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Prophylaxis for the Prevention of Infective Endocarditis

A new guideline from the American Heart Association includes some major changes in recommendations.

Even in high-risk patients, infective endocarditis (IE) is more likely to result from exposure to random bacteremia than from procedures associated with transient bacteremia (e.g., dental cleaning or extraction). The American Heart Association’s last guideline regarding the prevention of IE was released in 1997; given additional data that have accumulated during the past decade, the AHA has updated that guideline. The message in the new guideline is quite clear: Substantially less prophylaxis should be offered to patients. Highlights include:

1. Only high-risk patients with the following specific cardiac conditions should be offered prophylaxis:

• Prosthetic cardiac valve
  
• Previous IE
  
• Congenital heart disease (e.g., unrepaired cyanotic disease, completely repaired heart defect with prosthetic material, residual defects at or near site of prosthetic material)
  
• Cardiac transplantation with valvulopathy
  

2. Prophylaxis is no longer required for mitral valve prolapse.

3. In the high-risk patients noted previously, prophylaxis should be for all dental procedures in which there is "manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa."

4. In situations where prophylaxis is called for, it should be administered prior to the procedure but can be given up to 2 hours afterward.

5. Oral amoxicillin is the preferred antibiotic; cephalexin or other specified agents can be used in penicillin-allergic patients.

6. Prophylaxis is no longer recommended for gastrointestinal or genitourinary tract procedures.

Comment: What a welcome guideline! Rather than making therapeutic decisions more difficult, this one actually simplifies care. The authors state that previous recommendations were based on expert opinion, rather than on high-quality evidence, and that more-specific recommendations were required. They also note that the British Society for Antimicrobial Chemotherapy recommends prophylaxis only before dental procedures for patients with previous IE, surgically constructed pulmonary shunts or conduits, or cardiac valve replacement. Finally, the guideline recommends specific doses of antibiotics for children.

— Howard Bauchner, MD

Published in Journal Watch Pediatrics and Adolescent Medicine July 3, 2007

Citation(s):

Wilson W et al. Prevention of infective endocarditis. Guidelines from the American Heart Association. Circulation 2007 Apr 19; [e-pub ahead of print]. (http://dx.doi.org/10.1161/CIRCULATIONAHA.106.183095)