Prophylactic Antibiotic Coverage

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To prevent infective endocarditis in predisposed patients, the American Heart Association has established guidelines for antibiotic prophylaxis. These guidelines have been recently updated, and the following information comes from the most recent revision printed in the Journal of the American Medical Association (JAMA 277 (22): 1794-1801, 1997).

Patients are categorized as:

• High risk patients for bacterial endocarditis
• Moderate risk patients for bacterial endocarditis
• Negligible risk patients for bacterial endocarditis

Patients at high risk for bacterial endocarditis

• Prosthetic cardiac valves, including bioprosthetic and homograft valves
• Previous bacterial endocarditis
• Complex cyanotic congenital heart disease (e.g., Tetralogy of Fallot)
• Surgically constructed systematic pulmonary shunts or conduits

Patients at moderate risk for bacterial endocarditis

• Acquired valvular dysfunction (e.g., rheumatic heart disease)
• Hypertrophic cardiomyopathy
• Mitral valve prolapse with valvular regurgitation and/or thickened leaflets
• Most other congenital cardiac malformations (other than those cited as high or low risk)

Patients at negligible risk for bacterial endocarditis

• Mitral Valve Prolapse without valvar regurgitation
• Rheumatic Heart Disease or Kawasaki Disease without valvar dysfunction
• Physiologic, functional or innocent heart murmurs
• Previous coronary artery bypass surgery
• Cardiac pacemakers or defibrillators
• Isolated secundum atrial septal defect
• Surgical repair of atrial septal defect, ventricular septal defect, or patent ductus arteriosus (without
• residua beyond 6 months)

Indications for Antibiotic Prophylaxis

Prophylaxis is recommended for patients in high and moderate risk categories. Prophylaxis is not recommended for those patients in the negligible risk category. Their risk is estimated to be no greater than that of the general population.

In the revised guideline of the AHA, Antibiotic Prophylaxis is not recommended for all dental procedures, even for patients at high and moderate risk for endocarditis.

Dental procedures for which prophylaxis is recommended for high and moderate risk patients:

• Dental extractions
• Periodontal procedures including probing, scaling and root planing, surgery and recall maintenance
• Dental implant placement and reimplantation of avulsed teeth
• Endodontic instrumentation or surgery only beyond 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

Dental procedures for which prophylaxis is not recommended:

• Restorative dentistry (operative and prosthetic) with or without the use of retraction cord (Clinical
• judgment may indicate use of prophylaxis if significant bleeding is anticipated)
• Local anesthetic injections (other than intraligamentary)
• Intracanal endodontic or restorative treatments
• Placement of rubber dams
• Postoperative suture removal
• Placement of removable prosthodontic/orthodontic appliances
• Taking of oral impressions
• Fluoride treatments
• Taking of oral radiographs
• Orthodontic appliance adjustment
• Shedding of primary teeth

In Adults, the new antibiotic regime recommended for the prevention of bacterial endocarditis is:

Amoxycillin: 2.0 grams, 1 hour prior to the procedure (Four 500 mg tablets)

For those patients allergic to penicillin,

Clindamycin: 600 mg, 1 hour to the procedure (Four 150 mg tablets)

The guidelines for Children are:

Amoxycillin: 50 mg/kg, 1 hour prior to the procedure.

For those patients allergic to penicillin,

Clindamycin: 20 mg/kg, 1 hour prior to the procedure.

These new guidelines involve a number of changes from the previous set of guidelines. Firstly, only one antibiotic dosage is required. Secondly, the recommended antibiotic for penicillin-allergic patients is clindamycin not erythromycin. Lastly, prophylaxis is no longer required for many dental procedures.

In July 1997, the first guidelines regarding antibiotic prophylaxis for patients with total joint replacements came out. This was published in the Journal of the American Dental Association (JADA 125: 1004-1008, 1997). Antibiotic prophylaxis is recommended for patients with total joint replacements that are considered at increased risk of hematogenous total joint infection. They are the following:

• Joint replacement within the last two years

  Previous history of prosthetic joint infection

  Immunosuppressed/immunocompromised patients

  Inflammatory arthorpathies: Rheumatoid arthritis

  Disease-, drug- or radiation-induced immunosuppression

  Insulin dependent diabetics; Type 1

  Malnourished patients

  Hemophiliacs

The suggested antibiotic regimen for prophylaxis against total joint infection is:

• Amoxycillin: 2 g orally 1 hour prior to the procedure
  

• Clindamycin: 600 mg orally 1 hour prior to the procedure.

Note that this regime is identical to that of the AHA endocarditis prophylaxis. Antibiotic prophylaxis is not recommended for patients with pins, plates, and screws, or routinely for patients with total joint replacement.

It should be remembered that every time a patient is scaled and root planed a form of inoculation by a variety of organisms found in the periodontal region occurs. Increased systemic antibody titers to these organisms are well documented. The significance of this is unclear. The antibody mediated immune response typically seen in many exogenous infections has not yet been clearly demonstrated in periodontal conditions.