Endocarditis Prophylaxis, Children

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, 4]

Risk factors for developing IE include the following[4] :

• Heart valve disease
• Previous  heart valve surgery
• Congenital heart disease
• Intravenous drug use
• Previous history of IE

High-risk cardiac conditions

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

• Prosthetic cardiac valve
• Prosthetic material used for heart valve repair, such as annuloplasty rings, chords, or clips
• 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 valve regurgitation due to a structurally abnormal valve ^[4]
• Mechanical circulatory support ^[5]  

Prophylaxis is reasonable because endothelialization of prosthetic material occurs within 6 months after the procedure.[4]

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

Additional considerations

The practitioner and patient should consider possible clinical circumstances that may suggest the presence of a significant medical risk in providing dental care without antibiotic prophylaxis, as well as the known risks of frequent or widespread antibiotic use.

As part of the evidence-based approach to care, this clinical recommendation should be integrated with the practitioner’s professional judgment in consultation with the patient’s physician, along with the patient’s needs and preferences.[6, 7]

These considerations include, but are not limited to, the following:

• Patients with previous late artificial joint infection
• Increased morbidity associated with joint surgery (wound drainage/hematoma)
• Patients undergoing treatment for severe and spreading oral infections (cellulitis)
• Patients with increased susceptibility to systemic infection
• Congenital or acquired immunodeficiency
• Patients on immunosuppressive medications
• Patients with diabetes who have poor glycemic control
• Patients with systemic immunocompromising disorders (eg, rheumatoid arthritis, lupus erythematosus)
• Patients in whom extensive and invasive procedures are planned
• Prior to surgical procedures in patients at significant risk for medication-related jaw osteonecrosis of the jaw ^{[6, 7]}

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 of the following pediatric doses are administered once as a single dose 30-60 minutes before the procedure[7] :

• Standard general prophylaxis: Amoxicillin 50 mg/kg PO; not to exceed 2 g/dose

• Unable to take oral medication: Ampicillin 50 mg/kg IV/IM; not to exceed 2 g/dose

• Allergic to penicillin: (1) cephalexin 50 mg/kg PO (not to exceed 2 g/dose) or other first- or second-generation oral cephalosporin in equivalent dose (do not use cephalosporins in patients with a history of immediate-type hypersensitivity penicillin allergy, such as urticaria, angioedema, anaphylaxis) or (2) azithromycin or clarithromycin 15 mg/kg PO (not to exceed 500 mg/dose)

• Allergic to penicillin and unable to take oral medication: cefazolin or ceftriaxone 50 mg/kg IV/IM (not to exceed 1 g/dose) (do not use cephalosporins in patients with a history of immediate-type hypersensitivity penicillin allergy, such as urticaria, angioedema, anaphylaxis)

Clindamycin is not recommended for antibiotic prophylaxis for a dental procedure.[7]

Vaccines to prevent microbial infections in a high-risk paediatric population

Arguments were established that active or passive immunization techniques would be extremely efficient in a high-risk neonatal or paediatric population. Vaccines for viridans streptococci, Candida albicans, and Staphylococci species have been developed and are at the preclinical phase. Some of these also have been tested in clinical trials.[5]