Maintenance of good oral hygiene is much more important in preventing infective endocarditis of dental origin than giving antimicrobial prophylaxis.
Appropriate treatment of skin injuries and good skin care in general are also important. People at the risk of endocarditis should avoid getting tattoos and piercings.
Patient groups requiring antimicrobial prophylaxis
Antimicrobial prophylaxis before the procedures listed below is appropriate in patients with
prosthetic cardiac valve or prosthetic material used for cardiac valve repair (including TAVI and percutaneous repair of mitral or tricuspid valve)
previous infectious endocarditis
unrepaired cyanotic congenital heart disease, including palliative shunts and conduits
repaired congenital heart disease with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device
repaired congenital heart defect using prosthetic material, shunts and conduits and patients with device closure, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure
cardiac transplantation who develop cardiac valvulopathy.
Prophylactic treatment is indicated before procedures with disruption of mucous membranes and possible or probable bacteraemia. Such interventions include, e.g.
tooth or periodontal procedures commonly associated with gum bleeding (tooth extraction, curettage) or including periapical manipulation (root canal treatment, resection)
cleansing of the dental support tissue (removal of subgingival calculus, scaling) performed by a dentist or a dental surgery assistant
drainage of maxillary sinuses
tonsillectomy, adenoidectomy
bronchoscopy associated with collection of a specimen or other invasive procedures.
In procedures of the urinary or gastrointestinal tract, possible infection in the operative area should be treated prior to the procedure (unless the procedure is necessary to treat the infection).
Antimicrobial prophylaxis not needed
Antimicrobial prophylaxis to prevent infective endocarditis is not needed e.g. in the following procedures:
dental procedures with no bleeding (dental filling; root canal treatment not interfering with the periapical region)
local anaesthesia in the mouth
fitting of a dental prosthesis
dental cleansing with paste
gastroscopy
colonoscopy
TURP (transurethral resection of the prostate)
gynaecological and obstetric procedures
labour and delivery
procedures on skin and soft tissue (e.g. mole removal).
Antimicrobial prophylaxis of endocarditis
Oral
First-line therapy
Amoxicillin: a single dose of 2 g one hour before the procedure, for children 50 mg/kg
Alternative treatments for patients allergic to penicillin
Cephalexin: a single dose of 2 g one hour before the procedure, for children 50 mg/kg (only if penicillin has not caused an anaphylactic reaction)
Clindamycin: a single dose of 600 mg, for children 20 mg/kg
Azithromycin: a single dose of 500 mg, for children 15 mg/kg
Roxithromycin: a single dose of 300 mg, for children 10 mg/kg
Clarithromycin: a single dose of 500 mg, for children 15 mg/kg
Alternative treatments for patients allergic to penicillin
Cefuroxime: 750 mg-1.5 g infusion, for children 60 mg/kg (only if penicillin has not caused an anaphylactic reaction)
lindamycin: 600-900 mg infusion, for children 20 mg/kg
The prophylaxis always has to cover viridans group streptococci. If a patient is already receiving antimicrobial therapy when arriving for the procedure, the antimicrobial drug for endocarditis prophylaxis is chosen from another pharmacological class than the one already in use. Thus e.g. in a patient belonging to a risk group and already receiving penicillin, clindamycin or a macrolide may be chosen in association with a bloody treatment procedure, if needed.
References
Habib G, Lancellotti P, Antunes MJ et al. 2015 ESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J 2015;36(44):3075-128. [PubMed]
Prevention of infective endocarditis. Guidelines from the American Hearth Association (AHA). Circulation. 2007;116:1736-1754 [PubMed]