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INFECTIVE ENDOCARDITIS PROPHYLAXIS.

Dr Murray F. Matangi MB ChB, FRACP, FRCPC, FACP, FACC
Cardiologist
Kingston Heart Clinic

Major changes in the updated recommendations include the following: 

 (1)  Emphasis that most cases of endocarditis are not attributable to an invasive procedure.

(2)  Cardiac conditions are stratified into high-, moderate-, and negligible-risk categories based on potential outcome if endocarditis develops.

(3)  Procedures that may cause bacteremia and for which prophylaxis is recommended are more clearly specified. 

(4)  An algorithm was developed to more clearly define when prophylaxis is recommended for patients with mitral valve prolapse.

(5)  For oral or dental procedures the initial amoxicillin dose is reduced to 2 g, a follow-up antibiotic dose is no longer recommended, erythromycin is no longer recommended for penicillin-allergic individuals, but clindamycin and other alternatives are offered. 

(6)  For gastrointestinal or genitourinary procedures, the prophylactic regimens have been simplified. These changes were instituted to more clearly define when prophylaxis is or is not recommended, improve practitioner and patient compliance, reduce cost and potential gastrointestinal adverse effects, and approach more uniform worldwide recommendations.

The Spectrum of Patients at risk for Endocarditis.

 Traditional Risk:

 1.     Most congenital cardiac malformations.

2.     Rheumatic and other aquired valvular dysfunction.

3.     Hypertrophic cardiomyopathy.

4.     Mitral valve prolapse with valvular regurgitation.

     Highest risk:

5.     Previous endocarditis.

6.     Prosthetic cardiac valves, mechanical and bioprosthetic.

7.     Systemic to pulmonary surgical shunts for cyanotic congenital HD.

8.     Complex cyanotic congenital heart disease.

     Controversial risk:

9.     The many other patients with mitral valve prolapse. **

10.  Permanent pacemaker and ICD implants within 6 months of implant.

11.  Patients with other indwelling intra-vascular catheters.

12.  Mitral regurgitation due to papillary muscle dysfunction.

13.  Ventriculo-jugular shunts for hydrocephalus.

14.  Synthetic vascular grafts within the first 6 months of surgery.

15.  Renal dialysis patients with AV fistulas.

16.  Patients with prosthetic joints, hip, knee or shoulder.

** patients with MVP who have thickening or redundancy of the mitral valve are probably at increased risk and should have prophylaxis, particularly men >45 years of age.

LOW or NO RISK of Infective Endocarditis.

 1.     Isolated secundum atrial septal defect.

2.     Beyond 6 months after repair of ASD, VSD or Patent Ductus.

3.     Cardiac transplant patients.

4.     CABG patients.

5.     Physiologic or functional murmurs.

6.     Previous rheumatic fever without cardiac involvement.

7.     Kawasaki disease without valvular involvment.

8.     Parenteral drug abuse without valvular involvement. 

Procedures which entail risk for Infective Endocarditis.

1.     Dental procedures known to produce gingival or mucosal bleeding including cleaning.

2.     Tonsillectomy and adenoidectomy.

3.     Surgical operations involving intestinal or respiratory mucosa.

4.     Bronchoscopy with a rigid bronchoscope.

5.     Sclerotherapy for esophageal varices.

6.     Esophageal stricture dilatation.

7.     ERCP.

8.     Cholecystectomy.

9.     Cystoscopy.

10.  Urethral dilatation.

11. Urinary catheterization in the presence of urinary infection.

12. Urinary tract surgery in the presence of urinary infection.

13. Prostatic surgery.

14. Incision and drainage of infected tissue.

15. Vaginal delivery in the presence of infection.

16. Endotonia.

17. Endoaortic instrumentation or surgery.

Procedures which entail uncertain risk for Infective Endocarditis.

1.     Alveolar ridge incision in denture patients without pre-existent ulceration.

2.     Various crown and bridge procedures.

3.     Nasal septoplasty.

4.     Ear piercing.

5.     Acupuncture.

6.     Dermatologic procedures.

7.     Inguinal herniorraphy.

8.     Lithotripsy.

9.     Trans-rectal prostatic biopsy.

10. Transesophageal echocardiography.