Antimicrobial prophylaxis for bacterial endocarditis

Author
Daniel J Sexton, MD
Section Editor
Catherine M Otto, MD
Deputy Editors
Elinor L Baron, MD, DTMH
Susan B Yeon, MD, JD, FACC

Disclosures
Last literature review version 19.3: Fri Sep 30 00:00:00 GMT 2011 | This topic last
updated: Thu Jun 09 00:00:00 GMT 2011 (More)

INTRODUCTION — Antimicrobial prophylaxis for bacterial endocarditis has become standard in most
developed countries, despite the fact that no prospective randomized trial has proven that such
therapy is beneficial. Furthermore, given the extremely low incidence of endocarditis following
procedures such as dental surgery and the medicolegal climate in the United States and Europe, it is
unlikely that such a study will ever be undertaken. It has been estimated that a randomized trial to
assess the effectiveness of prophylaxis after dental procedures would require at least 6000 patients in
each study group [1].

The theoretical basis for antimicrobial prophylaxis for endocarditis and the most recent guideline that
was published by the American Heart Association (AHA) in 2007 on the prevention of infective
endocarditis will be reviewed here [2]. As will be seen, this guideline made important revisions to
previous guidelines. (See 'AHA guideline' below.)

THEORETICAL BASIS FOR PROPHYLAXIS — The pathogenesis of infective endocarditis (IE) is

presumed to involve the following sequence of events [3]:

 Formation of a small noninfected thrombus on an abnormal endothelial surface

 Secondary infection of this nidus with bacteria that are transiently circulating in the bloodstream
 Proliferation of bacteria resulting in the formation of vegetations on the endothelial surface

Since the occurrence of bacteremia is crucial to the initiation of an episode of IE, it is theoretically
reasonable to conclude that preventing or promptly treating transient bacteremia will prevent the
above sequence even if a predisposing valvular lesion is present.

Animal studies — Bacterial endocarditis can be predictably induced experimentally if bacteria with a
known ability to cause endocarditis (eg, streptococci) are injected into laboratory animals after their
heart valves have been traumatized using vascular catheters [4]. However, endocarditis does not occur
if antibiotics with activity against streptococci are given immediately before or for up to 30 minutes
after bacteria are injected [3,5]. In contrast, endocarditis is not prevented if such therapy is delayed
for six hours after the injection of bacteria. Protection can also be abolished if penicillinase is given
after the combination of amoxicillin and streptococci have been injected into susceptible animals.

These data suggest that antimicrobial therapy can prevent endocarditis either by killing bacteria before
they establish a nidus of infection on a susceptible heart valve or by killing bacteria after they adhere
to a localized area of damaged valvular endothelium [3].

Human studies

Prevention of bacteremia — Bacteremia is common after invasive procedures. The frequency, time
course, and effect of amoxicillin on bacteremia after dental procedures were evaluated in a careful
study of 100 children ages one to eight years (mean 3.5 years) who underwent endotracheal
intubation, dental restoration and cleaning, and tooth extractions [6]. Children who had conditions
considered to require antibiotic prophylaxis were excluded; those enrolled were randomly assigned to
receive amoxicillin or placebo. Blood cultures were obtained at eight time points before and after
procedures, ranging from two minutes postintubation to 45 minutes after the last extraction.
The following observations were made:

 The highest incidence of positive blood cultures occurred 1.5 minutes after the last extraction
(46 percent).
 The majority of the 152 positive cultures and the 29 different bacteria identified was gram-
positive cocci, especially viridans streptococci.
 The overall incidence of positive blood cultures was significantly lower among patients
receiving amoxicillin than placebo (33 versus 84 percent).

A second study of 500 children aged 3 to 16 determined the duration of bacteremia following a dental
extraction [7]. Children were randomly allocated to 1 of 10 post-procedure time groups, and blood
samples were taken both pre- and post-extraction (time point determined according to the assigned
group) for the isolation of bacteria. The difference between the pre-procedure blood sample and the
post-procedure sample was used to estimate the duration of bacteremia, which was found to be 11
minutes, considerably less than previously thought.

The specific antibiotics used for antimicrobial prophylaxis are dependent upon the bacteremia-causing
procedure the patient is undergoing. Standard guidelines have suggested clindamycin as an alternative
in the penicillin-allergic patient at risk for endocarditis who is undergoing a dental extraction.

Researchers in Spain have investigated whether clindamycin is effective in this setting, given the
increasing resistance of oral bacteria to this antibiotic. In a randomized, controlled trial, 221 adults
who underwent dental extractions were assigned to one of the following: 2 g amoxicillin, 600 mg
clindamycin, 400 mg moxifloxacin, or no antibiotic, orally one to two hours before the procedure [8].

Blood cultures were drawn at 30 seconds, 15 minutes, and one hour after the dental extraction. At all
time points, clindamycin was ineffective in preventing bacteremia, with similar bacteremia rates as the
no antibiotic control patients (85 versus 96, 70 versus 64, and 22 versus 20 percent at 30 seconds, 15
minutes, and one hour, respectively). In contrast, both amoxicillin and moxifloxacin significantly
reduced bacteremia rates (46 and 57, 11 and 24, and 4 and 7 percent at 30 seconds, 15 minutes, and
one hour, respectively).

The results of this study may not be generalizable to all populations, as a high prevalence of resistant
oral flora is a particular concern in this geographic region. In addition, the baseline (before dental
extraction) rates of bacteremia, 5 to 13 percent in the study groups, may in part be due to drawing the
blood for culture from an indwelling catheter. Reports of antibiotic prophylaxis failure
with clindamycin for dental extractions remain rare [9,10].

Prevention of endocarditis — Although biologic plausibility is very high, no study in humans has
definitively demonstrated that prophylactic antibiotics prevent endocarditis after invasive procedures.
Only observational studies are available, with conflicting evidence of treatment benefit [11,12].

 A case control study compared 273 patients with community-acquired endocarditis, who were
not injection drug users, and an equal number of controls matched for age, sex, and
neighborhood to assess the risk of endocarditis following dental procedures [13]. Dental
procedures were not more frequent in case patients than controls during one, two, or three
months before the diagnosis of the infection, even in patients with endocarditis caused by
recognized dental flora. The type of dental procedure also did not appear to affect the risk of
infection, although the number of extractions among cases and controls were not sufficient to
include this in the analysis. Known valvular abnormality, not the dental procedure, was the
major risk factor for endocarditis in this study with prior cardiac valve surgery and a previous
episode of endocarditis being the two most significant (adjusted odds ratios of 75 and 37,
respectively).

The authors concluded that dental treatment does not seem to be a risk factor for infective
endocarditis, even in patients with valvular abnormalities, and that few cases of infective
 endocarditis would be preventable with antibiotic prophylaxis. An editorial accompanying this
study suggested that the time had arrived to refine guidelines for antimicrobial prophylaxis to
markedly reduce the number of patients for whom prophylaxis is recommended [14].
 A small observational study published in the 1980s evaluated 304 patients with prosthetic heart
valves who received antibiotics immediately prior to undergoing invasive procedures thought to
be capable of causing bacteremia with organisms known or likely to cause endocarditis; the
outcome was compared with that in 229 similar patients with prosthetic heart valves who did
not receive antimicrobial therapy [15]. Endocarditis developed in none of the 304 treated
patients compared with 6 of the 220 (2.7 percent) untreated patients. The risk of endocarditis
in this nonrandomized study was higher than in subsequent epidemiological studies.
 An epidemiologic study from France estimated that the risk of developing IE following a dental
procedure in adults with predisposing cardiac conditions was 1 in 11,000 for patients with
prosthetic valves and no prophylaxis, 1 in 54,000 for patients with native valves and no
prophylaxis, and 1 in 150,000 for patients who received prophylaxis [16]. Thus, a large number
of prophylaxis doses would be necessary to prevent a very small number of IE cases,
suggesting that only the highest-risk procedures and populations should receive prophylaxis.
 Two other studies that attempted to demonstrate the efficacy of IE prophylaxis prior to dental
work provided conflicting results: one suggested benefit [17] and the other did not [18].
However, both studies had serious limitations in design or lacked statistical power to
demonstrate efficacy [3].

Failure of prophylaxis — Given the limited evidence of benefit, it is not surprising that failure of
currently recommended prophylactic antibiotic regimens occasionally occurs. One report, for example,
evaluated 52 cases of IE that occurred despite receipt of antimicrobial therapy prior to invasive surgical
procedures [9]. Approximately two-thirds of the pathogens causing endocarditis were susceptible in
vitro to the prophylactic antimicrobial agents that were administered.

It has been estimated that, even if antimicrobial prophylaxis were assumed to be 100 percent
effective, less than 10 percent of all cases of endocarditis could be prevented by the proper use of
antimicrobial therapy before invasive procedures [10]. Various epidemiologic studies have shown that
between 2.7 and 5 percent of all cases of endocarditis are preceded by a dental procedure [1].
However, even in cases in which there is a close temporal relationship between a dental procedure and
the occurrence of endocarditis, it is impossible to know whether this is a causal relationship, as it is
possible that endocarditis occurred as a consequence of the dental condition that led to the procedure
or from daily activity such as tooth brushing.

GUIDELINES

AHA guideline — The 2007 American Heart Association (AHA) guideline for the prevention of infective
endocarditis (IE) [2] made major revisions to the 1997 AHA guideline, the 2005 update of those
guidelines published by the Medical Letter [19], and the 2006 ACC/AHA guideline on the management
of valvular heart disease [20]. Since the publication of the 2007 AHA guideline, the ACC/AHA guideline
was updated in 2008 [21]. The 2009 European Society of Cardiology (ESC) guidelines are largely in
agreement with the American guidelines [22].

The recommendation for antimicrobial prophylaxis for dental and other procedures (and others) is now
limited to those patients with cardiac conditions with the highest risk of adverse outcome from IE [2].
In contrast, the prior guidelines recommended prophylaxis for patients at moderate to high risk of IE, a
much larger population [19,20]. (See 'Patients at highest risk' below.)

The rationale for this change was to make guidelines more evidence-based since, as noted above,
there is no convincing evidence that antimicrobial prophylaxis provides significant benefit in most
patients in terms of prevention of IE. This change has the added advantage of simplifying care for
practitioners and patients. (See 'Prevention of endocarditis' above.)

The following points were made by the AHA in support of their recommendation for the important
change [2]:
  IE is much more likely to result from frequent exposure to random bacteremias associated with
daily activities (eg, tooth brushing) than from bacteremia caused by a dental, gastrointestinal,
or genitourinary procedure.
 Prophylaxis may prevent an exceedingly small number of cases of IE, if any, in individuals who
undergo these procedures.
 The risk of antibiotic-associated adverse events exceeds the benefit, if any, from prophylactic
antibiotic therapy.
 Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from
daily activities and is therefore more important than prophylactic antibiotics for a dental
procedure to reduce the risk of IE.

The guideline recommendations were based upon results of in vitro studies, clinical experience, data
from experimental animal models, and assessment of both the bacteria most likely to produce
bacteremia from a given site and those most likely to result in endocarditis.

The guidelines are not intended to be the standard of care in all instances in which prophylactic
antibiotic therapy might be considered [2]. Clinicians can exercise their own judgment in selecting the
dose and duration of antibiotic therapy in individual cases or in special circumstances.

Patients at highest risk — Prophylaxis was recommended only in those settings associated with the
highest risk of developing an adverse outcome if IE was to occur [2]. Patients with the following
cardiac conditions were considered to meet this criterion:

 Prosthetic heart valves, including bioprosthetic and homograft valves. (See "Management of
patients with prosthetic heart valves", section on 'Endocarditis prophylaxis'.)
 Prosthetic material used for cardiac valve repair
 A prior history of IE.
 Unrepaired cyanotic congenital heart disease, including palliative shunts and conduits.
 Completely repaired congenital heart defects with prosthetic material or device, whether placed
by surgery or by catheter intervention, during the first six months after the procedure.
 Repaired congenital heart disease with residual defects at the site or adjacent to the site of the
prosthetic device.
 Cardiac "valvulopathy" in a transplanted heart. Valvulopathy is defined as documentation of
substantial leaflet pathology and regurgitation [23].

Similar limited criteria for prophylaxis were proposed in 2006 by the Working Party of the British
Society for Antimicrobial Chemotherapy [23]. "Valvulopathy" in a transplanted heart was not included,
but these guidelines also included complex left ventricular outflow abnormalities including aortic
stenosis and bicuspid aortic valves, or acquired valvulopathy or mitral valve prolapse with
echocardiographic evidence of substantial leaflet pathology and regurgitation [23].

No longer indicated — Common valvular lesions for which antimicrobial prophylaxis is no longer
recommended in the 2007 AHA guidelines include bicuspid aortic valve, acquired aortic or mitral valve
disease (including mitral valve prolapse with regurgitation), and hypertrophic cardiomyopathy with
latent or resting obstruction.

Procedures that may result in transient bacteremia — The 2007 AHA guidelines recommend that
antimicrobial prophylaxis be given to patients with the cardiac lesions cited above when they undergo
procedures likely to result in bacteremia with a microorganism that has the potential ability to cause
endocarditis [2]. (See 'Patients at highest risk' above.)

Dental — The risk of IE is generally considered to be the highest for all dental procedures that involve
manipulation of either gingival tissue or the periapical region of teeth or perforation of the oral mucosa
[2,23].
All individuals at risk for developing IE should establish and maintain a program of oral health care
including regular professional care, the regular use of manual or powered toothbrushes, dental floss,
and other plaque removing devices.

Respiratory tract — Although a variety of organisms may cause bacteremia during respiratory tract
procedures, there is no direct evidence that such bacteremias cause IE. The AHA guideline does not
recommend routine antimicrobial prophylaxis for procedures unless they involve incision or biopsy of
the respiratory tract mucosa [2]. Examples of such procedures include tonsillectomy, adenoidectomy,
or bronchoscopy with biopsy.

In patients who undergo an invasive respiratory tract procedure as part of the treatment of an
established infection:

 The ongoing antibiotic regimen should include an agent that is active against viridans group
streptococci.
 In patients who have a respiratory tract infection that is known or suspected to be caused by
Staphylococcus aureus, the regimen should include an agent active against S. aureus.

Genitourinary and gastrointestinal tracts — The risk of bacteremia is significantly lower for
invasive genitourinary (GU) procedures such as dilation of strictures, insertions of catheters, and
prostatectomy compared with dental or respiratory tract infections. Invasive gastrointestinal (GI)
procedures, such as lower bowel endoscopy with biopsy or endoscopic retrograde
cholangiopancreatography, have an even lower risk of IE since bacteremia due to organisms capable of
causing endocarditis occurs in less than 5 to 10 percent of cases.

The AHA guidelines no longer consider any GI (including diagnostic colonoscopy or

esophagogastroduodenoscopy) or GU procedures high risk and therefore do not recommend routine
use of IE prophylaxis even in patients with the highest risk cardiac conditions defined above [2]. Data
evaluating the risk of IE associated with GI endoscopy are discussed in detail elsewhere.
(See "Antibiotic prophylaxis for gastrointestinal endoscopic procedures".)

Some patients with established infections of the GI or GU tract may have enterococcal bacteremia. For
patients with the highest risk cardiac conditions who have ongoing GI or GU tract infection or who are
undergoing a procedure for which antibiotic therapy to prevent wound infection or sepsis is indicated,
the AHA suggests an antibiotic regimen that includes an agent active against enterococci. (See 'Choice
of antimicrobial agent' below.)

For those patients with an enterococcal urinary tract infection or colonization scheduled to undergo
elective cystoscopy or urinary tract manipulation, eradication of the organism prior to the procedure
should be attempted.

Vaginal or cesarean delivery — Vaginal or cesarean delivery is not an indication for routine
antibiotic prophylaxis since the rate of bacteremia with these procedures is low [3,24]. The 2007 AHA
guidelines specify that prophylaxis is not indicated for vaginal delivery or cesarean section [2,25], and
the 2008 AHA/ACC guidelines note that antibiotic prophylaxis is not recommended for genitourinary
procedures [21].

The American College of Obstetricians and Gynecologists (ACOG), Committee on Obstetic Practice has
endorsed the 2007 AHA recommendations, noting that infective endocarditis prophylaxis is not
recommended for vaginal or cesarean delivery in the absence of infection [26]. In patients with the
highest risk lesions with established infection that could cause bacteremia (such as chorioamnionitis or
pyelonephritis) the underlying infection should be treated in the usual fashion; treatment should
include an intravenous regimen effective for infective endocarditis prophylaxis. (See 'Patients at
highest risk' above and "Intraamniotic infection (chorioamnionitis)" and "Urinary tract infections and
asymptomatic bacteriuria in pregnancy", section on 'Acute pyelonephritis'.)

The 2008 ACC/AHA guidelines for management of adults with congenital heart disease contain
antibiotic prophylaxis recommendations that generally agree with the 2007 AHA prophylaxis guidelines
[27]. However, the 2008 ACC/AHA adult congenital heart disease guidelines include a recommendation
that is it reasonable to consider antibiotic prophylaxis against infective endocarditis before vaginal
delivery at the time of membrane rupture in select patients with the highest risk of adverse outcomes.
This includes patients with prosthetic cardiac valve or prosthetic material used for cardiac valve repair
and patients or unrepaired or palliated cyanotic heart disease, including surgically constructed
palliative shunts and conduits. However, proof of efficacy of prophylaxis in this setting is not available.

Skin or musculoskeletal tissue — Patients with infected skin, skin structure, or musculoskeletal
tissue may have polymicrobial infections. When such patients undergo a surgical procedure, only
bacteremia with staphylococci or beta-hemolytic streptococci are likely to cause IE. The appropriate
antibiotic regimen is discussed below. (See 'Special circumstances' below.)

NICE guideline — The United Kingdom National Institute for Health and Clinical Excellence (NICE)
published a guideline in 2008 recommending that NO antimicrobial prophylaxis for IE be administered
prior to dental or other invasive procedures [28]. In the two years following the issuance of these
guidelines, a ‘before and after’ study noted a 78 percent reduction in antibiotic prophylaxis
prescriptions after the guidelines were introduced, with no significant increase in the incidence of
infective endocarditis [29].

These findings do not exclude the possibility that antibiotic prophylaxis may benefit some high risk
patients (eg those with prosthetic valves, congenital heart disease or a history IE), for whom
prophylaxis is still recommended in Europe and the United States.

CHOICE OF ANTIMICROBIAL AGENT — Among the selected patients for whom antimicrobial
prophylaxis is suggested, the antimicrobial regimen recommended by the AHA guidelines varies with
the procedure being performed (table 1) [2].

Dental, oral, or upper respiratory tract procedures — The primary antibiotic regimen for most
patients, including those with prosthetic valves, is amoxicillin, 2 g orally 30 to 60 minutes before the
procedure; a second dose is not necessary [2,30].

A different regimen is warranted in the following circumstances; all drugs are given 30 to 60 minutes
before the procedure [2]:

 Patients who are allergic to penicillins or ampicillin can be treated with cephalexin (2 g)
or azithromycin or clarithromycin (500 mg) or clindamycin (600 mg).
 Patients who are unable to take oral medications can be treated with 2 g of intravenous or
intramuscular ampicillin. Patients allergic to penicillin can be given cefazolin or ceftriaxone (1 g
intravenously) OR 600 mg of intravenous or intramuscular clindamycin.

Genitourinary or gastrointestinal procedures — For those high risk patients who undergo
gastrointestinal or genitourinary procedures at a time of ongoing gastrointestinal or genitourinary
infection, antibiotic coverage for enterococcal bacteremia should be provided
with amoxicillin or ampicillin or, in the patient unable to tolerate these drugs, vancomycin.
(See "Antibiotic prophylaxis for gastrointestinal endoscopic procedures" and 'Procedures that may
result in transient bacteremia' above.)

Skin and musculoskeletal tissue — Although infection of the skin or musculoskeletal tissue is often
polymicrobial, only staphylococcal or beta-hemolytic streptococcal bacteremia is likely to cause
endocarditis in such circumstances. Thus, an antistaphylococcal penicillin or a cephalosporin is
appropriate (table 1). In patients undergoing procedures involving infected skin and musculoskeletal
tissue (eg, incision and drainage of skin abscess), the treatment regimen should include drugs active
against these organisms. Clindamycin or vancomycin may be used when the patient is unable to take a
beta-lactam or is known or suspected to have an infection caused by a methicillin-resistant
staphylococcus. (See "Skin abscesses, furuncles, and carbuncles".)
Pregnancy — As noted above, uncomplicated vaginal or cesarean delivery is not a routine indication
for antibiotic prophylaxis although prophylaxis may be considered in certain circumstances
(see 'Vaginal or cesarean delivery' above).

If antibiotic prophylaxis is given to prevent enterococcal endocarditis, amoxicillin, ampicillin,

and vancomycin are appropriate agents and they should be administered at the time of delivery.

Children — Children given endocarditis prophylaxis should receive the same antibiotic regimens and
dosing intervals as noted above. Equivalent pediatric doses for oral therapy are as follows:

 Amoxicillin — 50 mg/kg to a maximum dose of 2 g

 Azithromycin or clarithromycin — 15 mg/kg to a maximum dose of 500 mg
 Clindamycin —20 mg/kg to a maximum dose of 600 mg
 Cephalexin — 50 mg/kg to a maximum dose of 2 g

Equivalent pediatric doses for intramuscular or intravenous therapy are as follows:

 Ampicillin — 50 mg/kg to a maximum dose of 2 g

 Cefazolin or ceftriaxone — 50 mg/kg to a maximum dose of 1 g
 Clindamycin — 20 mg/kg to a maximum dose of 600 mg
 Vancomycin — 15 mg/kg to a maximum dose of 1 g

SPECIAL CIRCUMSTANCES — The following four situations require special attention:

Patients on antibiotics — If patients are receiving antibiotics for other indications at the time that
dental or invasive procedures are undertaken, an alternate antibiotic of a different class is often
chosen. As an example, if a patient receiving penicillin for rheumatic fever prophylaxis undergoes an
invasive dental procedure and requires IE prophylaxis, clindamycin, cephalexin, or azithromycin is
often chosen.

Patients receiving anticoagulants — Intramuscular injections of antibiotics should be avoided in

patients receiving anticoagulation therapy. Oral antibiotic regimens are preferred, and intravenous
therapy should be used when oral treatment is not possible.

Surgery for placement of prosthetic valves or intracardiac/intravascular materials — Patients

undergoing surgery for placement of prosthetic valves or intracardiac or intravascular materials are at
risk for the development of bacterial endocarditis [31]. In this setting the morbidity and mortality of
infection is high and antimicrobial prophylaxis directed against staphylococci is advisable. First
generation cephalosporins are often used, but local hospital susceptibility patterns need to be taken
into account, and if methicillin-resistant staphylococci are common or prevalent local
pathogens, vancomycin should be substituted for cephalosporins.

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 Beyond the Basics topics (see "Patient information: Antibiotics before procedures")
SUMMARY AND RECOMMENDATIONS — Despite the devastating consequences of bacterial
endocarditis, evidence to support antimicrobial prophylaxis as an effective preventative measure is
weak and inconclusive. The 2007 AHA guideline for the prevention of infective endocarditis, with which
we agree, has narrowed the indications for bacterial endocarditis prophylaxis, compared with prior
versions, in recognition of the absence of strong supportive evidence [2]. Similar indications were
proposed in 2006 by the Working Party of the British Society for Antimicrobial Chemotherapy [23].
(See 'AHA guideline' above.)

Despite a lack of evidence supporting the necessity of antimicrobial prophylaxis for IE, we believe that
it is reasonable to prescribe antimicrobial prophylaxis for patients with the highest risk medical
conditions undergoing procedures likely to result in bacteremia with a microorganism that has the
potential ability to cause bacterial endocarditis (Grade 2C).

Which patients — The following are the highest risk conditions (see 'Patients at highest risk' above):

 Prosthetic heart valves, including bioprosthetic and homograft valves.

 A prior history of IE.
 Unrepaired cyanotic congenital heart disease, including palliative shunts and conduits.
 Completely repaired congenital heart defects with prosthetic material or device, whether placed
by surgery or by catheter intervention, during the first six months after the procedure.
 Repaired congenital heart disease with residual defects at the site or adjacent to the site of the
prosthetic device.
 Cardiac valvulopathy in a transplanted heart.

The following are the highest risk procedures (see 'Procedures that may result in transient
bacteremia' above):

 All dental procedures that involve manipulation of either gingival tissue or the periapical region
of teeth or perforation of the oral mucosa.
 Procedures of the respiratory tract that involve incision or biopsy of the respiratory mucosa.
 Procedures in patients with ongoing GI or GU tract infection.
 Procedures on infected skin, skin structure, or musculoskeletal tissue.
 Surgery to place prosthetic heart valves or prosthetic intravascular or intracardiac materials.
(See 'Special circumstances' above.)

Which antibiotic — The choice of antibiotic is patient and procedure specific.

For patients undergoing a dental procedure, who will be the majority of individuals for whom
prophylaxis is appropriate, the preferred regimen is oral amoxicillin two grams given 30 to 60 minutes
before the procedure. Alternative regimens for patients with penicillin allergy or who are unable to take
oral medication are shown above.

Regimens for non-dental procedures are described in detail above. Patients with skin or
musculoskeletal infections undergoing procedures should receive agents active against staphylococci
and beta-hemolytic streptococci. In patients with GI or GU tract infection, antibiotic therapy to prevent
associated wound infection or sepsis should include an agent active against enterococci. (See 'Choice
of antimicrobial agent' above.)