Endocarditis Prophylaxis, Adults

Updated: Aug 04, 2021
Author: Vinh Q Nguyen, MD, FACC; Chief Editor: Buck Christensen 

Endocarditis Prophylaxis, Adults

AHA Guidelines (2007), ESC Guidelines for the Management of Infective Endocarditis (2015), AHA/ACC Focused Update of Patients with Valvular Heart Disease (2017)

The American Heart Association (AHA) Guidelines for Prevention of Infective Endocarditis were updated in 2007 and included numerous changes from the previous 1997 version. The guidelines were approved by the Council on Scientific Affairs of the American Dental Association as it relates to dentistry. Additionally, the guideline is endorsed by the Infectious Diseases Society of America.[1]

Major changes in the updated AHA guidelines include the following:

  • Only an extremely small number of cases of infective endocarditis (IE) might be prevented by antibiotic prophylaxis for dental procedures even if such prophylactic therapy were 100% effective.
  • IE prophylaxis for dental procedures should be recommended only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from IE.
  • For patients with these underlying cardiac conditions, 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.
  • Prophylaxis is not recommended based solely on an increased lifetime risk of acquisition of infective endocarditis.
  • Administration of antibiotics solely to prevent endocarditis is not recommended for patients who undergo a genitourinary or gastrointestinal tract procedure.

The antibiotic prophylactic regimens recommended by the AHA are only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis.[1, 2]

High-risk cardiac conditions

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

  • Prosthetic cardiac valve, including transcatheter aortic valve replacement (TAVR) [3, 2]
  • Prosthetic material used for valve repair, ie, annuloplasty rings and chords [3]
  • Cardiac transplant with valve regurgitation due to a structurally abnormal valve [3]
  • Congenital heart disease (CHD) (except for the conditions listed below, antibiotic prophylaxis is no longer recommended for any other form of CHD): (1) Any type of cyanotic congenital heart disease; (2) Any congenital heart disease repaired with a prosthetic material placed surgically or percutaneously, up to 6 months after the procedure or lifelong if there is residual shunt or valvular regurgitation; (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

AAOS Guidelines

A clinical practice guideline produced jointly by the American Academy of Orthopaedic Surgeons (AAOS) and the American Dental Association (ADA) was published in April 2013.[4] The recommendation proposes that the practitioner consider discontinuing the long-standing practice of routinely prescribing prophylactic antibiotic for patients with orthopaedic implants who undergo dental procedures. The grade of recommendation is listed as limited, indicating unconvincing evidence. The previous guideline from 2003 was updated in 2009 and endorsed antibiotic prophylaxis before dental procedures in all patients with prosthetic joints, with no 2-year time limit.[5] The 2009 guideline position had been criticized for excessive and unwarranted antibiotic use.[6] Furthermore, the 2014 expert panel developed an evidenced-based guideline that does not recommend prophylactic antibiotics prior to dental procedures to prevent prosthetic joint infection.[7]

For further information on infective endocarditis, see Infective Endocarditis, Pediatric Bacterial Endocarditis, Infectious Endocarditis, and Neurological Sequelae of Infective Endocarditis.

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:

  • Treatment of superficial caries [2]
  • 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

Cardiac or Vascular Interventions

In patients undergoing percutaneous implantation of a prosthetic valve, pacemaker, or implantable cardiodefibrillator, perioperative antibiotic prophylaxis is recommended; efficacy of cefazolin 1 g has been demonstrated.[2]

Respiratory Tract, Infected Skin, Skin Structures, or Musculoskeletal Tissue Procedures

Antibiotic prophylaxis is not recommended for respiratory tract procedures, including bronchoscopy, laryngoscopy, and endotracheal intubation.[2] However, it is recommended for invasive respiratory tract procedures that involve incision or biopsy of the respiratory mucosa (eg, tonsillectomy, adenoidectomy). For invasive respiratory tract procedures to treat an established infection (eg, drainage of abscess, empyema), administer an antibiotic that is active against Streptococcus viridans.[1]

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 in patients undergoing genitourinary or gastrointestinal tract procedures, including vaginal or caesarean delivery.

Infective Endocarditis Incidence after Implementing AHA and NICE Revised Guidelines

In 2002, the French recommendations for endocarditis prophylaxis[8] deemphasized broad use of antibiotic prophylaxis and limited the indication to individuals with highest benefit-to-risk ratio. They noted lack of scientific proof of efficacy and that bacteremia causing endocarditis related more to daily oral-to-blood transfer than the occasional dental procedure. The 2007 AHA and 2009 ESC guidelines followed suit and reserved prophylaxis only for patients at highest risk. The UK National Institute for Health and Care Excellence (NICE) guidelines[9] made a drastic deviation and recommended against antibiotic prophylaxis irrespective of patient risk profile. Subsequently, Dayer et al showed an increased rate of infective endocarditis in England associated with the introduction of the NICE Guidelines.[10] Although the data from the study did not establish a causal association, prescriptions of antibiotic prophylaxis fell substantially, and the incidence of infective endocarditis increased significantly.

Thornhill et al also reported, that since March 2008, there has been an increase in IE cases since the 2008 NICE guidelines.[11] Thereafter, the guideline was modified to “antibiotic prophylaxis is not routinely recommended.”[9] In 2015, The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC) released their guidelines that continued to recommend antibiotic prophylaxis only for patients at the highest risk.[2]

A study by Thornhill et al that reviewed five years of English hospital admissions for conditions associated with increased infective endocarditis risk reported that the patients at highest risk of recurrence or death during an infective endocarditis admission were patients with a previous history of infective endocarditis. Risks were also high in patients with prosthetic valves and previous valve repair. Patients at moderate risk included those with congenital valve anomalies. Congenital heart conditions repaired with prosthetic material were at lower risk and risk was also seen in patients with cardiovascular implantable electronic devices.[12]

Several studies have tracked the incidence of viridans group streptococci infective endocarditis (VGS-IE) following the guideline changes in the United States and the United Kingdom instituted in 2007 and 2008, respectively. In the United States, Desimone et al found no perceivable increase in the incidence of VGS-IE in a localized area of Minnesota since publication of the 2007 AHA endocarditis prevention guidelines. Rates of incidence (per 100,000 person-years) during the intervals of 1999-2002, 2003-2006, 2007-2010, and 2011-2013 were 3.6, 2.7, 0.7, and 1.5, respectively, reflecting an overall significant decrease (P=.03 from Poisson regression). Likewise, nationwide estimates of hospital discharges with a VGS-IE diagnosis trended downward during 2000-2011, with a mean number per year of 15,853 and 16,157 for 2000-2003 and 2004-2007, respectively, decreasing to 14,231 in 2008-2011 (P=.05 from linear regression using weighted least squares method).[13, 14]

Antibiotic Prophylaxis 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 min before the procedure:


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