally |
| High-risk patients allergic to penicillin | Vancomycin** + Gentamicin** |
Adults: vancomycin 1g IV over
1-2 h + gentamicin 1.5 mg/kg IV/IM (not to exceed 120 mg); complete
infusion within 30 min of starting the procedure
Children: vancomycin 20 mg/kg IV over 1-2 h + gentamicin 1.5 mg/kg IV/IM; complete infusion within 30 min of starting the procedure |
| Moderate-risk patients | Amoxicillin or Ampicillin |
Adults: amoxicillin 2 g orally
1 h before procedure, or ampicillin 2 g IM/IV within 30 min of starting
procedure
Children: amoxicillin 50 mg/kg orally 1 h before procedure, or ampicillin 50 mg/kg IM/IV within 30 min of starting procedure |
| Moderate-risk patients allergic to penicillin | Vancomycin | Adults: vancomycin 1 g IV
over 1-2 h; complete infusion within 30 min of starting the procedure
Children: vancomycin 20 mg/kg IV over 1-2 h; complete infusion within 30 min of starting the procedure |
* Total children's dose should
not exceed adult dose
**Second dose of Vancomycin / Gentamicin not recommended
Specific Situations and Circumstances
Infected Patients: In addition to the prophylactic regimen for those procedures that involve infected tissue, antibiotic therapy should be directed against the most likely bacterial pathogen.
Patients Currently On Antibiotics: If a patient is currently taking an antibiotic normally used for endocarditis prophylaxis, it is prudent to select a drug from a different class, rather than increase the dose of the current antibiotic.
Algorithm for determining need for prophylaxis in Mitral Valve Prolapse:
| Murmur of Mitral Regurgitation Present | Prophylaxis recommended |
| Presence or Absence of Mitral Regurgitation Not Determined or Not Known: Refer for Evaluation | |
| Murmur and/or Echocardiographic/Doppler Demonstration of Mitral Regurgitation | Prophylaxis recommended |
| No Regurgitation or Echocardiographic Findings (if performed) | Prophylaxis, not recommended |
| No Confirmation Available, Immediate Need for Procedure | Prophylaxis recommended |
Indications for Antibiotic Prophylaxis for Endocarditis
| Prophylaxis Recommended | Prophylaxis Not 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 Most forms of uncorrected or corrected congenital heart defects (other than those in high or negligible risk category) Acquired valvular dysfunction (eg, rheumatic heart disease) Hypertrophic cardiomyopathy Mitral valve prolapse with valvular regurgitation and/or thickened leaflets |
Negligible-risk category (no greater risk than the general population) Isolated secundum atrial septal defect Surgically repaired atrial septal defect, ventricular septal defect, or patent ductus arteriosus (without residua beyond 6 mo) Previous coronary artery bypass graft surgery Mitral valve prolapse without valvular regurgitation Physiologic, functional, or innocent heart murmurs Previous Kawasaki disease (without valvular dysfunction) Previous rheumatic fever (without valvular dysfunction) Cardiac pacemakers (intravascular and epicardial) or implanted Defibrillators |
Procedures Requiring Prophylaxis
| Prophylaxis Recommended | Prophylaxis Not Recommended |
|
Dental Procedures: Dental extractions Prophylactic cleaning of teeth or implants (when bleeding is anticipated) Initial placement of orthodontic bands (not brackets) Periodontal procedures (surgery, scaling & root planing, probing, recall maintenance) Dental implant placement and reimplantation of avulsed teeth Endodontic (root canal) instrumentation or surgery Subgingival placement of antibiotic fibers or strips Intraligamentary local anesthetic injections |
Dental Procedures: Restorative dentistry (filling cavities, replace missing teeth) Local anesthetic injections (nonintraligamentary) Postoperative suture removal Placement of removable prosthodontic or orthodontic appliances Taking of oral impressions & oral radiographs Fluoride treatments Orthodontic appliance adjustment Shedding of primary teeth |
|
Respiratory tract: Tonsillectomy and/or adenoidectomy Surgical operations that involve respiratory mucosa Bronchoscopy with a rigid bronchoscope Gastrointestinal tract:* Sclerotherapy for esophageal varices Esophageal stricture dilation Endoscopic retrograde cholangiography Biliary tract surgery Surgical operati ons that involve intestinal mucosa Genitourinary tract: Prostatic surgery Cystoscopy Urethral dilation
*Prophylaxis is recommended for high-risk patients, optional for medium-risk patients. |
Respiratory tract: Endotracheal intubation Bronchosocpy with flexible bronchoscope, with/without biopsy Tympanostomy tube insertion Gastrointestinal tract: Transesophageal echocardiography Endoscopy with or without gastrointestinal biopsy Genitourinary tract: Vaginal hysterectomy Vaginal delivery Cesarean section In uninfected tissue: Urethral catheterization Uterine dilatation and curettage Therapeutic abortion Sterilization procedures Insertion or removal of intrauterine devices Other: Cardiac catheterization, including balloon angioplasty Implanted cardiac pacemakers, defibrillators & coronary stents Incision or biopsy of surgically scrubbed skin Circumcision |
