INDICATIONS FOR PROPHYLACTIC ANTIBIOTICS

 by:Joseph W. Costa, Jr., D.M.D., and Dale Potter, D.D.S.

For what cardiac conditions is prophylaxis for endocarditis recommended in patients receiving dental care?

High- Risk Category
• Prosthetic cardiac valves, including both bioprosthetic and homograft valves
• Previous bacterial endocarditis
• Complex cyanotic congenital heart disease (e.g., single ventricle states, transposition of the great arteries, tetralogy of Fallot)
• Surgically constructed systemic pulmonary shunts or conduits




Moderate-Risk Category
• Most congenital cardiac malformations other than above and below (see next question)
• Acquired valvular dysfunction (e.g., rheumatic heart disease)

• Hypertrophic cardiomyopathy
• Mitral valve prolapse with valvular regurgitation and/or thickened leaflets

What cardiac conditions do not require endocarditis prophylaxis? Negligible-risk category (no higher than the general population)
• Isolated secundum atrial septal defect
• Surgical repair of atrial septal defect, ventricular septal defect, or patent ductus arteriosus (without residua beyond 6 months)
• Previous coronary artery bypass graft surgery
• Mitral valve prolapse without valvular regurgitation
• Physiologic, functional, or innocent heart murmurs
• Previous Kawasaki disease without valvular regurgitation
• Previous rheumatic fever without valvular regurgitation
• Cardiac pacemakers (intravascular and epicardial) and implanted
defibrillators

What are the antibiotics and dosages recommended by the American Heart Association (AHA) for prevention of endocarditis from dental procedures?The AHA updates its recommendations every few years to reflect new findings. The dentist has an obligation to be aware of the latest recommendations. The patient’s well-being is the dentist’s responsibility. Even if a physician recommends an alternative prophylactic regimen, the dentist is liable if the patient
develops endocarditis and the latest AHA recommendations were not followed.

Standard regimen
Amoxicillin, 2.0 gm orally 1 hr before procedure
For patients allergic to amoxicillin and penicillin
Clindamycin, 600 mg orally 1 hr before procedure or
Cephalexin* or cefadroxil,* 2.0 gm orally 1 hr before procedure or
Azithromycin or clarithromycin, 500 mg orally 1 hr before procedure
Patients unable to take oral medications
Ampicillin, intravenous or intramuscular administration of 2 gm 30 mm
before procedure
For patients allergic to ampicillin, amoxicillin, and penicillin
Clindamycin, intravenous administration of 600 mg 30 mm before procedure
or Cefazolin,* intravenous or intramuscular administration of 1.0 gm within
30 mm before procedure
* Cephalosporins should not be used in patients with immediate-type
hypersensitivity reaction (urticaria, angioedema. or anaphylaxis) to penicillins.

For what dental procedures is antibiotic premedication recommended in patients identified as being at risk for endocarditis?• Dental extractions
•Periodontal procedures including surgery, scaling and root planing,
probing, and recall maintenance
• Dental implant placement and reimplantation of avulsed teeth
• Endodontic (root canal) instrumentation or surgery only beyond the apex
• Subgingival placement of antibiotic fibers or strips
• Initial placement of orthodontic bands but not brackets
• Intraligamentary local anesthetic injections
• Prophylactic cleaning of teeth or implants if bleeding is anticipated
Dajani AS, et a!: Prevention of bacterial endocarditis: Recommendations by the American Heart
Association. JAMA 277:1794-1801, 1997. 

For what dental procedures is antibiotic premedication not
recommended in patients identified as being at risk for endocarditis?•Restorative dentistry (including restoration of

carious teeth and
prosthodontic replacement of teeth) with or without retraction cord
(clinical judgment may indicate antibiotic use in selected circumstances
that may create significant bleeding)
• Local anesthetic injections (nonintraligamentary)
• Intracanal endodontic treatment (after placement and build-up)
• Placement of rubber dams
• Postoperative suture removal
• Placement of removable prosthodontic or orthodontic appliances
• Making of impressions
• Fluoride treatments
• Intraoral radiographs
• Orthodontic appliance adjustment
• Shedding of primary teeth

Should a patient who has had a coronary bypass operation be
placed on prophylactic antibiotics before dental treatment?No evidence indicates that coronary artery bypass graft surgery introduces a
risk for endocarditis. Therefore, antibiotic prophylaxis is not needed.

What precautions should you take when treating a patient with a central line such as a Hickman or Portacath?Patients with central venous access are usually receiving intensive antibiotic therapy, chemotherapy, or nutritional support. It is imperative to consult with the patient’s physician before performing any dental procedures. If it is determined that the dental procedure is necessary, the patient should receive antibiotic
prophylaxis to protect the central venous access line from infection secondary to transient bacteremias. The same antibiotic regimen recommended for the prevention of endocarditis should be prescribed.

Should a patient with a prosthetic joint be placed on prophylactic
antibiotics before dental treatment?
Case studies support the hematogenous seeding of prosthetic joints. However, it is questionable whether organisms from the oral cavity are a source for late deep infections of prosthetic joints. The decision whether to premedicate should be determined by the dentist’s clinical judgment in consultation with the
patient’s physician or orthopedic surgeon. Patients considered at high risk for developing a late infection of a prosthetic joint should be premedicated. Such patients can be grouped based on predisposing systemic conditions, issues associated with joint prostheses, or presence of acute infection at sites distant to
the joint prosthesis.
From Fitzgerald RH, et al: Advisory statement: Antibiotic prophylaxis for dental patients with total
joint re placements. American Dental Association; American Academy of Orthopaedic Surgeons. J
Am Dent Assoc 128: 1004—1007, 1997; and Little JW: Managing dental patients with joint
prostheses. JAm Dent Assoc 125:1374—1379, 1994. 

What are the antibiotics and dosages recommended by the American Dental Association and the American Academy of Orthopaedic Surgeons to prevent late joint infections in patients considered to be at
high risk? 

Standard regimen
Cephalexin* or cephradine* or amoxicillin, 2 gm orally 1 hr before
procedure

For patients allergic to amoxicillin and penicillin
Clindamycin, 600 mg orally 1 hr before procedure

Patients unable to take oral medications

Cefazolin,* intravenous or intramuscular administration of 1.0 gm 1 hr
before procedure or
Ampicillin, intravenous or intramuscular administration of 2.0 gm 1 hr before
procedure For patients allergic to ampicillin, amoxicillin, and penicillin
Clindamycin, intravenous or intramuscular administration of 600 mg 1 hr
before procedure
* Cephalosporins should not be used in patients with immediate-type hypersensitivity
reaction (urticaria, angioedema, or anaphylaxis) to penicillins.
Fitzgerald RH, eta!: Advisory statement: Antibiotic prophylaxis for dental patients with total joint
replace ments. American Dental Association; American Academy of Orthopaedic Surgeons. JAm Dent Assoc 128:1004—1007, 1997.

Is it necessary to prescribe prophylactic antibiotics for a patient on renal dialysis?
Patients on dialysis with arteriovenous (AV) shunts should be premedicated before any dental treatment that has the potential of producing a transient bacteremia. The dosages for antibiotic coverage are as follows:
Standard regimen
Amoxicillin, 2.0 gm orally 1 hr before procedure

For patients allergic to amoxicillin and penicillin
Clindamycin, 600 mg orally 1 hr before procedure or
Cephalexin* or cefadroxil,* 2.0 gm orally 1 hr before procedure
Azithromycin or clarithromycin, 500 mg orally 1 hr before procedure

Patients unable to take oral medications
Ampicillin, intravenous or intramuscular administration 2.0 gm within 30 mm
before procedure

For patients allergic to ampicillin, amoxicillin, and penicillin
Clindamycin, intravenous administration of 600 mg within 30 mm before
procedure or
Cefazolin,* intravenous or intramuscular administration of 1.0 gm within 30
mm before procedure
* Cephalosporins should not be used in patients with immediate-type hypersensitivity
reaction (urticaria, angioedema, or anaphylaxis) to penicillins