Chapter 118. Infective Endocarditis (Part 14) Antibiotic prophylaxis, if 100% effective, likely prevents only a small number of cases of endocarditis; nevertheless, it is possible that rare cases are prevented. Weighing the potential benefits, potential adverse events, and costs associated with antibiotic prophylaxis, the expert committee of the American Heart Association has dramatically restricted the recommendations for antibiotic prophylaxis. Prophylactic antibiotics (Table 118-7) are advised only for those patients at highest risk for severe morbidity or death from endocarditis (Table 118- 8). Prophylaxis is recommended only for dental procedures wherein there is manipulation of gingival tissue or the periapical region of the teeth or perforation of the oral mucosa (including surgery on the respiratory tract). Although prophylaxis is not advised for patients undergoing gastrointestinal or genitourinary tract procedures, it is recommended that effective treatment be given to these high- risk patients before or when they undergo procedures on an infected genitourinary tract or on infected skin and related soft tissue. Maintaining good dental hygiene is also advised. (For further details, see http://www.americanheart.org/presenter.jhtml?identifier=3047083.) Table 118- 7 Antibiotic Regimens for Prophylaxis of Endocarditis in Adults with High-Risk Cardiac Lesions a,b A. Standard oral regimen 1. Amoxicillin 2.0 g PO 1 h before procedure B. Inability to take oral medication 1. Ampicillin 2.0 g IV or IM within 1 h before procedure C. Penicillin allergy 1. Clarithromycin or azithromycin 500 mg PO 1 h before procedure 2. Cephalexin c 2.0 g PO 1 h before procedure 3. Clindamycin 600 mg PO 1 h before procedure D. Penicillin allergy, inability to take oral medication 1. Cefazolin c or ceftriaxone c 1.0 g IV or IM 30 min before procedure 2. Clindamycin 600 mg IV or IM 1 h before procedure a Dosing for children: for amoxicillin, ampicillin, cephalexin, or cefadroxil, use 50 mg/kg PO; cefazolin, 25 mg/kg IV; clindamycin, 20 mg/kg PO, 25 mg/kg IV; clarithromycin, 15 mg/kg PO; gentamicin, 1.5 mg/kg IV or IM; and vancomycin, 20 mg/kg IV. b For high-risk lesions, see Table 118- 8. Prophylaxis is not advised for other lesions. c Do not use cephalosporins in patients with immediate hypersensitivity (urticaria, angioedema, anaphylaxis) to penicillin. Source: W Wilson et al: Circulation, published online 4/19/07. Table 118-8 High- Risk Cardiac Lesions for Which Endocarditis Prophylaxis Is Advised before Dental Procedures Prosthetic heart valves Prior endocarditis Unrepaired cyanotic congenital heart dise ase, including palliative shunts or conduits Completely repaired congenital heart defects during the 6 months after repair Incompletely repaired congenital heart disease with residual defects adjacent to prosthetic material Valvulopathy developing after cardiac transplantation Source: W Wilson et al: Circulation, published online 4/19/07. Further Readings Baddour LM et al: 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. Circulation 111:e394, 2005 Durack DT (ed): Infective endocarditis. Infect Dis Clin North Am 16:255, 2002 Fowler VG Jr et al: Endocarditis and intravascular infections, in Principles and Practice of Infectious Diseases , 6th ed, GL Mandell et al (eds). Philadelphia, Elsevier Churchill Livingstone, 2005, pp 975–1021 Horstkotte D et al: Guidelines on prevention, diagnosis and treatment of infective endocarditis. Executive summary, The Task Force on Infective Endocarditis of the European Society of Cardiology. Eur Heart J 25:267, 2004 [PMID: 14972429] Karchmer AW: Infective endocarditis, in Heart Disease , 8th ed, E Braunwald et al (eds). Philadelphia, Elsevier Saunders, 2007, in press ——— , Longworth DL: Infections of intracardiac devices. Cardiol Clin 21:253, 2003 Li JS et al: Propose d modifications to the Duke criteria for the diagnosis of infective endocarditis. Clin Infect Dis 30:633, 2000 [PMID: 10770721] Moreillon P, Que YA: Infective endocarditis. Lancet 363:139, 2004 [PMID: 14726169] Morris AJ et al: Bacteriological outcome after valve surgery for active infective endocarditis: Implications for duration of treatment after surgery (abstract). Clin Infect Dis 41:187, 2005 [PMID: 15983914] Vikram HR et al: Impact of valve surgery on 6- month mortality in adults with complicated, left- sided native valve endocarditis: A propensity analysis. JAMA 290:3207, 2003 [PMID: 14693873] Wilson W et al: Prevention of infective endocarditis. Guidelines from the American Heart Association. A guideline from the American Heart Association Rheu matic 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 Interdiscipli nary Working Group. Circulation, April 19, 2007 (epub ahead of print) (http://www.americanheart.org/presenter.jhtml?identifier=3047083) . Chapter 118. Infective Endocarditis (Part 14) Antibiotic prophylaxis, if 100% effective, likely prevents only a small number of cases of endocarditis; nevertheless,. treatment of infective endocarditis. Executive summary, The Task Force on Infective Endocarditis of the European Society of Cardiology. Eur Heart J 25:267, 2004 [PMID: 14972429] Karchmer AW: Infective. modifications to the Duke criteria for the diagnosis of infective endocarditis. Clin Infect Dis 30:633, 2000 [PMID: 10770721] Moreillon P, Que YA: Infective endocarditis. Lancet 363:139, 2004 [PMID: 14726169]