ENDOCARDITIS: CURRENT PROPHYLAXIS GUIDELINES
RISK OF ENDOCARDITIS ASSOCIATED WITH CARDIAC CONDITIONS
CARDIAC CONDITION RISK  PROPHYLX
        RX
Prosthetic cardiac valves, including bioprosthetic and homograft valves High Yes
Previous bacterial endocarditis High Yes
Complex, cyanotic congenital heart disease (tetralogy, single ventricles, etc.) High Yes
Surgically constructed systemic pulmonary shunts or conduits High Yes
Most congenital cardiac malformations (other than high or negligible risks) Moderate Yes
Acquired valvular dysfunction (eg, rheumatic heart disease) Moderate Yes
Hypertrophic cardiomyopathy Moderate Yes
MVP with valvular regurgitation and/or thickened leaflets Moderate Yes
Isolated secundum atrial septal defect Negligible No
Surgical repair of atrial septal defect, VSD, or PDA (without residua beyond 6 mo) Negligible No
Previous coronary artery bypass graft surgery Negligible No
MVP without mitral regurgitation Negligible No
Physiologic, functional, or innocent heart murmur Negligible No
Previous Kawasaki disease without valvular dysfunction Negligible No
Previous rheumatic disease without valvular dysfunction Negligible No
Cardiac pacemakers (intravascular and epicardial) and implanted defibrillators Negligible No

PROCEDURES FOR WHICH ENDOCARDITIS PROPHYLAXIS IS RECOMMENDED
DENTAL
Extractions
Periodontal procedures, including surgery, scaling, root planing, probing and recall maintenance
Implant placement and reimplantation of avulsed teeth
Endodontic (root canal) instrumentation or surgery only beyond the apex
Subgingival placement of antibiotic fibers or strips
Initial placement of orthodontic bands but not brackets
Intraligamentary local anesthetic injections
Prophylactic cleaning of teeth or implants in which bleeding is anticipated
 RESPIRATORY TRACT
Tonsillectomy and/or adenoidectomy
Surgical operations that involve respiratory mucosa
Rigid bronchoscopy
GI TRACT
Sclerotherapy for esophageal varices
Esophageal stricture dilatation
Endoscopic retrograde cholangiography with biliary obstruction
Biliary tract surgery
Surgical operations that involve intestinal mucosa
GENITOURINARY TRACT
Prostatic surgery
Cystoscopy
Urethral dilatation

PROCEDURES FOR WHICH ENDOCARDITIS PROPHYLAXIS IS
GENERALLY NOT RECOMMENDED
 DENTAL
Restorative dentistry (operative and prosthodontic) with or without retraction cord
Local anesthetic injectionas (nonintraligamentary)
Intracanal endodontic treatment; after placement and buildup
Placement of rubber dams
Postoperative suture removal
Placement of removable prosthodontic or orthodontic appliances
Taking of oral impressions
Fluoride treatments
Taking of oral radiographs
Orthodontic appliance adjustment
Shedding of primary teeth
RESPIRATORY TRACT
Endotracheal intubation
Flexible bronchoscopy with or without biopsy
Tympanostomy tube insertion
GI TRACT
Transesophageal echocardiography
Endoscopy, with or without biopsy
GENITOURINARY TRACT
Vaginal hysterectomy
Vaginal delivery
Cesarean section
Urethral catheterization (in uninfected fetus)
Uterine dilatation and curettage (in uninfected tissue)
Therapeutic abortion (in uninfected tissue)
Sterilization procedures (in uninfected tissue)
Insertion or removal of intrauterine devices (in uninfected tissue)
OTHER
Cardiac catheterization, including balloon angioplasty
Implanted cardiac pacemakers, implanted defibrillators, and coronary stents
Circumcision
 Note: Also not recommended for restoration of decayed teeth, filling cavities and missing teeth. Antibiotics may be indicated in selected cases and circumstances that may create significant bleeding. Prophylaxis is optional for high risk patients.

RECOMMENDED PROPHYLAXIS FOR DENTAL, ORAL, RESPIRATORY TRACT
OR ESOPHAGEAL PROCEDURES
Patient status Agent Regimen
Not allergic to penicillin and able to take oral medications Amoxicillin Adults: 2 g (children: 50 mg/kg) PO 1 hr before procedure
Unable to take oral medications Ampicillin Adults: 2 g (children: 50 mg/kg) IM or IV within 30 mins before procedure
Allergic to penicillin Clindamycin or Adults: 600 mg (children: 20 mg./kg) PO
1 h before procedure
  Cephalexin or cefadroxil or Adults: 2 g (children 50 mg/kg) PO 1 h before procedure
  Azithromycin or clarithromycin Adults: 500 mg (children: 15 mg/kg) PO
1 h before procedure
Allergic to penicillin and unable to take oral medications Clindamycin or Adults: 600 mg (children: 20 mg/kg) IV within 30 min before procedure
  Cefazolin Adults: 1 g (children: 25 mg/kg) IM or IV within 30 min before procedurre

Avoid using cephalosporins in persons with immediate hypersensitivity reaction to penicillin, such as urticaria,
ngioedema or anaphylaxis.

RECOMMENDED PROPHYLAXIS FOR GENITOURINARY AND GI
(EXCLUDING ESOPHAGEAL) PROCEDURES
Patient status Agent Regimen
High risk Ampicillin plus gentamycin Adults: ampicillin, 2 g IM or IV, plus gentamicin, 1.5 mg/kg (not to exceed 120 mg) within 30 min of starting procedure; 6 h later, give ampicillin 1 g IM or IV, or amoxicillin, 1 g PO
    Children: ampicillin, 50 mg/kg IM or IV (not to exceed 2 g), plus gentamicin, 1.5 mg/kg, within 30 min of starting procedure; 6 h later, give ampicillin, 25 mg/kg IM or IV, or amoxicillin, 25 mg/kg PO
High risk and allergic to ampicillin/amoxicillin Vancomycin plus gentamicin Adults: vancomycin, 1 g IV ovber 1-2 h, plus gentamicin, 1.5 mg/kg IV or IM (not to exceed 120 mg); complete injection/infusion within 30 min of starting procedure
    Children: vancomycin, 20 mg/kg IV over 1-2 h, plus gentamicin, 1.5 mg/kg/IV or IM; complete injection/infusion within 30 min of starting procedure
Moderate risk Amoxicillin or ampicillin Adults: amoxicillin, 2 g 1 h before procedure, or ampicillin, 2 g IM or IV within 30 min of starting procedure
    Children: amoxicillin, 50 mg/kg PO 1 h before procedure, or ampicillin, 50 mg/kg IM or IV within 30 min of starting procedure
Moderate risk and allergic to ampicillin/amoxicillin Vancomycin Adults: vancomycin, 1 g IV over 1-2 h; complete infusion within 30 min of starting procedure
a   Children: vancomycin, 20 mg/kg IV over 1-2 h; complete infusion within 30 min of starting procedure

Total children dose should not exceed adult dose. A second dose of vancomycin or gentamicin is not recommended.
Source: Endocarditis: Current Guidelines on Prophylaxis . Matthew Levision, MD and Elias Abrutyn, MDFebruary 1998. Consultant