Antibiotic Prophylactic Regimens for Endocarditis

The following antibiotic prophylactic regimens 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.

High-risk cardiac conditions

• Prosthetic cardiac valve
• History of infective endocarditis
• Congenital heart disease (CHD)*
  • Unrepaired cyanotic CHD, including palliative shunts and conduits
  • 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
  • Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization)
• Cardiac transplantation recipients with cardiac valvular disease

*Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD.

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 active against Streptococcus viridans.

Patients with high cardiac risk that 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 unable to tolerate beta-lactam antibiotics). Vancomycin is recommended for known or suspected methicillin-resistant strains of S aureus.

Genitourinary or gastrointestinal tract procedures

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

Antibiotic regimens for endocarditis prophylaxis for patients with underlying high-risk cardiac conditions undergoing specified dental or respiratory tract procedures

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.

Description	Drug	Adult Dose*	Pediatric Dose*
Standard general prophylaxis	Amoxicillin	2 g PO	50 mg/kg PO; not to exceed 2 g/dose
Unable to take oral medication	Ampicillin	2 g IV/IM	50 mg/kg IV/IM; not to exceed 2 g/dose
Allergic to penicillin	Clindamycin	600 mg PO	20 mg/kg PO; not to exceed 600 mg/dose
	Cephalexin† or other first- or second-generation oral cephalosporin in equivalent dose	2 g PO	50 mg/kg; not to exceed 2 g/dose
	Azithromycin or clarithromycin	500 mg PO	15 mg/kg PO; not to exceed 500 mg/dose
Allergic to penicillin and unable to take oral medication	Clindamycin	600 mg IV	20 mg/kg IV; not to exceed 600 mg/dose
	Cefazolin or ceftriaxone†	1 g IV/IM	50 mg/kg IV/IM; not to exceed 1 g/dose

^*All doses are administered once as a single dose 30-60 min before procedure.

^†Do not use cephalosporins with history of immediate-type hypersensitivity penicillin allergy (eg, urticaria, angioedema, anaphylaxis).

Last update: June 8, 2007

References:

1. Wilson W, Taubert KA, Gewtiz M, Lockhart PB, Baddour LM, Levison M, et al. Prevention of Infective Endocarditis. Guidelines From the American Heart Association. A Guideline From the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. Published online before print, April 19, 2007.

http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.106.183095v1.pdf