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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.


'''The AHA now recommends the administration of pre-endodontic procedural prophylactic antibiotics to patients with the highest risk of adverse outcomes subsequent to the development of endocarditis'''<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>:
==Antibiotic Prophylaxis==
:* '''Patients with a prosthetic cardiac valve'''
===Antimicrobial Regimen===
:* '''Patients with a prior history of [[infective endocarditis]]'''
* 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>
:* '''[[Cardiac transplantation]] recipients who develop cardiac valvulopathy'''
:* '''Patients with [[congenital heart disease]]:'''
::*'''Patients with unrepaired cyanotic congenital heart disease in which shunts and conduits are present'''
::*'''Patients who have undergone complete repair of a congenital heart defect with prosthetic material or a device either by surgery or catheter repair within the past 6 months'''
::*'''Patient with repaired congenital heart disease with residual defects at the site of a prosthetic patch or device (which inhibits endothelialization)'''


The following endodontal procedures that involve manipulation of the gingival tissue or the periapical region of teeth or perforation of the oral mucosa require coverage in this high risk population:
:* 1.1 '''Oral regimen'''
:*'''Any type of dental extractions'''
::* Preferred regimen: [[Amoxicillin]] 2 g PO single dose (30-60 minutes before procedure)
:*'''Any type of periodontal procedures and gingival surgery'''
::* Pediatric dose: [[Amoxicillin]] 50 mg/kg PO single dose (30-60 minutes before procedure)
:**'''Placement of dental implants and avulsed teeth replantation'''
:**'''Dental canal or root surgery'''
:**'''Antibiotic fibres or strips placement at subgingival area'''
:**'''Initial placement of orthodontic brackets'''
:**'''Intraligamentous injection of local anesthetic drugs''' 
:**'''Bleeding during prophylactic cleaning of teeth or implants'''


Other scenarios that are not dental procedures and for which prophylaxis is not recommended include shedding of [[deciduous teeth]] and trauma to the lips and oral mucosa. Routine anesthetic injections through non-infected tissue, the taking of dental radiographs, placement of removable prosthodontic or orthodontic appliances, placement of orthodontic brackets, or adjustment of orthodontic appliances do not require prophylaxis.
:* 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


In this high risk population, prophylactic antimicrobial therapy should be directed against [[Streptococcus viridans]]. Acknowledging an estimated 10-20 fold greater risk of single-dose fatal anaphylaxis with [[amoxicillin]] compared to single dose cephalosporin, macrolide and clindamycin regimens, the AHA believes prophylaxis with [[amoxicillin]] is a safe practice as there have been no reports of fatal [[anaphylaxis]] arising from a single-dose of pre-dental [[endocarditis]] prophylaxis using oral [[amoxicillin]]which  is well absorbed in the gastrointestinal tract and provides high and sustained serum concentrations.
:* 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


For those patients who have an allergy to [[penicillin]]s or [[amoxicillin]], then the use of [[cephalexin]] or another first-generation oral [[cephalosporin]], [[clindamycin]], [[azithromycin]], or [[clarithromycin]] is recommended. For those patients who cannot tolerate oral antibiotics, treatment with [[ampicillin]], [[ceftriaxone]], or [[cefazolin]] administered either intramuscularly or intravenously is recommended. Finally, for those patients who are [[ampicillin]] allergic and who are also unable to take an oral antibiotic, therapy with either parenteral [[cefazolin]], [[ceftriaxone]], or [[clindamycin]] is recommended.
:* 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


A complete list of antibiotics that are acceptable for use as prophylaxis of [[infective endocarditis]] include the following:
* 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


*[[Amoxicillin]]
* 3. '''Regimens for Respiratory Tract Procedures'''
*[[Ampicillin]]
:* 3.1 '''Oral regimen'''
*[[Cefazolin]]
::* Preferred regimen: [[Amoxicillin]] 2 g single dose (30-60 minutes before procedure)
*[[Ceftriaxone]]
::* Pediatric dose: [[Amoxicillin]] 50 mg/kg single dose (30-60 minutes before procedure)
*[[Cephalexin]]
*[[Clindamycin]]
*[[Azithromycin]]
*[[Clarithromycin]]


==ACC/AHA 2008 Guideline Update on Valvular Heart Disease: Focused Update on Infective Endocarditis <ref name="pmid18663090">{{cite journal| author=Nishimura RA, Carabello BA, Faxon DP, Freed MD, Lytle BW, O'Gara PT et al.| title=ACC/AHA 2008 guideline update on valvular heart disease: focused update on infective endocarditis: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. | journal=Circulation | year= 2008 | volume= 118 | issue= 8 | pages= 887-96 | pmid=18663090 | doi=10.1161/CIRCULATIONAHA.108.190377 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18663090  }} </ref> (DO NOT EDIT)==
:* 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)


{|class="wikitable"
::* Pediatric doses: [[Ampicillin]] 50 mg/kg; [[Cefazolin]] 50 mg/kg; [[Ceftriaxone]] 50 mg/kg
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|'''1.''' <nowiki>"</nowiki>Modified recommendation (changed class of recommendation from I to IIa, changed text). There are no Class I recommendations for infective endocarditis prophylaxis.<nowiki>"</nowiki>
|}


{|class="wikitable"
:* 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)
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm)
::* Pediatric doses:  [[Cephalexin]] 50 mg/kg; [[Clindamycin]] 20 mg/kg; [[Azithromycin]] 15 mg/kg; [[Clarithromycin]] 15 mg/kg
|-
|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. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|}


{|class="wikitable"
:* '''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)
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
::* Pediatric doses: [[Cefazolin]] 50 mg/kg; [[Ceftriaxone]] 20 mg/kg
|-
|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 mucosa4: '' <nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|'''1a.''' <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"|'''1b.''' <nowiki>"</nowiki>Patients with previous infective endocarditis. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|'''1c.''' <nowiki>"</nowiki>Patients with CHD. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|'''1d.''' <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"|'''1e.''' <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"|'''1f.''' <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"|'''1g.''' <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>
|}


* 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.<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>


==Recommendations Regarding Antibiotic Prophylaxis Prior to Procedures on Infected Skin or Musculoskeletal Tissue==
==2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease (VHD)==


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>
===Recommendation for Infective Endocarditis (IE) Prophylaxis===


==Antibiotic Prophylaxis For Respiratory Tract Procedures==
{| class="wikitable" style="width: 80%; text-align: justify;"
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>
! style="width:12%" | '''COR'''
! style="width:8%" | ''' LOE'''
! style="width:40%" | '''RECOMMENDATION'''
! style="width:40%" | '''COMMENT/RATIONALE'''
|-
| 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.
'''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.
|| '''{{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.
|}


:*[[Tonsillectomy]]
===Recommendations for Infective Endocarditis Intervention===
:*[[Adenoidectomy]]
:*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.
{| class="wikitable" style="width: 80%; text-align: justify;"
 
! style="width:12%" | '''COR'''
==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>==
! style="width:8%" | ''' LOE'''
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]].
! style="width:40%" | '''RECOMMENDATION'''
 
! style="width:40%" | '''COMMENT/RATIONALE'''
==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>==
|-  
 
| 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.
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.
|-
 
| 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.
==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>==
|-
 
| 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.
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.
|-  
 
| 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.
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="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.
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.
|-  
 
| 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.
==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.
| bgcolor="LightGreen" | I || bgcolor="LightBlue" | B ||Complete removal of pacemaker or defibrillator systems, including all leads and the generator, is indicated as
Major changes include:
part of the early management plan in patients with IE with documented infection of the device or leads.
* [[Bacteremias]] associated with daily activities (which are frequent) are considered more likely to cause [[endocarditis]] than are endodontic-procedural induced [[bacteremias]].
|2014 recommendation remains current.
*Optimal oral hygiene is emphasized as an important practice to prevent endocarditis.
|-
*A patient’s lifetime risk of endocarditis is no longer a consideration for initiating prophylactic antibiotic therapy.
| 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.
*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).
|-
 
| 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.
===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.
| 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.
 
|-  
*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>
| 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 [[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.
| 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.
</ref>:
|-  
:*[[Congenital heart disease]]: 1 per 475,000
| 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.
:*[[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>
 
*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>
 
*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.
 
===The Efficacy of Prophylactic Antibiotic===
*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.
*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.
#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%.
#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%.
 
===Safety Concerns with Antibiotic Prophylaxis===
''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>
*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>
*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>
*[[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.
</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.
*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.
 
==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>
*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.
*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.
*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.


==References==
==References==
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Latest revision as of 13:37, 26 October 2017
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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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