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Revised AHA Guidelines for Prevention of Infective Endocarditis

Antibiotics solely to prevent infective endocarditis are now recommended for only the highest-risk patients and, even in this group, for very few procedures.

Target Population: Physicians and dentists who perform procedures on patients with cardiac abnormalities

Sponsoring Organizations: The American Heart Association, the American Dental Association, the Infectious Diseases Society of America, and the Pediatric Infectious Diseases Society

Type: Evidence-based consensus statement from a multispecialist writing group. This document updates the American Heart Association’s guidelines for prevention of infective endocarditis (IE), last revised in 1997.

Key Points: Recent findings have cast doubt on the benefits of antibiotic prophylaxis for dental procedures, because bacteremia associated with such procedures is usually transient, and transient bacteremia occurs much more commonly during routine daily activities (e.g., chewing and toothbrushing). In the absence of data demonstrating effectiveness of prophylaxis in reducing IE risk among people with cardiac abnormalities, the committee recommends offering prophylaxis to a more limited group. The committee believes that the risks of taking antibiotics are reasonable only for the patients most likely to benefit from these agents.

Whereas previous guidelines stressed prophylaxis for patients undergoing the procedures deemed most likely to produce bacteremia, this document stresses prophylaxis for patients with cardiac conditions associated with the highest risk for adverse outcomes from IE. The list includes individuals with prosthetic heart valves; previous IE; unrepaired cyanotic congenital heart disease (including patients with palliative shunts and conduits); a congenital heart defect that was completely repaired with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 postprocedure months; repaired congenital heart disease with residual defect at, or adjacent to, the site of a prosthetic patch or prosthetic device; and cardiac valvulopathy following heart transplantation.

Even for these high-risk patients, the only dental procedures for which antibiotic prophylaxis is recommended involve perforation of the oral mucosa or manipulation of the gingival tissue or the periapical region of teeth. Among these patients, prophylaxis may be considered for invasive respiratory-tract procedures that involve incision or biopsy of the respiratory mucosa. Antibiotic coverage for organisms likely to cause IE is recommended for high-risk individuals who undergo respiratory-tract procedures to treat established infections and those who undergo surgical procedures involving infected skin, skin structures, or musculoskeletal tissue. Antibiotic prophylaxis solely to prevent IE is no longer recommended for gastrointestinal tract or genitourinary tract procedures. However, for many of these procedures, prophylaxis is recommended to prevent sepsis or wound infection.

Comment: Doctors, dentists, and patients will need time to adapt to these guidelines because they are so different from the recommendations promoted over the past 50 years. Forgoing antibiotics where they were formerly used will cause some anxiety. With these new guidelines, the emphasis should be shifted away from antibiotic prophylaxis and toward improving access to dental care and oral health in patients with conditions that predispose to acquisition of IE and patients at the highest risk for adverse outcomes from IE.

— Robert S. Baltimore, MD

Dr. Baltimore served on the guideline committee.

Published in Journal Watch Infectious Diseases May 16, 2007

Citation(s):

Wilson W et al. Prevention of infective endocarditis. Guidelines from the American Heart Association. A guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 2007 Apr 19; [e-pub ahead of print]. (http://dx.doi.org/10.1161/CIRCULATIONAHA.106.183095)