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NICE 2008 recommendations are the most far reaching and recommend cessation of prophylaxis solely to prevent IE for dental and nondental procedures.216 NICE 2016 updated recommendations added the possibility for individual decision.5 The ESC 2009 and AHA 2007 guidelines still required that a small group of high-risk patients have prophylaxis for dental procedures, with manipulation of the gingival or periapical region of the teeth or perforation of the oral mucosa (see earlier for recommendations extrapolated to piercing of the oral mucosa) The ESC 2015 recommendations discard the indication for transplanted heart valvulopathy The current ESC 2015 recommendations for antibiotic prophylaxis are summarized in Box 56.6 Box 56.6 Recommendations on the European Society of Cardiology 2015 Guidelines for Antibiotic Prophylaxis Around Dental Procedures Antibiotic Prophylaxis Should Be Considered for Patients at Highest Risk for IE: Patients with any prosthetic valve, including a transcatheter valve, or those in whom any prosthetic material was used for cardiac valve repair Patients with a previous episode of IE Patients with CHD: ■ Any type of cyanotic CHD ■ Any type of CHD repaired with a prosthetic material, whether placed surgically or by percutaneous techniques, up to 6 months after the procedure or lifelong if residual shunt or valvar regurgitation remains Antibiotic prophylaxis is not recommended in other forms of valvar or CHD Recommended Prophylaxis for High-Risk Dental Procedures in High-Risk Patients: Antibiotic single-dose 30–60 minutes before procedure No allergy to penicillin or ampicillin: Amoxicillin 2 g orally or IV (children 50 mg/kg orally or IV) Allergy to penicillin or ampicillin: Clindamycin 600 mg orally or IV (children 20 mg/kg orally or IV) Cephalosporins should not be used in patients with anaphylaxis, angioedema, or urticaria after intake of penicillin or ampicillin due to cross-sensitivity CHD, Congenital heart disease; IE, infective endocarditis Recommendations are largely in line with US AHA 2007 recommendations Prophylaxis has been downgraded in France since 2002 UK NICE 2008 (amended 2016): no prophylaxis recommended unless there is individual decision Modified from ESC 2009/2015 IE guidelines The impression is that prosthetic valves, percutaneously implanted pulmonary valves, and surgically implanted bovine jugular vein conduits present higher risk for IE However, the data show that while the risk of IE in the listed conditions might be higher, there are little data to support the effectiveness of prophylaxis.245 It has been ascertained that it is invasive heart procedures and not dental procedures that are more significantly associated with IE in children with CHD.246 Prophylaxis for Nondental Procedures Systematic antibiotic prophylaxis is not recommended for nondental procedures Antibiotic therapy is needed only when invasive procedures are performed in the context of infection For PPM and ICD implantations, prophylaxis should be administered within 1 hour before the procedure.10 The current preference is for Teicoplanin, which is easy to administer as a bolus There is no evidence of a benefit of a repeat dose, although the prophylaxis should be continued for 48 hours after a prolonged procedure Preoperative screening of the nasal carriage for S aureus is recommended before elective cardiac surgery to treat carriers The use of local mupirocin or chlorhexidine is advocated.247,248 Systematic local treatment without screening is not recommended It is recommended that potential sources of dental sepsis should be eliminated at least 2 weeks before implantation of a prosthetic valve or other intracardiac or intravascular foreign material, unless the latter procedure is urgent Prophylaxis Recommendations of 2007–2008 Compliance There are few studies on compliance with the IE prophylaxis recommendations A 2016 paper reports that more than half of the pediatric cardiologists in the United States were skeptical and up to 56% of pediatric cardiologists on the survey did not totally adhere to the AHA 2007 IE prophylaxis recommendations.249 There is heterogeneity in the attitudes among cardiologists in Canada and Australia.250 By 2015, there had been certain reduction in the prescriptions for IE prophylaxis among pediatric and adult congenital cardiologists in Canada251; the prescriptions have decreased by more than 90% in the United Kingdom.252 Prophylaxis Recommendations of 2007–2008 (for France 2002) Impact There are currently controversial data on the impact of the reduction in IE prophylaxis.253 No change in incidence The majority of papers report no change of IE incidence in adult or mixed cohorts254–256 and VGS incidence.256,257 The results for pure pediatric IE cohorts also have shown no increase in overall pediatric IE incidence,20,16,258,259 with some increase in VGS pediatric IE in the older children259 or without VGS increase.16 Increase in incidence There are two papers mostly on adult cases published in 2015 reporting minimally increased IE incidence in the United States260 and the United Kingdom261 but without increase of the rate of hospitalization or valve surgery.260 However, the authors stopped short of making a causal link between that IE incidence increase and the cessation of IE prophylaxis  ... cohorts254–256 and VGS incidence.256,257 The results for pure pediatric IE cohorts also have shown no increase in overall pediatric IE incidence,20,16,258,259 with some increase in VGS pediatric IE in the older children259 or without VGS... There are few studies on compliance with the IE prophylaxis recommendations A 2016 paper reports that more than half of the pediatric cardiologists in the United States were skeptical and up to 56% of pediatric cardiologists on the survey did not totally adhere to the AHA 2007 IE prophylaxis... in Canada and Australia.250 By 2015, there had been certain reduction in the prescriptions for IE prophylaxis among pediatric and adult congenital cardiologists in Canada251; the prescriptions have decreased by more than 90%