UHN/MSH Medical Consult Service
Endocarditis 1997
CARDIAC CONDITIONS ASSOCIATED WITH ENDOCARDITIS

Endocarditis prophylaxis recommended
High-risk category
Prosthetic cardiac valves, including bioprosthetic and homograft valves
Previous bacterial endocarditis
Complex cyanotic congenital heart disease (eg, single ventricle states, transposition of the great arteries, tetralogy of Fallot)
Surgically constructed systemic pulmonary shunts or conduits
Moderate-risk category
Most other congenital cardiac malformations (other than above and below)
Acquired valvar dysfunction (eg, rheumatic heart disease)
Hypertrophic cardiomyopathy
Mitral valve prolapse with valvar regurgitation and/or thickened leaflets

Endocarditis prophylaxis not recommended
Negligible-risk category (no greater risk 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 mo)
Previous coronary artery bypass graft surgery
Mitral valve prolapse without valvar regurgitation1
Physiologic, functional, or innocent heart murmurs
Previous Kawasaki disease without valvar dysfunction
Previous rheumatic fever without valvar dysfunction
Cardiac pacemakers (intravascular and epicardial) and implanted defibrillators
DENTAL PROCEDURES AND ENDOCARDITIS PROPHYLAXIS

Endocarditis prophylaxis recommended
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 where bleeding is anticipated

Endocarditis prophylaxis not recommended
Restorative dentistry (operative and prosthodontic) with or without retraction cord
Local anesthetic injections (nonintraligamentary)
Intracanal endodontic treatment; post placement and buildup
Placement of rubber dams
Postoperative suture removal
Placement of removable prosthodontic or orthodontic appliances
Taking of oral impressions
Fluoride treatments
Taking of oral radiographs
Orthodontic appliance adjustment
Shedding of primary teeth
OTHER PROCEDURES AND ENDOCARDITIS PROPHYLAXIS

Endocarditis prophylaxis recommended
Respiratory tract
Tonsillectomy and/or adenoidectomy
Surgical operations that involve respiratory mucosa
Bronchoscopy with a rigid bronchoscope
Gastrointestinal tract
Sclerotherapy for esophageal varices
Esophageal stricture dilation
Endoscopic retrograde cholangiography with biliary obstruction
Biliary tract surgery
Surgical operations that involve intestinal mucosa
Genitourinary tract
Prostatic surgery
Cystoscopy
Urethral dilation

Endocarditis prophylaxis not recommended
Respiratory tract
Endotracheal intubation
Bronchoscopy with a flexible bronchoscope, with or without biopsy
Tympanostomy tube insertion
Gastrointestinal tract
Transesophageal echocardiography
Endoscopy with or without gastrointestinal biopsy
Genitourinary tract
Vaginal hysterectomy
Vaginal delivery
Cesarean section
In uninfected tissue:
Urethral catheterization
Uterine dilatation and curettage
Therapeutic abortion
Sterilization procedures
Insertion or removal of intrauterine devices
Other
Cardiac catheterization, including balloon angioplasty
Implanted cardiac pacemakers,implanted defibrillators, and coronary stents
Incision or biopsy of surgically scrubbed skin
Circumcision
SITUATION
AGENT
REGIMEN
Standard general prophylaxis
Amoxicillin
2 g 1 hour before procedure
Unable to take oral medications
Ampicillin
2 g IM/IV 30 min before procedure
Allergic to penicillin
Clindamycin
or
600 mg 1 hour before procedure
Cephalexin
or
2 g 1 hour before procedure
Azithromycin
500 mg 1 hour before procedure
Allergic to penicillin and unable to take oral medications
Clindamycin
or
600 mg IV 30 min before procedure
Cefazolin
1 g 30 min IV/IM before procedure
PROPHYLACTIC REGIMENTS FOR DENTAL, ORAL, RESPIRATORY TRACT, OR
ESOPHAGEAL PROCEDURES
SITUATION
AGENT
REGIMEN
High-risk patients
Ampicillin +
Gentamicin
Ampicillin 2 g IM/IV plus gentamicin 1.5 mg/kg (max 120
mg) 30 min before procedure;
6 hours later, ampicillin 1g IM/IV or amoxicillin 1 g oral
High-risk patients allergic to ampicillin
Vancomycin +
Gentamicin
Vancomycin 1 g IV over 1-2 h plus gentamicin 1.5 mg/kg
IV/IM (max 120 mg).  Complete infusion 30 min before
procedure
Moderate-risk patients
Amoxicillin or
Ampicillin
Amoxicillin 2 g orally 1 hr before procedure or ampicillin
2 g IM/IV 30 min before procedure
Moderate-risk patients allergic to ampicillin
Vancomycin
Vancomycin 1g IV over 1-2 h.  Complete infusion 30 min
prior to procedure
PROPHYLACTIC REGIMENTS FOR GENITOURINARY, GASTROINTESTINAL
(NOT ESOPHAGEAL) PROCEDURES
The following are recommendations based on AHA guidelines.
Please see complete set of AHA guidelines on their website.

For 2007 AHA Endocarditis guidelines, click here.
1997 AHA Endocarditis Guidelines