Primary prevention
The evidence for antibiotic prophylaxis preventing infection following dental procedures and instrumentation of the respiratory, genitourinary, or gastrointestinal tract is weak.[51] An increase in incidence of IE in recent years has not been found to be temporally related to changes in recommendations regarding use of prophylactic antibiotics.[51][52][53][54] Conflicting data suggest that a reduction in bacteremia may not result in a lower incidence of IE in low-risk individuals.[55] The risk of bacteremia resulting from interventions such as dental procedures and instrumentation of the respiratory, genitourinary, or gastrointestinal tract is significantly smaller than from usual lifetime activities such as toothbrushing or chewing.[51][56] Data have indicated that even if treatment with prophylactic antibiotics were 100% effective, only a small number of cases would be prevented. Indeed, the risk of fatalities from anaphylaxis resulting from antibiotic prophylaxis is higher than the benefit of preventing endocarditis.
There is consensus that antibiotic prophylaxis should therefore be largely reserved for patients at the highest risk of developing endocarditis and at high risk of experiencing adverse outcomes from it.[20][40][57][58][59] Decisions about antibiotic prophylaxis should only be made after careful evaluation of the individual patient’s circumstances, following discussion with the patient, taking into account the patient’s values and preferences, and using your clinical judgement.[57][58][60]
The American Heart Association (AHA), the American College of Cardiology (ACC), and European Society of Cardiology (ESC) list the following high-risk features:[6][7][20]
Prosthetic cardiac valves, including transcatheter-implanted prostheses and homografts
Prosthetic material used for valve repair, such as annuloplasty rings, chords, or clips
Previous IE
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
Cardiac transplant recipients
Ventricular assist devices
Antibiotic prophylaxis is recommended in these highest-risk patients when undertaking dental procedures that involve manipulation of gingival tissues or the periapical region of the tooth, or perforation of the oral mucosa.[20][40]
The most common cause of IE following dental procedures is Streptococcus viridans (alpha-hemolytic streptococci). Antibiotics for prophylaxis are, therefore, directed toward this organism, and administered as a single dose 30 to 60 minutes before the procedure. Guidelines recommend oral amoxicillin. If the patient is allergic to penicillin, alternative options are: first- or second-generation oral cephalosporin, azithromycin or clarithromycin, doxycycline. If the patient is unable to take oral medication, alternative options are: intramuscular or intravenous ampicillin, cefazolin, or ceftriaxone.[40]
Antibiotic prophylaxis is not recommended in high-risk patients for the following dental procedures: 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 primary teeth, and bleeding from trauma to the lips or oral mucosa.[40]
Antibiotic prophylaxis is not recommended in high-risk patients undergoing nondental procedures (e.g., transthoracic echocardiogram, esophagogastroduodenoscopy, colonoscopy, or cystoscopy) in the absence of active infection.[20][40]
Antibiotic prophylaxis is not recommended in patients with moderate-risk lesions.[20][40]
The table that follows summarizes recommendations for primary prevention of infective endocarditis taken from the ACC/AHA guidance on valvular heart disease.[20]
Note that an individual patient may fall into more than one group and so interventions might be additive; please review all population and subpopulation groups to assess all that apply.
Patients with valvular heart disease at high risk of IE
Prosthetic cardiac valve or prosthetic material used for cardiac valve repair; history of previous IE; congenital heart disease; cardiac transplant recipients
All
Intervention
Maintain optimal oral health
Regular professional dental care is recommended (twice a year routine visits where available).
Advise use of appropriate dental products (e.g., manual, powered, and ultrasonic toothbrushes; dental floss; other plaque-removal devices).
Goal
Reduce potential sources of bacterial seeding
Undergoing dental procedure involving manipulation of gingival tissues or the periapical region of the tooth, or perforation of the oral mucosa
Intervention
Prophylactic antibiotics
Antibiotic prophylaxis is reasonable in this subset of patients at highest risk of IE.
Goal
Reduce risk of IE by reducing bacteremia
There is a high risk of morbidity and mortality if the patient develops IE, therefore prevention is very important in this group.
Undergoing dental procedures involving 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 primary teeth, and bleeding from trauma to the lips or oral mucosa
Intervention
No prophylactic antibiotics required
Goal
Reduce antibiotic resistance, decrease risk of Clostridioides difficile-associated disease
Antibiotic stewardship reduces development of multidrug-resistant microorganisms including Streptococcus viridans, as well as reducing costs and individual patient complications such as Clostridioides difficile-associated disease, anaphylaxis, and drug toxicity.
Undergoing nondental procedure (e.g., transesophageal echocardiogram, esophagogastroduodenoscopy, colonoscopy, cystoscopy, lithotripsy); with active infection
Intervention
Antibiotics to treat active infection
Antibiotics are only recommended for nondental procedures if there is active infection present.
In patients with bacteriuria, give appropriate antimicrobial therapy before elective surgery, instrumentation, or diagnostic procedures that involve the genitourinary tract.
Goal
Reduce potential sources of bacterial seeding
Undergoing nondental procedure; without active infection
Intervention
No prophylactic antibiotics required
The risk of IE after most procedures is low and there are no controlled data supporting the use of antibiotic prophylaxis in the absence of active infection.
Transient bacteremia due to endoscopy is infrequent (rate 2% to 5%), and typically the organisms identified are unlikely to cause IE. Biopsy, polypectomy, or sphincterotomy have not been shown to increase the risk of bacteremia. Even for procedures associated with higher rates of bacteremia (e.g., esophageal dilation, endoscopic retrograde cholangiopancreatography), no studies have demonstrated a reduction in IE with antibiotic prophylaxis.
Goal
Reduce antibiotic resistance, decrease risk of Clostridioides difficile-associated disease
Antibiotic stewardship reduces development of drug resistance, as well as reducing costs and individual patient complications such as Clostridioides difficile-associated disease, anaphylaxis, and drug toxicity.
Patients with valvular heart disease at moderate or low risk of IE
All
Intervention
Maintain optimal oral health
Regular professional dental care is recommended (twice a year routine visits where available).
Use of appropriate dental products (e.g., manual, powered, and ultrasonic toothbrushes; dental floss; other plaque-removal devices).
Goal
Reduce potential sources of bacterial seeding
Secondary prevention
Patients with a previous history of IE are at high risk of a further episode of endocarditis. These patients should receive antibiotic prophylaxis for dental procedures that involve manipulation of gingival tissues or the periapical region of the tooth, or perforation of the oral mucosa.[20][40]
IE may signify occult malignancy. The relationship between Streptococcus gallolyticus (formerly Streptococcus bovis) infection and colon cancer is well documented. Exclusion of occult colon cancer is recommended in cases of IE secondary to infection with these organisms. Annual colonoscopy is strongly suggested for those individuals where no tumor is detected.[144]
There has been an increase in the number of individuals affected by congenital heart disease and the incidence of IE in this group is reported as being 15 to 140 times higher than that of the general population, although the prognosis remains better than in other forms of IE.[145][146] Primary prevention in those with congenital heart disease is paramount, and patient education regarding oral, dental, and skin hygiene, and the avoidance of tattoos and piercings remains crucial.[145][146]
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