Endocarditis Prophylaxis
by Burke A. Cunha, MD, Chief, Infectious Disease Division, Winthrop-University
Hospital, Mineola, New York, Professor of Medicine, State University of New York,
Stony Brook, New York
Endocarditis
prophylaxis is designed to prevent native/prosthetic cardiac valve infections by
preventing procedure-related bacteremias due to cardiac pathogens. For procedures
above-the-waist, usual pathogens are viridans streptococci from the mouth. For procedures
below-the-waist, usual pathogens are enterococci. Since procedure-related bacteremias are
usually asymptomatic and last less than 15 minutes, single-dose oral regimens prior to the
procedure usually provide effective prophylaxis. Parenteral SBE prophylaxis is preferred
for patients with previous endocarditis, shunts, or prosthetic heart valves. Regimens vary
among the experts, and no regimen is fully protective.
Endocarditis prophylaxis is indicated
for patients with cardiac conditions in Column A undergoing procedures in Column A in the
Table 1, below. Prophylaxis is not recommended for patients or procedures in Column B.
Specific prophylaxis regimens for above-the-waist and below-the-waist procedures are shown
in Tables 2 and 3, respectively.
Table. Indications for Infective Endocarditis
(IE) Prophylaxis |
Subset |
Prophylaxis Recommended
(Column A) |
Prophylaxis Not Recommended
(Column B) |
Cardiac conditions |
Ostium primum ASD
Prosthetic heart valves,
including bioprosthetic and homograft valves
Previous infective
endocarditis
Most congenital cardiac
malformations
Rheumatic valve disease
Hypertrophic
cardiomyopathy
MVP with valvular
regurgitation |
Isolated ostium secundum ASD
Surgical repair without
residue beyond 6 months of ostium secundum ASD or PDA
Previous coronary artery
bypass surgery
MVP without valvular
regurgitation
Physiologic, functional,
or innocent murmurs
Previous Kawasaki's
cardiac disease or rheumatic fever without valve disease |
Procedures |
Dental procedures known to induce gingival/mucosal bleeding, including dental
cleaning
Tonsillectomy or
adenoidectomy
Surgical operations
involving intestinal or respiratory mucosa
Rigid bronchoscopy
Sclerotherapy for
esophageal varices
Esophageal dilation
Gallbladder surgery
Cystoscopy or urethral
dilation
Urethral catheterization
or urinary tract surgery if UTI is present
Prostate surgery
I & D of infected
tissue
Vaginal hysterectomy
Vaginal delivery, D &
C, IUD insertion/removal, or therapeutic abortion in the presence of infection |
Dental procedures not likely to induce gingival bleeding
Tympanostomy tube
insertion
Flexible bronchoscopy
with or without biopsy
Endotracheal intubation
Endoscopy "
gastrointestinal biopsy
Cesarean section
D & C, IUD
insertion/removal, or therapeutic abortion in the absence of infection
Cardiac
pacemaker/defibrillator insertion
Coronary stent
implantation
Percutaneous transluminal
coronary angioplasty (PTCA)
Cardiac catheterization |
Table 2. Endocarditis Prophylaxis for
Above-the-Waist (Dental, Oral, Esophageal, Respiratory Tract) Procedures* |
Prophylaxis** |
Reaction to Penicillin |
Antibiotic Regimen |
Oral prophylaxis
|
None |
Amoxicillin
2 gm (PO) 1 hour pre-procedure+ |
Non-anaphylactoid |
Cephalexin
1 gm (PO) 1 hour pre-procedure |
Anaphylactoid |
Clindamycin
300 mg (PO) 1 hour pre-procedure++ |
IV prophylaxis
|
None |
Ampicillin
2 gm (IV) 30 minutes pre-procedure |
Non-anaphylactoid |
Cefazolin
1 gm (IV) 15 minutes pre-procedure |
Anaphylactoid |
Clindamycin
600 mg (IV) 30 minutes pre-procedure |
* Endocarditis prophylaxis is directed against Streptococcus viridans, the
usual SBE pathogen above the waist. Macrolide regimens are less effective than other
regimens; clarithromycin/azithromycin regimens (500 mg PO 1 hour pre-procedure) are of
unproven efficacy
** Oral prophylaxis is preferred to IV prophylaxis, except in patients with previous
endocarditis, shunts, or prosthetic heart valves
+ Some recommend a 3 gm dose of amoxicillin, which is excessive given the
sensitivity of viridans streptococci to amoxicillin
++ Some recommend a 600 mg dose of clindamycin, but a 300 mg dose gives adequate
blood levels and is better tolerated (less diarrhea) |
Table 3. Endocarditis Prophylaxis for
Below-the-Waist (Genitourinary, Gastrointestinal) Procedures* |
Prophylaxis** |
Reaction to Penicillin |
Antibiotic Regimen |
Oral prophylaxis
|
None |
Amoxicillin
2 gm (PO) 1 hour pre-procedure |
Non-anaphylactoid,
anaphylactoid |
Linezolid 600 mg (PO) 1 hour pre-procedure |
IV prophylaxis
|
None |
Ampicillin
2 gm (IV) 30 minutes pre-procedure
plus
Gentamicin 80 mg (IM or IV) over 1 hour 60 minutes pre-procedure |
Non-anaphylactoid, anaphylactoid |
Vancomycin
1 gm (IV) over 1 hour 60 minutes pre-procedure
plus
Gentamicin 80 mg (IM or IV) over 1 hour 60 minutes pre-procedure |
* Endocarditis prophylaxis is directed
against Enterococcus faecalis, the usual SBE pathogen below the waist
** Oral prophylaxis is preferred to IV prophylaxis, except in patients with previous
endocarditis, shunts, or prosthetic heart valves |
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