Endocarditis Prophylaxis

Recently significant changes to the prophylaxis guidelines have been made with more restricted indications.

Children at risk should establish and maintain the best possible oral health to reduce potential sources of bacteraemia which includes tooth brushing and regular dental review.

Dental health for children with heart conditions

Single dose antibiotic prophylaxis is now only recommended for children with the highest risk of adverse outcome of infective endocarditis (see Table 1)

In certain individual circumstances, medical and dental practitioners may consider giving antibiotics to patients not covered by these revised guidelines including those who have received prophylaxis over their lifetime.  Recommendations for individual patients should be discussed with the treating cardiologist.

Cardiac Conditions for which endocarditis prophylaxix with dental procedures is reasonable

Prosthetic cardiac valve or prosthetic valve material used for cardiac valve repair

Previous episode of infective endocarditis

Congenital heart disease (CHD) but only if it involves:

Unrepaired cyanotic defects, including palliative shunts and conduits

Repaired congenital heart defect with prosthetic material or device (surgical or catheter intervention) during the first 6 months after the procedure

Repaired defects with residual defect at the site or adjacent to the sire of a prosthetic patch or prosthetic device

Rheumatic heart disease in indigenous Australians

Cardiac transplantation recipients who develop cardiac valvulopathy

 At risk procedures that require prophylaxis include:

Dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa,

Invasive respiratory procedures (incision or biopsy of respiratory mucosa - including tonsillectomy and adenoidectomy)

Invasive genitourinary and gastrointestinal procedures.

Incision and drainage of local abscesses

Surgical procedures through infected skin (cellulitus)

Recommended prophylaxis:

amoxicillin 50 mg/kg oral 1 hour before procedure (max. 2 g)

if unable to take oral medication, give amoxicillin/ampicillin 50 mg/kg i.v. at induction (max. 2 g)

If hypersensitive to penicillin, and those on long-term penicillin therapy or who have taken penicillin pr a related beta lactam antibiotic more than once in the previous month, use:

clindamycin 600 mg (child: 15 mg/kg up to 600 mg) orally, 1 hour before the procedure

or clindamycin 600 mg (child: 15 mg/kg up to 600 mg) IV over at least 20 minutes, just before the procedure

               OR

lincomycin 600 mg (child: 15 mg/kg up to 600 mg) IV over at least 1 hour, just before the procedure

              OR

vancomycin 25 mg/kg up to 1.5 g (child less that 12 years: 30 mg/kg up to 1.5 g) IV by slow infusion (over at least 60 minutes; rate not exceeding   10 mg/min), ending the infusion just before the procedure

OR

teicoplanin 400 mg (child: 10 mg/kg up to 400 mg) IV, just before the procedure

              OR

teicoplanin 400 mg (child: 10 mg/kg up to 400 mg) IM, 30 minutes before the procedure.

There is no oral liquid formulation of clindamycin in Australia.  An alternative for patients who are hypersensitive to penicillin (excluding immediate hypersensitivity), is:

cephalexin 2 g (child: 50 mg/kg up to 2 g) orally, 1 hour before the procedure.

Cephalexin is not suitable for those who have been on long-term penicillin or have taken related beta-lactam antibiotic more than once in the previous month.

NOTE:  These guidelines are those used at RCH, but may differ from recommendations at other centres.

Reference:  Infective Endocarditis Prophylaxis Expert Group. 

Prevention of endocarditis. 2008 update from Therapeutic guidelines: 

antibiotic version 13, and Therapeutic guidelines: oral and dental version 1. 

Melbourne:  Therapeutic Guidelines Limited; 2008.

http://www.tg.org.au/uploads/PDFs/Prevention%20of%20endocarditis.pdf

These guidelines are those currently endorsed by the Cardiac Society of

Australia and New Zealand.