Endocarditis primary prevention

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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

• 1.1 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

• 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

• 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)

• Pediatric doses: Ampicillin 50 mg/kg; Cefazolin 50 mg/kg; Ceftriaxone 50 mg/kg

• 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)
• Pediatric doses: Cephalexin 50 mg/kg; Clindamycin 20 mg/kg; Azithromycin 15 mg/kg; Clarithromycin 15 mg/kg

• 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. In France, following restricted use of antibiotics the incidence of IE was stable.

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.