Review of

Antibiotics
and Indications for
Prophylaxis
Dent Clin N Am 56 (2012) 235244

INFECTIVE ENDOCARDITIS
IE is an uncommon, but life-threatening infection of the inner lining
of the heart (endocardium)
It is characterized by the presence of vegetations composed of

Platelets
Fibrin
Microorganisms
Inflammatory cells

Endothelial damage caused by turbulent blood flow normally seen in

congenital or acquired heart disease causes platelets and fibrin
deposition leading to formation of nonbacterial thrombotic
endocarditis (NBTE)

INFECTIVE ENDOCARDITIS
In this environment, an incidence of bacteremia could result in
bacterial adherence to NBTE, bacterial proliferation within the
NBTE, and formation of vegetations
IE most commonly occurs in conjunction with
Invasive dental
Gastrointestinal (GI)
Genitourinary (GU) tract procedures

INFECTIVE ENDOCARDITIS
Certain underlying cardiac conditions may predispose an individual
to developing endocarditis, such as artificial heart valves
If left untreated, endocarditis can damage or destroy heart valves
and can lead to life-threatening complications
Often patients with IE have substantial morbidity and mortality
despite technological and medical advancements

WHY WERE THE PREVIOUS

GUIDELINES CHANGED?
AHA guidelines (1997) separated cardiac conditions into high-,
moderate and low-risk (negligible risk) categories, with prophylaxis
not advised for the low risk group
A detailed list (of dental, respiratory, GI and GU, tract procedures for
which prophylaxis was and was not recommended) was included
It was found that the basis for recommendations for IE prophylaxis
was not well-established, and the quality of evidence was not
adequate

WHY WERE THE PREVIOUS

GUIDELINES CHANGED?
Number of cases of IE that could be prevented by antibiotic
prophylaxis, even if 100% effective, is very small
Most endocarditis cases caused by oral microflora are the result of
bacteremia caused by routine daily activities (eg, tooth brushing and
flossing)
Thus, the current AHA guidelines shift the emphasis away from
antibiotic prophylaxis for dental procedures and toward improved
access to dental care and oral health for patients, especially those
with underlying cardiac risk factors

WHY WERE THE PREVIOUS

GUIDELINES CHANGED?
Many authorities and advisory bodies have questioned the efficacy
of antimicrobial prophylaxis to prevent endocarditis in patients who
undergo a dental, GI, or GU tract procedure and have pushed for
alterations to the 1997 AHA guidelines

2007 UPDATED ANTIBIOTIC

PROPHYLAXIS GUIDELINES
AHA (2007) new guidelines suggest that antibiotic prophylaxis is
reasonable for all dental procedures that involve manipulation of
gingival tissues or the periapical region of teeth or perforation of oral
mucosa only for patients with underlying cardiac conditions
associated with the highest risk of adverse outcome from IE
However, certain procedures do not require antibiotic prophylaxis,
including the routine anesthetic injections through noninfected
tissue, the taking of dental radiographs, the placement of removable
prosthodontic or orthodontic appliances, and the adjustment of
orthodontic appliances

2007 UPDATED ANTIBIOTIC

PROPHYLAXIS GUIDELINES
Cardiac conditions associated with the highest risk of adverse
outcome from endocarditis for which prophylaxis with dental
procedures is reasonable
1. Prosthetic cardiac valve or prosthetic material used for cardiac
valve repair
2. Previous infective endocarditis
3. Congenital heart disease (CHD)
a) Unrepaired cyanotic CHD, including palliative shunts and conduits
b) Completely repaired congenital heart defect with prosthetic material or
device, whether placed by surgery or by catheter intervention, during the
first 6 months after the procedure
c) Repaired CHD with residual defects at the site or adjacent to the site of a
prosthetic patch or prosthetic device (which inhibit endothelialization)

4. Cardiac transplantation recipients who develop cardiac

valvulopathy

2007 UPDATED ANTIBIOTIC

PROPHYLAXIS GUIDELINES

Antibiotics Used for Prophylaxis

Antibiotics Used for Prophylaxis

Antibiotics should be given 30 to 60 minutes before starting the
indicated procedure
According to the AHA, if the drug is inadvertently omitted before the
procedure, it may be administrated up to 2 hours after the procedure
with some protective benefit

Antibiotics Used for Prophylaxis

Penicillins
Ampicillin and amoxicillin are aminopenicillins that have identical
coverage as penicillin against the same nonbeta-lactamase
containing gram-positive pathogens
This group has additional coverage against nonbeta-lactamase
producing strains of Haemophilus influenzae, Escherichia coli,
Proteus mirabilis, Salmonella, and Shigella but lacks coverage
against Pseudomonas aeruginosa
Aminopenicillins have an increased incidence of drug
hypersensitivity reactions with rashes as compared with other
penicillins

Antibiotics Used for Prophylaxis

Cephalosporins
They can often be used in place of penicillins when patients have a
history of mild rashes associated with penicillin use
However, cephalosporins should not be used in patients who
describe anaphylaxis, angioedema, urticaria, or asthma when using
penicillin

Antibiotics Used for Prophylaxis

Cephalosporins
Cefazolin-----intravenous first-generation cephalosporin----recommended for patients who those patients who are allergic to
penicillin
It has similar activity against most gram-positive cocci including
Staphylococcus aureus, group A beta-hemolytic Streptococcus
(Streptococcus pyogenes), and penicillin-susceptible Streptococcus
pneumonia

Antibiotics Used for Prophylaxis

Cephalosporins
Cephalexin is also a first-generation oral cephalosporin and is most
effective against Streptococcus pyogenes
Ceftriaxone is a third-generation cephalosporin that covers many
important infections because of its broad coverage, high potency
etc.
However, this agent has less activity against gram-positive
pathogens compared with the first-generation cephalosporins

Antibiotics Used for Prophylaxis

Macrolides
Clarithromycin and azithromycin are commonly used to treat
infections caused by gram-positive bacteria, Streptococcus
pneumoniae, and Haemophilus influenzae infections such as
respiratory tract and soft-tissue infections
The antimicrobial spectrum of macrolides is slightly wider than that
of penicillin, and, therefore, macrolides remain a common
alternative for patients with a penicillin allergy
Concerns with macrolide antibiotics include GI distress, drugdrug
interactions, and QT prolongation

Antibiotics Used for Prophylaxis

Lincosamides
Clindamycin is a semisynthetic derivative of lincomycin
It is bacteriostatic by inhibiting protein synthesis
Clindamycin is an excellent agent for the treatment of infections of
the oral cavity and is effective against most pneumococci and
streptococci and most penicillin-resistant staphylococci including
some methicillin-resistant Staphylococcus aureus (MRSA) isolates

Antibiotics Used for Prophylaxis

Lincosamides
Clostridium difficile pseudomembranous colitis is a complication that
may occur after all antibacterial agents but has been linked most
often with clindamycin
Treatment includes discontinuation of the antibiotic and treatment
with oral metronidazole, vancomycin, or nitazoxanide

Antibiotic Prophylaxis for Full

Joint Replacement
Joint guidelines were published in 2003 by the American Dental
Association (ADA) and the American Academy of Orthopedic
Surgeons (AAOS) regarding antibiotic prophylaxis for dental
patients with total joint replacements
They stated: The risk/benefit and cost/effectiveness ratios fail to
justify the administration of routine antibiotic prophylaxis for
individuals with joint replacements
However, these guidelines also suggest that patients at greater risk
because of specific medical conditions should be considered for
prophylaxis

Antibiotic Prophylaxis for Full

Joint Replacement
These include patients
whose prostheses are less than 2 years old
those who have high-risk conditions such as
inflammatory arthropathies (rheumatoid arthritis, systemic lupus
erythematosus)
drug-induced or radiation-induced immunosuppression
previous joint infection
malnourishment
hemophilia
human immunodeficiency virus infection
insulin-dependent diabetes
Malignancy

Antibiotic Prophylaxis for Full

Joint Replacement
In February 2009, without a joint effort with organized dentistry or
nonorthopedic physician specialties, the AAOS published what it
called an Information Statement entitled Antibiotic Prophylaxis for
Bacteremia in Patients With Joint Replacements.
It stated: Given the potential adverse outcomes and cost of treating
an infected joint replacement, the AAOS recommends that clinicians
consider antibiotic prophylaxis for all total joint replacement patients
before any invasive procedure thatmay cause bacteremia.

Antibiotic Prophylaxis for Full

Joint Replacement
In a position paper from the American Academy of Oral Medicine
(AAOM), it was suggested that the statement issued by the AAOS
was made with little or no scientific data to suggest a link between
late prosthetic joint infections and organisms specific to the mouth
Currently, the ADA and the AAOS are working together to develop
evidence-based, clinical practice guidelines for antibiotic prophylaxis
for dental patients with total joint replacement

Antibiotic Prophylaxis for

Nonvalvular Cardiovascular
Devices
Dental patients with nonvalvular cardiovascular devices (prosthetic
valves, pacemakers, defibrillators, ventriculoatrial shunts, closure
devices, patches, stents, vascular grafts, dacron grafts or patches,
vena caval filters, vascular closure devices, total artificial hearts,
and L ventricular assist devices) do not require antibiotic prophylaxis
for dental treatment
An exception involves patients with nonvalvular cardiovascular
devices that undergo extraction or incision and drainage for
infection, or to replace an infected device

Antibiotic Prophylaxis for Renal

Dialysis Shunt
The AHA does not recommend antibiotic prophylaxis for patients
undergoing hemodialysis when they are receiving invasive dental
procedures

Antibiotic Prophylaxis for

Patients with
Immunosuppression secondary
to cancer and cancer
chemotherapy
The National Cancer Institute Web site suggests that patients with
indwelling venous access lines and neutrophil counts between 1000
and 2000 mm3 receive the AHA-recommended regimen for
antibiotics, with consideration given to a more aggressive antibiotic
therapy in the presence of infection

Antibiotic Prophylaxis for

Insulin-dependent diabetes
Some articles and opinion papers suggest that patients with
unstable, insulindependent diabetes should receive coverage with
prophylactic antibiotics for invasive dental procedures
Others, however, suggest prophylaxis only in the presence of an
acute oral infection

Antibiotic Prophylaxis for

Vascular Grafts
Some texts and narrative review papers recommend and stress the
importance of antibiotic prophylaxis
In contrast, other authors have suggested that there is no indication
for antibiotic prophylaxis.

Antibiotic Prophylaxis for Organ

Transplants
The new AHA IE prevention guidelines state that there is lack of
evidence to support prophylaxis in heart transplant patients;
however, the AHA did recommend it for those patients who
developed cardiac valvulopathy
As a general guideline, antibiotic prophylaxis for invasive dental
procedures should be considered for patients with a suppressed
immune response, regardless of the cause that is, neutropenia
(<1000/mm3) or a low CD4 count (<200/mm3)
The clinician and the patients physician should decide together
whether antibiotic prophylaxis is required or not

Antibiotic Resistance
Widespread use of antibiotic therapy promotes the emergence of
resistant microorganisms most likely to cause endocarditis, such as
viridans groupstreptococci and enterococci
This increased resistance has reduced the efficacy and number of
antibiotics available for the treatment of IE

Antibiotic Resistance
Antibiotic resistance has also contributed to the rise of methicillinresistant MRSA
MRSA refers to Staphylococcus aureus that is resistant to all
currently available b-lactam antimicrobial agents, including
antistaphylococcal penicillins (methicillin, oxacillin, nafcillin) and
cephalosporins
Controlled use of antibiotics may be the key adjustable factor for the
primary prevention of MRSA colonization