Antibiotic Prophylaxis for Infective Endocarditis
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Antibiotic prophylaxis for infective endocarditis (IE) is employed to prevent infection in high-risk individuals during medical procedures that might introduce bacteria into the bloodstream. Prophylaxis is pivotal in managing patients predisposed to IE by identifying those at high risk and the specific high-risk procedures.
Guidelines for Antibiotic Prophylaxis
Professional organizations such as the American Heart Association (AHA) and the European Society of Cardiology (ESC) have set forth guidelines, which are periodically updated to narrow prophylaxis to high-risk cases due to concerns over antibiotic resistance and overuse.
Routine prophylaxis for all patients undergoing dental or similar procedures is generally not recommended.
Indications for Antibiotic Prophylaxis
| Category | Indications |
|---|---|
| High-Risk Patients | – Prosthetic Heart Valves/Material: Includes mechanical or bioprosthetic valves, or valve repairs with prosthetic material like annuloplasty rings. |
| – History of Infective Endocarditis: Those previously diagnosed with IE are at increased recurrence risk. | |
| – Congenital Heart Disease (CHD): Includes unrepaired cyanotic CHD, repaired CHD with prosthetic material/device within the first 6 months, and CHD with residual defects. | |
| – Heart Transplant Patients with Valvulopathy: Those who have developed valvular regurgitation or other valve abnormalities post-transplantation. | |
| High-Risk Procedures | – Dental Procedures: Necessary for procedures that manipulate the gingival tissue, the periapical region of teeth, or involve perforation of the oral mucosa. |
| – Respiratory Tract Procedures: Required for procedures like tonsillectomy, bronchoscopy with biopsy, or adenoidectomy. | |
| – Infected Skin, Skin Structures/Musculoskeletal Procedures: Recommended for surgical procedures like abscess incision and drainage, or surgeries on infected tissues. |
Procedures Not Requiring Prophylaxis
Prophylaxis is not advised for routine gastrointestinal/genitourinary procedures, routine orthodontic or restorative dental procedures, routine injections, cardiac catheterization, or bronchoscopy without biopsy, even in high-risk patients.
Antibiotic Regimens for Prophylaxis
Appropriate antibiotic administration timing is crucial—typically 30–60 minutes before the procedure to ensure optimal blood levels during potential bacterial exposure.
| Procedure Type | First-line Antibiotic | For Penicillin-Allergic Patients |
|---|---|---|
| Dental and Respiratory Procedures | Amoxicillin 2 g orally (50 mg/kg for children) | Clindamycin 600 mg, Azithromycin or Clarithromycin 500 mg, or Cephalexin 2 g orally; avoid cephalosporins in severe penicillin allergy. |
| Parenteral Route/Severe Infections | Ampicillin 2 g IV or IM (50 mg/kg for children) | Cefazolin 1 g or Ceftriaxone 1 g IV/IM, Clindamycin 600 mg IV/IM. |
| Skin/Musculoskeletal Procedures | Cefazolin or Ceftriaxone 1 g IV or IM (50 mg/kg for children) | Vancomycin 15–20 mg/kg IV over 1–2 hours. |
References
- 2023 ESC Guidelines for the Management of Endocarditis. European Society of Cardiology (ESC). European Heart Journal. 2023;44(39):3948-4020. doi:10.1093/eurheartj/ehad193. Available at: https://academic.oup.com/eurheartj/article/44/39/3948/7243107.
- Delgado V, Borger MA. ESC Clinical Practice Guidelines on Endocarditis. American College of Cardiology. 2023. Available at: https://www.acc.org.