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Endocarditis

AHA Releases New Guidelines for Infective Endocarditis (IE) Prevention

The AHA has published new guidelines for IE prophylaxis that aims to be less confusing and more evidence-based in its recommendations. The current revision recognizes that IE is much more likely to result from frequent exposure to random bacteremias associated with daily activities rather than from bacteremia caused by a dental, GI tract or GU tract procedure. Furthermore, prophylaxis is likely to prevent only an exceedingly small number of cases of IE and the risks of antibiotic-associated adverse events often exceed the benefit, if any, from prophylactic therapy. Maintenance of optimal oral health and hygiene will reduce the incidence of bacteremia from normal daily activities and will be of greater benefit than dental prophylaxis in the prevention of infective endocarditis.

Doctor watching patient do an ETT

Which patients are now recommended for IE prophylaxis?

Patients considered to be at highest risk for IE are those with:

  • Prosthetic cardiac valve
  • Previous IE
  • 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 who develop cardiac valvulopathy


Antibiotic prophylaxis is no longer recommended for any other form of congenital heart disease, including mitral valve prolapse (MVP).

Which procedures qualify these patients for IE prophylaxis?

All dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa. These high-risk patients should also receive prophylaxis for procedures of the respiratory tract, infected skin, skin structures and musculoskeletal tissue. The following procedures and events do not need 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, and bleeding from trauma to the lips or oral mucosa.  

Antibiotic prophylaxis is no longer recommended for GU or GI tract procedures.

How should IE prophylaxis be given:

Situation

Agent

Adults

Children

Oral

Amoxicillin

2 g

50 mg/kg

Unable to take oral medication

Ampicillin
OR
cefazolin or ceftriaxone

2 g IM or IV

1 g IM or IV

50 mg/kg IM or IV
50 mg/kg IM or IV

Oral: Allergic to penicillin or ampicillin

Cephalexin*†
OR
Clindamycin
OR
Azithromycin or clarithromycin

2 g

600 mg

500 mg

50 mg/kg

20 mg/kg


15 mg/kg

Unable to take oral medication: 
Allergic to penicillins or ampicillin

Cefazolin or ceftriaxone†
OR
Clindamycin

1 g IM or IV

600 mg IM or IV

50 mg/kg IM or IV

20 mg/kg IM or IV


IM indicates intramuscular; IV, intravenous.
*Or other first- or second-generation oral cephalosporin in equivalent adult or pediatric dosage.
†Cephalosporins should not be used in an individual with a history of anaphylaxis, angioedema, or urticaria with penicillins or ampicillin.


Each of our Echo and Cardiac MR reports will continue to include a specific recommendation for IE prophylaxis consistent with these new guidelines. The complete AHA guideline may be downloaded in pdf format. If you have any questions, please do not hesitate to call any one of us at CARI.

Wilson W, Taubert KA, 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 Apr 19, 2007.