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| [[File:Siren.gif|30px|link=Infective endocarditis prevention resident survival guide]]|| <br> || <br>
| [[Infective endocarditis prevention resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
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{{Endocarditis}}
{{Endocarditis}}


{{CMG}}; '''Associate Editors-in-Chief:''' {{CZ}};[[Michael W. Tempelhof]], M.D.
{{CMG}}; '''Associate Editors-in-Chief:''' {{CZ}}; [[Michael W. Tempelhof]], M.D.; {{AKK}}


==Overview==
==Overview==
The presumed correlation between endodontic induced [[bacteremia]] and new onset [[endocarditis]] made pre-procedural antibiotic prophylaxis a reasonable practice for the preceding 60 years. However, there is a paucity of evidence in support of providing chemoprophylaxis for effective [[endocarditis]] prevention. Chewing, dental hygiene practices, kidney disease, diabetes, and skin colonization present a greater risk of significant [[bacteremia]] and greater cumulative [[endocarditis]] risk than any single invasive dental procedure. The AHA recommends reducing the incidence of [[bacteremia]] with the optimization of [[oral hygiene]] in at-risk patients and does not recommend indiscriminant pre-procedural chemoprophylaxis as a safe practice to prevent [[endocarditis]]. The AHA acknowledges that even if chemoprophylaxis conferred 100% efficacy, few cases of endocarditis would be prevented as the incidence of endodontic induced endocarditis is so low.  
Administration of antibiotic prophylaxis is only recommended to high-risk patients undergoing specific procedures. Generally, [[amoxicillin]] 30-60 minutes prior to the procedure is preferred for prophylaxis against endocarditis.


==Impact of Restricting Prophylactic Antibiotics==
==Antibiotic Prophylaxis==
There is data showing that the institution of these more restrictive guidelines does not increase the risk of endocarditis.  The NICE guidelines recommended no antibiotic prophylaxis for any patient, and despite a 78.6% reduction in the administration of IE prophylaxis, there was no documentation of an increase in IE cases due to streptococci <ref>Thornhill MH et al. BMJ 2011;342:d2392.</ref> In France, following restricted use of antibiotics the incidence of IE was stable.<ref>Duval X, et al. J Am Coll Card 2012;59:1968-76.</ref>
===Antimicrobial Regimen===
* 1. '''Prophylactic Regimens for Dental Procedures'''<ref name="pmid24589852">{{cite journal| author=Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA et al.| title=2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. | journal=Circulation | year= 2014 | volume= 129 | issue= 23 | pages= 2440-92 | pmid=24589852 | doi=10.1161/CIR.0000000000000029 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24589852 }} </ref><ref name="pmid23474606">{{cite journal| author=Vahanian A, Alfieri O, Andreotti F, Antunes MJ, Baron-Esquivias G, Baumgartner H et al.| title=[Guidelines on the management of valvular heart disease (version 2012). The Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)]. | journal=G Ital Cardiol (Rome) | year= 2013 | volume= 14 | issue= 3 | pages= 167-214 | pmid=23474606 | doi=10.1714/1234.13659 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23474606  }} </ref><ref name=AHA guideline 2014>{{cite web | title = AHA guideline 2014 | url = http://www.heart.org/idc/groups/heart-public/@wcm/@hcm/documents/downloadable/ucm_307644.pdf }}</ref><ref name="pmid17446442">{{cite journal| author=Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M et al.| title=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. | journal=Circulation | year= 2007 | volume= 116 | issue= 15 | pages= 1736-54 | pmid=17446442 | doi=10.1161/CIRCULATIONAHA.106.183095 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17446442  }} </ref>


==Infective Endocarditis Prophylaxis Regimens <ref>Wilson W, et al. Circulation 2007;116;1736-1754.</ref>==
:* 1.1 '''Oral regimen'''
The target of the infective endocarditis prophylaxis is [[streptococcus viridans]]:
::* Preferred regimen: [[Amoxicillin]] 2 g PO single dose (30-60 minutes before procedure)
===Oral Surgery===
::* Pediatric dose: [[Amoxicillin]] 50 mg/kg PO single dose (30-60 minutes before procedure)
====Able to take oral medication====
=====[[Amoxicillin]] as a single dose 30-60 min before procedure=====
*Adult: 2 gm
*Children: 50 mg/kg


====Unable to take oral medication====
:* 1.2 '''Unable to take oral medication'''
=====[[Ampicillin]]=====
::* Preferred regimen: [[Ampicillin]] 2 g IM/IV single dose (30-60 minutes before procedure) {{or}} [[Cefazolin]] 1 g IM/IV single dose (30-60 minutes before procedure) {{or}} [[Ceftriaxone]] 1 g IM/IV single dose (30-60 minutes before procedure)
*Adult:2 g IM or IV*
::* Pediatric dose: [[Ampicillin]] 50 mg/kg; [[Cefazolin]] 50 mg/kg; [[Ceftriaxone]] 50 mg/kg
*Children: 50 mg/kg IM or IV
or
=====[[Cefazolin]] or [[ceftriaxone]]=====
*Adult 1 g IM or IV
*Children: 50 mg/kg IM or IV


Given the risk of anaphylaxis, [[Cephalosporins]] should not be administered to an individual with a prior history of [[anaphylaxis]], [[angioedema]], or [[urticaria]] with [[penicillins]] or [[ampicillin]].
:* 1.3 '''Allergic to penicillins or ampicillin - Oral regimen'''
::* Preferred regimen: [[Cephalexin]] 2 g single dose (30-60 minutes before procedure) {{or}} [[Clindamycin]] 600 mg single dose (30-60 minutes before procedure) {{or}} [[Azithromycin]] 500 mg single dose ()30-60 minutes before procedure) {{or}} [[Clarithromycin]] 500 mg  single dose (30-60 minutes before procedure).
::* Pediatric doses:  [[Cephalexin]] 50 mg/kg single; [[Clindamycin]] 20 mg/kg; [[Azithromycin]] 15 mg/kg; [[Clarithromycin]] 15 mg/kg


==Infective Endocarditis Prophylaxis Regimens If the Patient is Penicillin or Ampicillin Allergic <ref>Wilson W, et al. Circulation 2007;116;1736-1754.</ref>==
:* 1.4 '''Allergic to penicillins or ampicillin and unable to take oral medication'''
The following single dose regimens can be administered 30-60 min before the procedure:
::*  Preferred regimen: [[Cefazolin]] 1 g IM/IV single dose (30-60 minutes before procedure) {{or}} [[Ceftriaxone]] 1 g IM/IV single dose (30-60 minutes before procedure) {{or}} [[Clindamycin]] 600 mg IM/IV single dose (30-60 minutes before procedure)
::* Pediatric doses: [[Cefazolin]] 50 mg/kg; [[Ceftriaxone]] 20 mg/kg


===Oral Cephalexin===
* 2. '''Gastrointestinal/Genitourinary Procedures'''
*Adult: 2 gm
:* Preferred regimen: Antibiotic prophylaxis to prevent [[IE]] is no longer recommended for patients who undergo a GI or GU tract procedure.
*Children: 50 mg/kg
:* Note: High risk patients who already have an established [[GI]] or GU tract infection, it is reasonable to administer [[Ampicillin]] 2 g IM/IV single dose
===Oral Clindamycin===
*Adult: 600 mg
*Children: 20 mg/Kg


===Oral Azithromycin or Clarithromycin===
* 3. '''Regimens for Respiratory Tract Procedures'''
*Adult: 500 mg
:* 3.1 '''Oral regimen'''
*Children: 15 mg/kg
::* Preferred regimen: [[Amoxicillin]] 2 g single dose (30-60 minutes before procedure)
::* Pediatric dose: [[Amoxicillin]] 50 mg/kg single dose (30-60 minutes before procedure)


==Infective Endocarditis Prophylaxis Regimens If the Patient is Penicillin or Ampicillin Allergic and Cannot Take Oral Medications <ref>Wilson W, et al. Circulation 2007;116;1736-1754.</ref>==
:* 3.2 '''Unable to take oral medication'''
===Cefazolin or Ceftriaxone===
::* Preferred regimen: [[Ampicillin]] 2 g IM/IV single dose (30-60 minutes before procedure) {{or}} [[Cefazolin]] 1 g IM/IV single dose (30-60 minutes before procedure) {{or}} [[Ceftriaxone]] 1 g IM/IV single dose (30-60 minutes before procedure)
*Adult: 1 g IM or IV
*Children: 50 mg/kg IM or IV
===Clindamycin===
*Adult: 600 mg IM or IV
*Children: 20 mg/kg IM or IV


==Recommendations Regarding Antibiotic Prophylaxis Prior to Procedures on Infected Skin or Musculoskeletal Tissue==
::* Pediatric doses: [[Ampicillin]] 50 mg/kg; [[Cefazolin]] 50 mg/kg; [[Ceftriaxone]] 50 mg/kg


These infections are often polymicrobial, but only staphylococci and beta hemolytic [[streptococci|beta-hemolytic streptococci]] are likely to cause Infective Endocarditis. For patients with high risk conditions who undergo a surgical procedure that involves infected skin, skin structure, or musculoskeletal tissue, it may be reasonable that the therapeutic regimen administered for treatment of the infection contain an agent active against [[staphylococci]] and [[streptococci|beta-hemolytic streptococci]], such as an antistaphylococcal [[penicillin]] or a [[cephalosporin]]. [[Vancomycin]] or [[clindamycin]] may be administered to patients unable to tolerate a [[beta-lactam]] or who are known or suspected to have an infection caused by a [[methicillin-resistant staphylococcus aureus]].<ref name=Wilson>{{cite journal | author = Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, Bolger A, Cabell CH, Takahashi M, Baltimore RS, Newburger JW, Strom BL, Tani LY, Gerber M, Bonow RO, Pallasch T, Shulman ST, Rowley AH, Burns JC, Ferrieri P, Gardner T, Goff D, Durack DT| title = American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee; American Heart Association Council on Cardiovascular Disease in the Young; American Heart Association Council on Clinical Cardiology; American Heart Association Council on Cardiovascular Surgery and Anesthesia; Quality of Care and Outcomes Research Interdisciplinary Working Group. 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| journal = Circulation | volume = 116 | issue = 15 | pages = 1736-54 | year = 2007 | id = PMID 17446442}}</ref>
:* 3.3 '''Allergic to penicillins or ampicillin — Oral regimen'''
::* Preferred regimen: [[Cephalexin]] 2 g single dose (30-60 minutes before procedure {{or}} [[Clindamycin]] 600 mg single dose (30-60 minutes before procedure) {{or}} [[Azithromycin]] 500 mg single dose (30-60 minutes before procedure) {{or}} [[Clarithromycin]] 500 mg  single dose (30-60 minutes before procedure)
::* Pediatric doses:  [[Cephalexin]] 50 mg/kg; [[Clindamycin]] 20 mg/kg; [[Azithromycin]] 15 mg/kg; [[Clarithromycin]] 15 mg/kg


==Antibiotic Prophylaxis For Respiratory Tract Procedures==
:* '''Allergic to penicillins or ampicillin and unable to take oral medication'''
It is recommended that the same individuals at the highest risk cited in the section on endodontic procedures who require the procedures listed below should receive antibiotic prophylaxis:<ref name=Wilson>{{cite journal | author = Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, Bolger A, Cabell CH, Takahashi M, Baltimore RS, Newburger JW, Strom BL, Tani LY, Gerber M, Bonow RO, Pallasch T, Shulman ST, Rowley AH, Burns JC, Ferrieri P, Gardner T, Goff D, Durack DT| title = American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee; American Heart Association Council on Cardiovascular Disease in the Young; American Heart Association Council on Clinical Cardiology; American Heart Association Council on Cardiovascular Surgery and Anesthesia; Quality of Care and Outcomes Research Interdisciplinary Working Group. 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| journal = Circulation | volume = 116 | issue = 15 | pages = 1736-54 | year = 2007 | id = PMID 17446442}}</ref>
::*  Preferred regimen: [[Cefazolin]] 1 g IM/IV single dose (30-60 minutes before procedure) {{or}} [[Ceftriaxone]] 1 g IM/IV single dose (30-60 minutes before procedure) {{or}} [[Clindamycin]] 600 mg IM/IV (30-60 minutes before procedure)
::* Pediatric doses: [[Cefazolin]] 50 mg/kg; [[Ceftriaxone]] 20 mg/kg


:*[[Tonsillectomy]]  
* 4. '''Regimens for Procedures on Infected Skin, Skin Structure, or Musculoskeletal Tissue'''
:*[[Adenoidectomy]]
:* Patients who undergo a surgical procedure that involves infected skin, skin structure, or musculoskeletal tissue, it may be reasonable that the therapeutic regimen administered for treatment of the [[infection]] contain an agent active against [[staphylococci]] and beta-hemolytic [[streptococci]], such as an antistaphylococcal [[penicillin]] or a [[cephalosporin]].
:*Rigid bronchoscopic manipulations
:*Respiratory mucosa related surgery
:*Invasive respiratory tract procedures to treat an established infection, such as drainage of an [[abscess]] or [[empyema]


Although there is no published data conclusively demonstrate a link between these procedures and [[infective endocarditis]], antibiotic prophylaxis is reasonable for these select high risk patients who undergo an invasive procedure of the respiratory tract that involves incision or biopsy of the respiratory mucosa  such as those listed above.  [[Bronchoscopy]] does not usually require antibiotic prophylaxis unless there is incision of the respiratory tract mucosa.
==Impact of Restricting Prophylactic Antibiotics==
There is data showing that the institution of these more restrictive guidelines does not increase the risk of endocarditis.  The NICE guidelines recommended no antibiotic prophylaxis for any patient, and despite a 78.6% reduction in the administration of IE prophylaxis, there was no documentation of an increase in IE cases due to streptococci.<ref>Thornhill MH et al. BMJ 2011;342:d2392.</ref> In France, following restricted use of antibiotics the incidence of IE was stable.<ref>Duval X, et al. J Am Coll Card 2012;59:1968-76.</ref>


==Antibiotic Prophylaxis for Gastrointestinal (GI) and Genitourinary (GU) Procedures<ref name= Baddour>{{cite journal | author = Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F.,  Levison Matthew E.,  Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato,  Taubert Kathryn A.| title = Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = 3167-84 | year = 2005 | id = PMID 15956145}}</ref> <ref name=Wilson>{{cite journal | author = Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, Bolger A, Cabell CH, Takahashi M, Baltimore RS, Newburger JW, Strom BL, Tani LY, Gerber M, Bonow RO, Pallasch T, Shulman ST, Rowley AH, Burns JC, Ferrieri P, Gardner T, Goff D, Durack DT| title = American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee; American Heart Association Council on Cardiovascular Disease in the Young; American Heart Association Council on Clinical Cardiology; American Heart Association Council on Cardiovascular Surgery and Anesthesia; Quality of Care and Outcomes Research Interdisciplinary Working Group. 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| journal = Circulation | volume = 116 | issue = 15 |pages = 1736-54 | year = 2007 | id = PMID 17446442}}</ref>==
==2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease (VHD)==
Routine administration of prophylactic antibiotics prior to GI and GU procedures including diagnostic [[esophagogastroduodenoscopy]] or [[colonoscopy]] is not recommended.  However, for the high risk patients listed in the endodontic section who already have  an established GI or GU tract infection, it is reasonable to administer antibiotics against [[enterococci]] which includes the following:  [[penicillin]],[[ampicillin]], [[piperacillin]], or [[vancomycin]]. Despite the reasonable nature of this approach, it should be noted that there are no published studies that demonstrate that this approach prevents [[enterococcal endocarditis]].  The preferred agents for enterococcal coverage are [[amoxicillin]] or [[ampicillin]], and  [[vancomycin]] can be administered to those patients who cannot tolerate[[ampicillin]].


==Patients Already Receiving Antibiotics<ref name= Baddour>{{cite journal | author = Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F.,  Levison Matthew E.,  Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato,  Taubert Kathryn A.| title = Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America. | journal = Circulation | volume = 111 | issue = 23 | pages = 3167-84 | year = 2005 | id = PMID 15956145}}</ref> <ref name=Wilson>{{cite journal | author = Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, Bolger A, Cabell CH, Takahashi M, Baltimore RS, Newburger JW, Strom BL, Tani LY, Gerber M, Bonow RO, Pallasch T, Shulman ST, Rowley AH, Burns JC, Ferrieri P, Gardner T, Goff D, Durack DT| title = American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee; American Heart Association Council on Cardiovascular Disease in the Young; American Heart Association Council on Clinical Cardiology; American Heart Association Council on Cardiovascular Surgery and Anesthesia; Quality of Care and Outcomes Research Interdisciplinary Working Group. 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| journal = Circulation | volume = 116 | issue = 15 |pages = 1736-54 | year = 2007 | id = PMID 17446442}}</ref>==
===Recommendation for Infective Endocarditis (IE) Prophylaxis===


It is recommended that an antibiotic from another class be administered to those patients who are already on long-term therapy with an antibiotic, such as those patients on antibiotics to prevent recurrent acute [[rheumatic fever]].  The chronic antibiotic dose is usually lower than what is required for prevention of [[endocarditis]].  Furthermore, these indiividuals oftin are colonized with viridans group streptococci in their oral that are relatively resistant to either [[penicillin]] or [[amoxicillin]]. In high risk  patients, either[[clindamycin]], [[azithromycin]], or [[clarithromycin]] are recommended for prophylaxis prior to a dental procedure.  In so far as there is the potential for cross-resistance among strep viridans groups, [[cephalosporin]]s, are not recommended.  Finally, if possible it is recommended that elective procedures be delayed for 10 days to allow for recolonization with the usual flora.
{| class="wikitable" style="width: 80%; text-align: justify;"
 
! style="width:12%" | '''COR'''
==Antibiotic Prophylaxis in Patients Who are Undergoing Cardiac Surgery<ref name= Baddour>{{cite journal | author = Baddour Larry M., Wilson Walter R., Bayer Arnold S., Fowler Vance G. Jr, Bolger Ann F.,  Levison Matthew E.,  Ferrieri Patricia, Gerber Michael A., Tani Lloyd Y., Gewitz Michael H., Tong David C., Steckelberg James M., Baltimore Robert S., Shulman Stanford T., Burns Jane C., Falace Donald A., Newburger Jane W., Pallasch Thomas J., Takahashi Masato,  Taubert Kathryn A.| title = Infective Endocarditis: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Statement for Healthcare Professionals From the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association-Executive Summary: Endorsed by the Infectious Diseases Society of America. | journal = Circulation |volume = 111 | issue = 23 | pages = 3167-84 | year = 2005 | id = PMID 15956145 }}</ref> <ref name=Wilson>{{cite journal | author = Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, Bolger A, Cabell CH, Takahashi M, Baltimore RS, Newburger JW, Strom BL, Tani LY, Gerber M, Bonow RO, Pallasch T, Shulman ST, Rowley AH, Burns JC, Ferrieri P, Gardner T, Goff D, Durack DT| title = American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee; American Heart Association Council on Cardiovascular Disease in the Young; American Heart Association Council on Clinical Cardiology; American Heart Association Council on Cardiovascular Surgery and Anesthesia; Quality of Care and Outcomes Research Interdisciplinary Working Group. 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| journal = Circulation | volume = 116 | issue = 15 | pages = 1736-54 | year = 2007 | id = PMID 17446442}}</ref>==
! style="width:8%" | ''' LOE'''
 
! style="width:40%" | '''RECOMMENDATION'''
Peri-operative antibiotics are recommended for those patients who are undergoing placement of prosthetic heart valves, prosthetic intravascular devices and intracardiac materials. The basis for this recommendation is the high risk of infection and the morbidity and mortality associated with such a complication.
! style="width:40%" | '''COMMENT/RATIONALE'''
 
|-
The most common causative agents in the development of early prosthetic valve [[endocarditis]] are [[S. aureus]], [[coagulase-negative staphylococci]], or [[diphtheroids]].  Unfortunately there is no single antibiotic that eradicates all three organisms, and the prophylaxis is therefore directed primarily at the  staphylococci and not the diptheroids.  While it is common to administer a first-generation [[cephalosporin]], consideration should be given to the antibiotic  susceptibility patterns at a given hospital. If the hospital has a high incidence of [[methicillin-resistant Staphylococcus aureus]] ([[MRSA]]), then prophylaxis  with [[vancomycin]] should be considered.  On the other hand, even though most nosocomial [[coagulase-negative staphylococci]] are [[methicillin-resistant]], a first-generation [[cephalosporin]] is recommended as [[vancomycin]] has not been shown to be superior to a [[cephalosporin]].  Likewise, if [[methicillin-resistant]]  [[S. epidermidis]] is prevalent at a hospital, prophylaxis with [[vancomycin]] is reasonable.
| bgcolor="LemonChiffon" | IIa || bgcolor="LightBlue" | C-LD || Prophylaxis against IE is reasonable before dental procedures that involve manipulation of gingival tissue, manipulation of the periapical region of teeth, or perforation of the oral mucosa in patients with the following:
 
'''1.''' Prosthetic cardiac valves, including transcatheter- implanted prostheses and homografts.
Prophylaxis should be administered immediately before surgery. In so far as renal function and extracorporeal circulation may alter drug concentrations, antibiotic concentrations should be monitored during and after the procedure. In order to prevent the emergence of resistant organisms, antibiotic therapy should be continued for only 48 hours.
   
 
'''2.''' Prosthetic material used for cardiac valve repair, such as annuloplasty rings and chords.
==Basis for AHA Recommendations Regarding Antibiotic Prophylaxis for Dental Procedures==
   
Endodontic procedures have been associated with a high incidence of [[bacteremia]] since the 1920s. Therefore, dental procedures were implicated as an independent risk factor for the development of bacterial [[endocarditis]]. However, only 4%-7.5% of all bacterial endocarditis cases are related to endodontic associated bacteremia.<ref>Gendron R, Grenier D, Maheu-Robert L. The oral cavity as a reservoir of bacterial pathogens for focal infections. Microbes Infect. 2000;2:897-906.  </ref> In 1955, the American Heart Association (AHA) published the first of ten subsequent [[endocarditis]] prevention guidelines. The most recent, 2007 guidelines underwent changes intended to clarify patient eligibility criteria for receiving [[endocarditis]] prophylaxis.
'''3.''' Previous IE.
Major changes include:
* [[Bacteremias]] associated with daily activities (which are frequent) are considered more likely to cause [[endocarditis]] than are endodontic-procedural induced [[bacteremias]].
'''4.''' Unrepaired cyanotic congenital heart disease or
*Optimal oral hygiene is emphasized as an important practice to prevent endocarditis.
repaired congenital heart disease, with residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch or prosthetic device.
*A patient’s lifetime risk of endocarditis is no longer a consideration for initiating prophylactic antibiotic therapy.
*The AHA now recommends the administration of single-dose prophylactic antibiotics prior to endodontic procedure only to patients with cardiac conditions associated with the highest risk of adverse outcomes following the acquisition of bacterial endocarditis (see the list above).
'''5.''' Cardiac transplant with valve regurgitation due to a structurally abnormal valve.  
 
|| '''{{Fontcolor|#FF0000|MODIFIED:}}''' LOE updated from B to C-LD. Patients with transcatheter prosthetic valves and patients with prosthetic material used for valve repair, such as annuloplasty rings and chords, were specifically identified as those to whom it is reasonable to give IE prophylaxis. This addition is based on observational studies demonstrating the increased risk of developing IE and high risk of adverse outcomes from IE in these subgroups. Categories were rearranged for clarity to the caregiver.
===The Risk of Endocarditis Following Endodontic Procedures===
|}
Based in the findings below, the AHA has concluded that the cumulative background bacteremia associated with chewing, daily dental hygiene practices, kidney disease, [[diabetes]], and skin colonization present a greater risk of significant [[bacteremia]] than any single invasive dental procedure.


*Following dental intervention, the absolute risk for developing [[endocarditis]] is estimated at 1 case per 14 million dental procedures.<ref>Pallasch TJ. Antibiotic prophylaxis: problems in paradise. Dent Clin North Am. 2003;47:665-679.</ref>
===Recommendations for Infective Endocarditis Intervention===
*The risk of [[endocarditis]] following an endodontic induced [[bacteremia]] in high risk patients is as follows<ref>Pallasch TJ, Wahl MJ. Focal infection: new age or ancient history?
Endodontic Topics. 2003;4:32-45.
</ref>:
:*[[Congenital heart disease]]: 1 per 475,000
:*[[Rheumatic heart disease]]: 1 per 142,000;
:*Patients with a prosthetic heart valve, 1 per 114,000
:*Patients with previous [[endocarditis]]: 1 per 95,000 dental procedures.
*Inocula of 1 x 108 (100 million) colony forming units [cfu]/mL or greater are required to consistently induce experimental [[endocarditis]].
**Recent human quantitative blood culture data support the implication that endodontic associated [[bacteremia]] inocula are of insufficient magnitude to induce [[endocarditis]]. [[Bacteremia]] intensities immediately following invasive human dental procedures are 1.5 cfu/ml-5.9 cfu/ml, 10 fold less then necessary to induce [[endocarditis]] in  animal models.<ref>Roberts GJ. Dentists are innocent! Everyday" bacteremia is the real culprit: A review and assessment of the evidence that dental surgical procedures are a principal cause of bacterial endocarditis in children. Pediatric Cardiology. 1999;20:317.</ref>


*The most recent case-control study of 104 patients with known, high-risk structural heart disease discovered that patients who developed [[endocarditis]] were actually less likely to have experienced an endodontic procedure within the 180 days prior to diagnosis of [[endocarditis]] than did control patients who did not develop [[endocarditis]] (OR 0.2 [95% CI 0.04-0.7]).<ref>Strom BL, Abrutyn E, Berlin JA, Kinman JL, Feldman RS, Stolley PD, et al. Dental and cardiac risk factors for infective endocarditis: A population-based, case-control study. Ann Int Med. 1998;129:761-769.</ref>
{| class="wikitable" style="width: 80%; text-align: justify;"
 
! style="width:12%" | '''COR'''  
*Among high-risk patients with underlying structural heart disease, kidney disease (OR 16.9 [95% CI 1.5-193.0]), [[diabetes]] (OR 2.7 [95% CI 1.4-5.2]) and skin flora infection (OR 3.5 [95% CI 0.7-17.0]) were associated with a greater risk for the development of bacterial endocarditis.<ref>Strom BL, Abrutyn E, Berlin JA, Kinman JL, Feldman RS, Stolley PD, et al. Risk factors for infective endocarditis: oral hygiene and nondental exposures. Circulation. 2000;102:2842.</ref>
! style="width:8%" | ''' LOE'''  
 
! style="width:40%" | '''RECOMMENDATION'''  
*Daily activities such as chewing and oral hygiene practices result in bacteremias more frequently, of longer duration and of greater magnitude in comparison to high-risk endodontic procedures.
! style="width:40%" | '''COMMENT/RATIONALE'''  
 
|-  
===The Efficacy of Prophylactic Antibiotic===
| bgcolor="LightGreen" | I || bgcolor="LightBlue" | B || Decisions about timing of surgical intervention should be made by a multispecialty Heart Valve Team of cardiology, cardiothoracic surgery, and infectious disease specialists. ||2014 recommendation remains current.
*The efficacy of antibiotic regimens for [[endocarditis]] prophylaxis ''has never been assessed under the scrutiny of a randomized controlled trial.''  
|-  
*Evidence supporting pre-endodontic chemoprophylaxis efficacy is extrapolated from data demonstrating reductions in bacteremia magnitudes immediately following the administration of antibiotics.
| bgcolor="LightGreen" | I || bgcolor="LightBlue" | B ||Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) is indicated in patients with IE who present with valve dysfunction resulting in symptoms of HF. ||2014 recommendation remains current.
*The '''Cochran Collaboration''' assessed whether prophylactic administration of penicillin to moderate- to high-risk patients prior to endodontic intervention conferred a mortality, serious illness or endocarditis incidence benefit.<ref>Oliver R, Roberts GJ, Hooper L. Penicillins for the prophylaxis of bacterial endocarditis in dentistry. Cochrane Database of Systematic Reviews 2004, Issue 2.</ref> The pooled, adjusted Odds Ratio across all studies for the development of IE among patients receiving prophylaxis was non-significant (0.56 [95% CI (0.15-2.15)]). ''The Cochrane Collaboration concluded that it is unclear whether antibiotic prophylaxis is effective and there is a lack of evidence to support published guidelines using penicillin as chemoprophylaxis for IE.''
|-  
*To date, ''only 4 case-control studies have assessed antibiotic efficacy'' for endocarditis prevention.
| bgcolor="LightGreen" | I || bgcolor="LightBlue" | B ||Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) is indicated in patients with left-sided IE caused by S. aureus, fungal, or other highly resistant organisms. ||2014 recommendation remains current.
#Strom et al discovered the administration pre-endodontic procedural antibiotics did not provide a protective benefit against the development of IE (OR 0.5 [CI .01-9.6]).
|-  
#Van Der Meer et al,<ref>Van der Meer JT, Thompson J, Valkenburg HA, Michel MF. Epidemiology of bacterial endocarditis in The Netherlands II. Antecedent procedures and use of prophylaxis. Arch Intern Med. 1992;152:1869-1873.</ref>8/48 case patients (16%) received antibiotics while 26/200 of control patients (13%) received antibiotics. Stratified Odds Ratio: 0.51 (0.11-2.29).Protective Efficacy 49%.
| bgcolor="LightGreen" | I || bgcolor="LightBlue" | B ||Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) is indicated in patients with IE complicated by heart block, annular or aortic abscess, or destructive penetrating lesions. ||2014 recommendation remains current.
#Lacassin et al<ref>Lacassin F, Hoen B, Leport C, Selton-Suty C, Delahaye F, Goulet V, et al. Procedures associated with infective endocarditis in adults - A case control study. Eur Heart J. 1995;16:1968-1974.</ref>6/37 case patients (23%) received antibiotics while 6/33 control patients (27%) received antibiotics. Matched and Adjusted Odds Ratio: 0.2 (0-0.8) Protective Efficacy 20%.
|-  
#Imperiale et al<ref>Imperiale TF, Horwitz RI. Does prophylaxis prevent post-dental infective endocarditis? A controlled evaluation of protective efficacy. Am J Med. 1990;88:131-136.</ref> 1/8 case pts (13%) received antibiotics.15/24 control patients (63%) received antibiotics. Matched Odds Ratio: .09 (CI upper limit of 0.93) (p=.025). Protective Efficacy 91%.
| bgcolor="LightGreen" | I || bgcolor="LightBlue" | B ||Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) for IE is indicated in patients with evidence of persistent infection as manifested by persistent bacteremia or fevers lasting longer than 5 to 7 days after onset of appropriate antimicrobial therapy. ||2014 recommendation remains current.
 
|-
===Safety Concerns with Antibiotic Prophylaxis===
| bgcolor="LightGreen" | I || bgcolor="LightBlue" | C ||Surgery is recommended for patients with prosthetic valve endocarditis and relapsing infection (defined as recurrence of bacteremia after a complete course of appropriate antibiotics and subsequently negative blood cultures) without other identifiable source for portal of infection. ||2014 recommendation remains current.
''Adverse reactions associated with the administration of beta-lactam antibiotics are common.''
|-  
*The adverse events range in severity from [[purititus]] to fatal [[anaphylactic shock]], the frequency of all adverse reactions from the administration of penicillin to the general population is 0.7% to 10%.<ref>Idsoe O, Guthe T, Willcox RR, De Weck A. Nature and extent of penicillin side-reactions, with particular reference to fatalities from anaphylactic shock. Bull World Health Organ. 1968;38:159-188.</ref>
| bgcolor="LightGreen" | I || bgcolor="LightBlue" | B ||Complete removal of pacemaker or defibrillator systems, including all leads and the generator, is indicated as
*Fatal [[anaphylaxis]] among patients receiving single-dose penicillin, ampillicin or amoxicillin therapy is approximately 20 cases per 1 million patients treated.<ref>The International Collaborative Study of Severe Anaphylaxis. Risk of anaphylaxis in a hospital population in relation to the use of various drugs: an international study. Pharmacoepidemiology and drug safety. 2003;12:195-202.</ref>
part of the early management plan in patients with IE with documented infection of the device or leads.  
*Single-dose, [[cephalosporin]]-associated fatal anaphylaxis risk is estimated at 0.5-5.7 cases per 10 million patients treated.<ref>Kelkar P,James T. Current concepts: cephalosporin allergy. N Engl J Med. 2001;345:804-9.</ref>
|2014 recommendation remains current.
*[[Macrolide]] and [[clindamycin]] single-dose fatal [[anaphylaxis]] risk is estimated at 0-5 cases per 1 million patients treated.<ref>Mazur N, Greenberger P, Regalado J. Clindamycin hypersensitivity
|-
appears to be rare. Ann Allergy Asthma Immunol. 1999;82:443–5.
| bgcolor="LemonChiffon" | IIa || bgcolor="LightBlue" | B ||Complete removal of pacemaker or defibrillator systems, including all leads and the generator, is reasonable in patients with valvular IE caused by S. aureus or fungi, even without evidence of device or lead infection. ||2014 recommendation remains current.
</ref>
|-
*The risk of mortality associated with the single-dose administration of beta-lactam antibiotics for IE prophylaxis is estimated at 1-3 anaphylactic deaths per 1 million patients treated.
| bgcolor="LemonChiffon" | IIa || bgcolor="LightBlue" | C ||Complete removal of pacemaker or defibrillator systems, including all leads and the generator, is reasonable in patients undergoing valve surgery for valvular IE. ||2014 recommendation remains current.
*According to the AHA, single dose administration of a beta-lactam antibiotic for IE prophylactic therapy is a safe practice as it has never resulted in a reportable case of fatal anaphylaxis.
|-
 
| bgcolor="LemonChiffon" | IIa || bgcolor="LightBlue" | B ||Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) is reasonable in patients with IE who present with recurrent emboli and persistent vegetations despite appropriate antibiotic therapy. ||2014 recommendation remains current.
==Cost Effectiveness of Oral Antibiotic Prophylaxis==
|-
To date, one report has addressed the cost-effectiveness of providing chemoprophylaxis to patients of moderate- and high-risk of IE acquisition prior to endodontic procedure.<ref>Agha Z, Lofgren RP, VanRuiswyk JV. Is antibiotic prophylaxis for bacterial endocarditis cost-effective? Med Decis Making. 2005;25:308-320.</ref>
| bgcolor="LemonChiffon" | IIb || bgcolor="LightBlue" | B ||Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) may be considered in patients with native valve endocarditis who exhibit mobile vegetations greater than 10 mm in length (with or without clinical evidence of embolic phenomenon). ||2014 recommendation remains current.
*The risk of drug-induced anaphylaxis and associated loss of QALYs with prophylactic oral amoxicillin or ampicillin to moderate-risk patients rendered this practice ineffective and therefore the authors did not complete a cost-effectiveness analysis.
|-  
*The estimated cost-effectiveness ratio for the prophylaxis of 10 million moderate-risk patients with clarithromycin, clindamycin or cephalexin, was $88,007, $101,142 and $99,373 per QALY saved, respectively.
| bgcolor="LemonChiffon" | IIb || bgcolor="LightBlue" | B-NR ||Operation without delay may be considered in patients with IE and an indication for surgery who have suffered a stroke but have no evidence of intracranial hemorrhage or extensive neurological damage. ||'''{{Fontcolor|#FF0000|NEW:}}''' The risk of postoperative neurological deterioration is low after a cerebral event that has not resulted in extensive neurological damage or intracranial hemorrhage. If surgery is required after a neurological event, recent data favor early surgery for better overall outcomes.
*Cost-effectiveness ratio for the use of clarithromycin in patients with the prior diagnosis of endocarditis was $40,334, and in patients with prosthetic valves, $16,818 per QALY saved.
|-
*Cost-effectiveness ratio of treating 10 million high-risk patients administered single dose clindamycin was $46,678 (prior endocarditis) and $19,936 (prosthetic valve) per QALY saved. #Cephalexin was associated with a cost-effectiveness of $37,916 per QALY saved in patients with a history of IE and $14,060 per QALY saved, in patients with a prosthetic valves.  
| bgcolor="LemonChiffon" | IIb || bgcolor="LightBlue" | B-NR ||Delaying valve surgery for at least 4 weeks may be considered for patients with IE and major ischemic stroke or intracranial hemorrhage if the patient is hemodynamically stable. ||'''{{Fontcolor|#FF0000|NEW:}}''' In patients with extensive neurological damage or intracranial hemorrhage, cardiac surgery carries a high risk of death if performed within 4 weeks of a hemorrhagic stroke.
*The cost-effective analyses suggest that the 2007 AHA IE prevention guidelines advocating chemoprophylaxis to patients with a high-risk of adverse outcomes upon acquisition of IE is a reasonable, cost-effective practice.
 
==2008 and Incorporated 2006 ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease (DO NOT EDIT) <ref name="pmid18820172">{{cite journal |author=Bonow RO, Carabello BA, Chatterjee K, ''et al.'' |title=2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons |journal=Circulation |volume=118 |issue=15 |pages=e523–661 |year=2008 |month=October |pmid=18820172 |doi=10.1161/CIRCULATIONAHA.108.190748 |url=}}</ref>==
 
===Prophylaxis (DO NOT EDIT) <ref name="pmid18820172">{{cite journal |author=Bonow RO, Carabello BA, Chatterjee K, ''et al.'' |title=2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons |journal=Circulation |volume=118 |issue=15 |pages=e523–661 |year=2008 |month=October |pmid=18820172 |doi=10.1161/CIRCULATIONAHA.108.190748 |url=}}</ref>===
 
{|class="wikitable"
|-
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm)
|-
|bgcolor="LightCoral"|'''1.''' <nowiki>"</nowiki>[[Prophylaxis]] against infective endocarditis is not recommended for nondental procedures (such as [[transesophageal echocardiogram]], [[esophagogastroduodenoscopy]], or [[colonoscopy]]) in the absence of active [[infection]]<ref name="pmid17446442">{{cite journal |author=Wilson W, Taubert KA, Gewitz M, ''et al.'' |title=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 |journal=Circulation |volume=116 |issue=15 |pages=1736–54 |year=2007 |month=October |pmid=17446442 |doi=10.1161/CIRCULATIONAHA.106.183095 |url=}}</ref>. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: B'']])''<nowiki>"</nowiki>
|}
|}
{|class="wikitable"
|-
|colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|bgcolor="LemonChiffon"|'''1.''' <nowiki>"</nowiki>[[Prophylaxis]] against [[infective endocarditis]] is reasonable for the following patients at highest risk for adverse outcomes from infective endocarditis who undergo dental procedures that involve manipulation of either gingival tissue or the periapical region of teeth or perforation of the [[oral mucosa]] <ref name="pmid17446442">{{cite journal |author=Wilson W, Taubert KA, Gewitz M, ''et al.'' |title=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 |journal=Circulation |volume=116 |issue=15 |pages=1736–54 |year=2007 |month=October |pmid=17446442 |doi=10.1161/CIRCULATIONAHA.106.183095 |url=}}</ref>: ''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|'''a.''' <nowiki>"</nowiki>Patients with [[prosthetic cardiac valves]] or prosthetic material used for cardiac valve repair. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: B'']])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|'''b.''' <nowiki>"</nowiki>Patients with previous infective endocarditis. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: B'']])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|'''c.''' <nowiki>"</nowiki>Patients with [[CHD]]. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: B'']])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|'''c-i.''' <nowiki>"</nowiki>Unrepaired cyanotic [[CHD]], including palliative shunts and conduits. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: B'']])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|'''c-ii.''' <nowiki>"</nowiki>Completely repaired [[congenital heart defect]] repaired with prosthetic material or device, whether placed by surgery or by [[catheter]] intervention, during the first 6 months after the procedure. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: B'']])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|'''c-iii.''' <nowiki>"</nowiki>Repaired [[CHD]] with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (both of which inhibit endothelialization). ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: B'']])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|'''d.''' <nowiki>"</nowiki>[[Cardiac transplant]] recipients with valve regurgitation due to a structurally abnormal valve. ([[ACC AHA guidelines classification scheme#Level of Evidence|''Level of Evidence: C'']])''<nowiki>"</nowiki>
|}
==Sources==
*2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease <ref name="pmid18820172">{{cite journal |author=Bonow RO, Carabello BA, Chatterjee K, ''et al.'' |title=2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons |journal=Circulation |volume=118 |issue=15 |pages=e523–661 |year=2008 |month=October |pmid=18820172 |doi=10.1161/CIRCULATIONAHA.108.190748 |url=}}</ref>


==References==
==References==
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[[Category:Cardiology]]
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Latest revision as of 13:37, 26 October 2017
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Endocarditis antibiotic prophylaxis On the Web

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Michael W. Tempelhof, M.D.; Arzu Kalayci, M.D. [3]

Overview

Administration of antibiotic prophylaxis is only recommended to high-risk patients undergoing specific procedures. Generally, amoxicillin 30-60 minutes prior to the procedure is preferred for prophylaxis against endocarditis.

Antibiotic Prophylaxis

Antimicrobial Regimen

  • 1. Prophylactic Regimens for Dental Procedures[1][2][3]
  • 1.1 Oral regimen
  • Preferred regimen: Amoxicillin 2 g PO single dose (30-60 minutes before procedure)
  • Pediatric dose: Amoxicillin 50 mg/kg PO single dose (30-60 minutes before procedure)
  • 1.2 Unable to take oral medication
  • Preferred regimen: Ampicillin 2 g IM/IV single dose (30-60 minutes before procedure) OR Cefazolin 1 g IM/IV single dose (30-60 minutes before procedure) OR Ceftriaxone 1 g IM/IV single dose (30-60 minutes before procedure)
  • Pediatric dose: Ampicillin 50 mg/kg; Cefazolin 50 mg/kg; Ceftriaxone 50 mg/kg
  • 1.3 Allergic to penicillins or ampicillin - Oral regimen
  • 1.4 Allergic to penicillins or ampicillin and unable to take oral medication
  • Preferred regimen: Cefazolin 1 g IM/IV single dose (30-60 minutes before procedure) OR Ceftriaxone 1 g IM/IV single dose (30-60 minutes before procedure) OR Clindamycin 600 mg IM/IV single dose (30-60 minutes before procedure)
  • Pediatric doses: Cefazolin 50 mg/kg; Ceftriaxone 20 mg/kg
  • 2. Gastrointestinal/Genitourinary Procedures
  • Preferred regimen: Antibiotic prophylaxis to prevent IE is no longer recommended for patients who undergo a GI or GU tract procedure.
  • Note: High risk patients who already have an established GI or GU tract infection, it is reasonable to administer Ampicillin 2 g IM/IV single dose
  • 3. Regimens for Respiratory Tract Procedures
  • 3.1 Oral regimen
  • Preferred regimen: Amoxicillin 2 g single dose (30-60 minutes before procedure)
  • Pediatric dose: Amoxicillin 50 mg/kg single dose (30-60 minutes before procedure)
  • 3.2 Unable to take oral medication
  • Preferred regimen: Ampicillin 2 g IM/IV single dose (30-60 minutes before procedure) OR Cefazolin 1 g IM/IV single dose (30-60 minutes before procedure) OR Ceftriaxone 1 g IM/IV single dose (30-60 minutes before procedure)
  • 3.3 Allergic to penicillins or ampicillin — Oral regimen
  • Allergic to penicillins or ampicillin and unable to take oral medication
  • Preferred regimen: Cefazolin 1 g IM/IV single dose (30-60 minutes before procedure) OR Ceftriaxone 1 g IM/IV single dose (30-60 minutes before procedure) OR Clindamycin 600 mg IM/IV (30-60 minutes before procedure)
  • Pediatric doses: Cefazolin 50 mg/kg; Ceftriaxone 20 mg/kg
  • 4. Regimens for Procedures on Infected Skin, Skin Structure, or Musculoskeletal Tissue
  • Patients who undergo a surgical procedure that involves infected skin, skin structure, or musculoskeletal tissue, it may be reasonable that the therapeutic regimen administered for treatment of the infection contain an agent active against staphylococci and beta-hemolytic streptococci, such as an antistaphylococcal penicillin or a cephalosporin.

Impact of Restricting Prophylactic Antibiotics

There is data showing that the institution of these more restrictive guidelines does not increase the risk of endocarditis. The NICE guidelines recommended no antibiotic prophylaxis for any patient, and despite a 78.6% reduction in the administration of IE prophylaxis, there was no documentation of an increase in IE cases due to streptococci.[4] In France, following restricted use of antibiotics the incidence of IE was stable.[5]

2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease (VHD)

Recommendation for Infective Endocarditis (IE) Prophylaxis

COR LOE RECOMMENDATION COMMENT/RATIONALE
IIa C-LD Prophylaxis against IE is reasonable before dental procedures that involve manipulation of gingival tissue, manipulation of the periapical region of teeth, or perforation of the oral mucosa in patients with the following:

1. Prosthetic cardiac valves, including transcatheter- implanted prostheses and homografts.

2. Prosthetic material used for cardiac valve repair, such as annuloplasty rings and chords.

3. Previous IE.

4. Unrepaired cyanotic congenital heart disease or repaired congenital heart disease, with residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch or prosthetic device.

5. Cardiac transplant with valve regurgitation due to a structurally abnormal valve.

MODIFIED: LOE updated from B to C-LD. Patients with transcatheter prosthetic valves and patients with prosthetic material used for valve repair, such as annuloplasty rings and chords, were specifically identified as those to whom it is reasonable to give IE prophylaxis. This addition is based on observational studies demonstrating the increased risk of developing IE and high risk of adverse outcomes from IE in these subgroups. Categories were rearranged for clarity to the caregiver.

Recommendations for Infective Endocarditis Intervention

COR LOE RECOMMENDATION COMMENT/RATIONALE
I B Decisions about timing of surgical intervention should be made by a multispecialty Heart Valve Team of cardiology, cardiothoracic surgery, and infectious disease specialists. 2014 recommendation remains current.
I B Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) is indicated in patients with IE who present with valve dysfunction resulting in symptoms of HF. 2014 recommendation remains current.
I B Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) is indicated in patients with left-sided IE caused by S. aureus, fungal, or other highly resistant organisms. 2014 recommendation remains current.
I B Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) is indicated in patients with IE complicated by heart block, annular or aortic abscess, or destructive penetrating lesions. 2014 recommendation remains current.
I B Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) for IE is indicated in patients with evidence of persistent infection as manifested by persistent bacteremia or fevers lasting longer than 5 to 7 days after onset of appropriate antimicrobial therapy. 2014 recommendation remains current.
I C Surgery is recommended for patients with prosthetic valve endocarditis and relapsing infection (defined as recurrence of bacteremia after a complete course of appropriate antibiotics and subsequently negative blood cultures) without other identifiable source for portal of infection. 2014 recommendation remains current.
I B Complete removal of pacemaker or defibrillator systems, including all leads and the generator, is indicated as

part of the early management plan in patients with IE with documented infection of the device or leads.

2014 recommendation remains current.
IIa B Complete removal of pacemaker or defibrillator systems, including all leads and the generator, is reasonable in patients with valvular IE caused by S. aureus or fungi, even without evidence of device or lead infection. 2014 recommendation remains current.
IIa C Complete removal of pacemaker or defibrillator systems, including all leads and the generator, is reasonable in patients undergoing valve surgery for valvular IE. 2014 recommendation remains current.
IIa B Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) is reasonable in patients with IE who present with recurrent emboli and persistent vegetations despite appropriate antibiotic therapy. 2014 recommendation remains current.
IIb B Early surgery (during initial hospitalization before completion of a full therapeutic course of antibiotics) may be considered in patients with native valve endocarditis who exhibit mobile vegetations greater than 10 mm in length (with or without clinical evidence of embolic phenomenon). 2014 recommendation remains current.
IIb B-NR Operation without delay may be considered in patients with IE and an indication for surgery who have suffered a stroke but have no evidence of intracranial hemorrhage or extensive neurological damage. NEW: The risk of postoperative neurological deterioration is low after a cerebral event that has not resulted in extensive neurological damage or intracranial hemorrhage. If surgery is required after a neurological event, recent data favor early surgery for better overall outcomes.
IIb B-NR Delaying valve surgery for at least 4 weeks may be considered for patients with IE and major ischemic stroke or intracranial hemorrhage if the patient is hemodynamically stable. NEW: In patients with extensive neurological damage or intracranial hemorrhage, cardiac surgery carries a high risk of death if performed within 4 weeks of a hemorrhagic stroke.

References

  1. ↑ Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA; et al. (2014). "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines". Circulation. 129 (23): 2440–92. doi:10.1161/CIR.0000000000000029. PMID 24589852.
  2. ↑ Vahanian A, Alfieri O, Andreotti F, Antunes MJ, Baron-Esquivias G, Baumgartner H; et al. (2013). "[Guidelines on the management of valvular heart disease (version 2012). The Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)]". G Ital Cardiol (Rome). 14 (3): 167–214. doi:10.1714/1234.13659. PMID 23474606.
  3. ↑ Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M; et al. (2007). "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. 116 (15): 1736–54. doi:10.1161/CIRCULATIONAHA.106.183095. PMID 17446442.
  4. ↑ Thornhill MH et al. BMJ 2011;342:d2392.
  5. ↑ Duval X, et al. J Am Coll Card 2012;59:1968-76.

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