Endocarditis Prophylaxis, Adults 

Updated: Dec 10, 2014
  • Author: Buck Christensen; Chief Editor: Buck Christensen  more...
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Endocarditis Prophylaxis, Adults

The antibiotic prophylactic regimens below are recommended by the American Heart Association (AHA) only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis (IE). [1, 2, 3]

High-risk cardiac conditions

Antibiotic prophylaxis is indicated for the following high-risk cardiac conditions:

  • Prosthetic cardiac valve
  • History of infective endocarditis
  • Congenital heart disease (CHD) (antibiotic prophylaxis is recommended only for the following forms of CHD [and no others]): (1) unrepaired cyanotic CHD, including palliative shunts and conduits; (2) completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure; and (3) repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibits endothelialization)
  • Cardiac transplant recipients with cardiac valvular disease

Dental procedures

For patients with high cardiac risk, antibiotic prophylaxis is recommended for all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa.

The following dental procedures do not require endocarditis prophylaxis:

  • Routine anesthetic injections through noninfected tissue
  • Taking dental radiographs
  • Placement of removable prosthodontic or orthodontic appliances
  • Adjustment of orthodontic appliances
  • Placement of orthodontic brackets
  • Shedding of deciduous teeth
  • Bleeding from trauma to the lips or oral mucosa

Respiratory tract, infected skin, skin structures, or musculoskeletal tissue procedures

Antibiotic prophylaxis is recommended for invasive respiratory tract procedures that involve incision or biopsy of the respiratory mucosa (eg, tonsillectomy, adenoidectomy). Antibiotic prophylaxis is not recommended for bronchoscopy unless the procedure involves incision of the respiratory tract mucosa. For invasive respiratory tract procedures to treat an established infection (eg, drainage of abscess, empyema), administer an antibiotic that is active against Streptococcus viridans.

Patients with high cardiac risk who undergo a surgical procedure that involves infected skin, skin structure, or musculoskeletal tissue should receive an agent active against staphylococci and beta-hemolytic streptococci (eg, antistaphylococcal penicillin, cephalosporin).

If the causative organism of respiratory, skin, skin structure, or musculoskeletal infection is known or suspected to be Staphylococcus aureus, administer an antistaphylococcal penicillin or cephalosporin, or vancomycin (if patient is unable to tolerate beta-lactam antibiotics). Vancomycin is recommended for known or suspected methicillin-resistant strains of S aureus.

Genitourinary or GI tract procedures

Antibiotics are no longer recommended for endocarditis prophylaxis for patients undergoing genitourinary or gastrointestinal tract procedures.

Treatment regimens

The most common cause of endocarditis for dental, oral, respiratory tract, or esophageal procedures is S viridans (alpha-hemolytic streptococci). Antibiotic regimens for endocarditis prophylaxis are directed toward S viridans, and the recommended standard prophylactic regimen is a single dose of oral amoxicillin. Amoxicillin, ampicillin, and penicillin V are equally effective in vitro against alpha-hemolytic streptococci; however, amoxicillin is preferred because of superior gastrointestinal absorption that provides higher and more sustained serum levels.

All doses shown below are administered once as a single dose 30-60 minutes before the procedure.