Infective Endocarditis Prevention Guidelines, UMB Dental School COB

The AHA/ADA recommends that most patients no longer need short-term antibiotics as a preventive measure before their dental treatment. Only those patients with the highest risk should receive prophylaxis.

The following highest risk individuals should receive IE prophylaxis:

Artificial heart valves
A history of infective endocarditis
Certain specific, heart conditions, including
1. unrepaired or incompletely repaired cyanotic congenital heart disease, including those with palliative shunts and conduits
2. a completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the procedure
3. any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device
An individual with cardiac transplant that develops a problem in a heart valve.

The guidelines recommend that except for the highest risk patients listed above, patients who have taken prophylactic antibiotics routinely in the past no longer need them.

This includes patients with:

mitral valve prolapse
rheumatic heart disease
bicuspid valve disease
calcified aortic stenosis
congenital heart conditions such as ventricular septal defect, atrial septal defect and hypertrophic cardiomyopathy.

The drug regimens have remained unchanged.

For those patients who are taking an antibiotic for another condition the patient must take another class of antibiotic for pre-medication prior to their dental appointment.

It is the responsibility of every clinician to adhere to the standard of care, which is, in this case, the new AHA Guidelines.

American Heart Associate Guidelines for the Prevention of Infective Endocarditis (IE)

Box 2. Primary Reasons for Revision of the IE Prophylaxis Guidelines.

IE is much more likely to result from frequent exposure to random bacteremias associated with

Box 3. Cardiac Conditions Associated with the Highest Risk of Adverse Outcome from Endocarditis for which Prophylaxis for Dental Procedures is Reasonable.

Prosthetic Cardiac Valve or prosthetic material used for cardiac valve repair

* Except for the conditions listed above, antibiotic

^┼Prophylaxis is reasonable because endothelialization

Box 4. Dental Procedures for which Endocarditis Prophylaxis is Reasonable for Patients in Box 3.

All dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa*

*The following procedures and events do not need prophylaxis: routine

Table 2. Regimens for a Dental Procedure.

		Regimen: Single dose 30-60 minutes before procedure
Situation	Agent	Adults	Children
Oral	Amoxicillin	2 g	50 mg/kg
Unable to take oral medication	Ampicillin OR Cefazolin or Cephtriaxone	2 g IM* or IV^┼ OR 1 g IM or IV	50 mg/kg IM or IV
Allergic to penicillins or ampicillin – oral	Cephalexin^╪§ OR Clindamycin OR Azithromycin or Clarithromycin	2 g OR 600 mg OR 500 mg	50 mg/kg OR 20 mg/kg OR 15 mg/kg
Allergic to penicillins or ampicillin – unable to take oral medication	Cefazolin or Cephtriaxone^§ OR Clindamycin	1 g IM or IV OR 600 mg IM or IV	50 mg/kg IM or IV OR 20 mg/kg IM or IV

*IM: intramuscular, ^┼IV: intravenous

^╪Or other first- or second-generation oral cephalosporin in equivalent adult or pediatric dosage.

^§Cephalosporins should not be used in a person with a history of anaphylaxis, angioedema, or urticaria with penicillins or ampicillin.

The complete guidelines as they relate to dentistry are published in The Journal of the American Dental Association 2008; 139(1): Special Supplement.

Modified from: Preventing Infective Endocarditis, J Am Dent Assoc 2008: 139(1) Special Supplement: 7s, 17S, 18S, 20S.