Infective Endocarditis Prophylaxis¶

Learning Objectives¶

Core Knowledge & Clinical Reasoning¶

[ ] Identify the 4 cardiac conditions requiring IE prophylaxis (prosthetic valve, prior IE, certain CHD, transplant valvulopathy)
[ ] Differentiate procedures that warrant prophylaxis (dental with gingival manipulation) from those that do not
[ ] Analyze why most common CHD lesions (VSD, ASD, AS) do NOT require prophylaxis

Prescribing¶

[ ] Prescribe appropriate prophylactic antibiotic regimens including alternatives for penicillin allergy
[ ] Calculate correct weight-based dosing for pediatric patients

Communication & Counseling¶

[ ] Educate families on which conditions require prophylaxis and which do not
[ ] Counsel patients on importance of good oral hygiene in preventing IE

Systems-Based Practice¶

[ ] Communicate prophylaxis requirements to dental and procedural teams
[ ] Ensure patients and families have written prophylaxis cards/documentation

Key Guidelines¶

2007 AHA Guidelines: Prevention of Infective Endocarditis (Remain Current) Circulation. 2007;116:1736-1754

2023 ESC Guidelines on Endocarditis Confirms AHA approach; minor updates

Fundamental Concept¶

Most CHD does NOT require IE prophylaxis

The 2007 guidelines dramatically reduced the number of patients requiring prophylaxis based on: - Lack of evidence that prophylaxis prevents IE - Cumulative risk from daily bacteremia >> procedure-related - Focus on highest-risk conditions only

High-Risk Conditions REQUIRING Prophylaxis¶

Condition	Rationale
Prosthetic cardiac valve	Highest risk for IE
Prosthetic material for valve repair	Includes annuloplasty rings
Previous infective endocarditis	High recurrence risk
Unrepaired cyanotic CHD	Including palliative shunts/conduits
Repaired CHD with prosthetic material	First 6 months only
Repaired CHD with residual defect	At or near prosthetic patch/device
Cardiac transplant with valvulopathy	Structural valve abnormality

Conditions NOT Requiring Prophylaxis¶

Isolated ASD (secundum)
Isolated VSD
Isolated PDA
Repaired ASD, VSD, PDA (>6 months, no residual)
Aortic stenosis (native valve)
Bicuspid aortic valve
Mitral valve prolapse
Innocent murmurs
Prior CABG
Pacemakers/ICDs

Procedures Requiring Prophylaxis¶

DENTAL Procedures - PRIMARY INDICATION¶

Prophylaxis ONLY for procedures involving: - Manipulation of gingival tissue - Periapical region of teeth - Perforation of oral mucosa

Examples requiring prophylaxis: - Tooth extraction - Dental implant placement - Root canal beyond apex - Subgingival scaling - Gingival surgery

NOT requiring prophylaxis: - Routine anesthetic injections - Dental X-rays - Adjustment of orthodontic appliances - Shedding of primary teeth - Lip/tongue trauma

Respiratory Tract Procedures¶

Only if involving incision or biopsy of respiratory mucosa: - Tonsillectomy/adenoidectomy - Bronchoscopy with biopsy (not routine bronch)

GI/GU Procedures¶

Routine prophylaxis NOT recommended - Even in high-risk patients - Exception: Established GI/GU infection (treat the infection)

Antibiotic Regimens¶

Standard Oral Regimen¶

Drug	Dose	Timing
Amoxicillin	50 mg/kg (max 2g)	30-60 min before

Unable to Take Oral¶

Drug	Dose	Timing
Ampicillin	50 mg/kg IM/IV (max 2g)	30-60 min before
Cefazolin/ceftriaxone	50 mg/kg IM/IV (max 1g)	30-60 min before

Penicillin Allergy (Non-Anaphylactic)¶

Drug	Dose	Timing
Cephalexin	50 mg/kg (max 2g)	30-60 min before
Azithromycin	15 mg/kg (max 500mg)	30-60 min before
Clarithromycin	15 mg/kg (max 500mg)	30-60 min before

Severe Penicillin Allergy (Anaphylaxis)¶

Azithromycin or clarithromycin (doses above)
Avoid cephalosporins

Common Clinical Scenarios¶

Scenario 1: Post-ASD Repair¶

Device closure 3 months ago
NEEDS prophylaxis (within 6 months of prosthetic material)
Re-evaluate at 6 months

Scenario 2: Post-VSD Repair¶

Surgical patch closure 2 years ago, no residual
NO prophylaxis needed

Scenario 3: Tetralogy of Fallot Repair¶

Repaired with RV-PA conduit
NEEDS prophylaxis (prosthetic conduit = lifelong)

Scenario 4: Bicuspid Aortic Valve¶

Mild AS, no prior intervention
NO prophylaxis needed (native valve disease)

2023 ESC Updates¶

Confirms AHA high-risk conditions
Emphasizes dental hygiene as primary prevention
May extend prophylaxis to certain high-risk GI procedures (institution-specific)
Transcatheter valve replacement = same as surgical valve

Board Pearls¶

Pearl: Most CHD does NOT require IE prophylaxis

Only highest-risk conditions; VSD, ASD, AS do NOT qualify

Pearl: Prophylaxis only for DENTAL procedures (gingival manipulation)

GI/GU procedures do NOT routinely require prophylaxis

Pearl: Prosthetic material: 6-month window

After 6 months without residual defect, prophylaxis not needed

Self-Assessment¶

Q1: A 10-year-old had surgical VSD closure 8 months ago with a Dacron patch. Follow-up echo shows tiny residual VSD at the patch margin. Does this patient need IE prophylaxis for dental cleaning?

Answer

**Answer**: Yes - needs prophylaxis **Rationale**: Although >6 months post-repair, there is a residual defect at/near the prosthetic patch. Per AHA guidelines, this is a high-risk condition requiring prophylaxis.

Q2: A 5-year-old with an isolated secundum ASD (no repair) is scheduled for tonsillectomy. What antibiotic prophylaxis is indicated?