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Bacterial Endocarditis Prophylaxis:
1997 Recommendations
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The full reference for the article is at the end of this page. The recommendations are from the American Heart Association along with the American Academy of Pediatrics, the American Dental Assoc., the Infectious Disease Society of America and the American Society for Gastrointestinal Endoscopy.
Major changes include:
- Emphasis that most cases of endocarditis are not due to invasive procedures
- Cardiac conditions are now classified as to the likelihood of a bad outcome
due to endocarditis
- Procedures that require prophylaxis are spelled out more clearly
- The post-oral procedure dose has been dropped, and erythromycin is no longer
recommended as a substitute for penicillin
- Mitral valve prolapse is given an in-depth discussion (which I won't address
here)
- Changes in the regimen with gastrointestinal and
genitourinary procedures
Important Note:While these statements appear fairly
straight-forward, please consult your cardiologist to make sure that your
child doesn't have any special requirements that would affect these
recommendations. These recommendations are to guide your cardiologist's decisions
but not to replace his or her judgment of the individual patient.
Cardiac Conditions
- I. Prophylaxis Recommended
- A. High-risk category
- Prosthetic cardiac valves
- Previous endocarditis
- Complex cyanotic congenital heart disease (single ventricle states, tetralogy
of Fallot, transposition of the great arteries, etc.)
- Surgically constructed shunts or conduits
- B. Moderate-risk category
- Most other cardiac malformations not listed above or below
- Acquired valvular dysfunction
- Mitral valve prolapse with regurgitation
- Hypertrophic cardiomyopathy
- II. Prophylaxis Not Recommended
- Negligible-risk category
- Isolated atrial septal defect
- Surgically repaired atrial septal defect, ventricular septal defect, or patent
ductus arteriosus (if there is no cardiac residual problems 6 months after
the surgery)
- Mitral valve prolapse without valvular dysfunction
- Physiologic, functional or innocent heart murmurs
- Previous Kawasaki Disease without valvular dysfunction
- Previous Rheumatic Fever without valvular dysfunction
- Cardiac pacemakers
The report lists all procedures for which prophylaxis is necessary. While few of these are procedures done on children, I'm going to list them all for completeness' sake:
Dental Procedures
- I. Prophylaxis Recommended
- 1. Dental extractions
2. Periodontal procedures (surgery, scaling, root planing,probing)
3. Implants and reimplants of avulsed teeth
4. Root canals
5. Initial placement of orthotic bands
6. Prophylactic cleaning where bleeding is expected
- II. Prophylaxis Not Recommended
- 1. Filling of cavities and other restorative dentistry
2. Placement of removable appliances or orthodontic adjustments
3. Taking of oral impressions
4. Fluoride treatments
5. Taking dental Xrays
6. Shedding of primary teeth
Other Procedures
- I. Respiratory
- A. Prophylaxis Recommended
- Tonsillectomy and/or adenoidectomy
- Surgical operations involving respiratory mucosa
- Bronchoscopy with a rigid bronchoscope
B. Prophylaxis Not Recommended
- Endotracheal intubation
- Bronchoscopy with flexible bronchoscope
- Tympanostomy ("P-E" or "vent") tube insertion
- II. Gastrointestinal Tract
- A. Prophylaxis Recommended (optional for medium-risk patients)
- Sclerotherapy for esophageal varices
- Esophageal stricture dilitation
- Endoscopic retrograde cholangiography
- Biliary tract surgery
- Surgical operations involving intestinal mucosa
B. Prophylaxis Not Recommended
- Endoscopy with or without biopsy (except high-risk
patients)
- III. Genitourinary Tract
- A. Prophylaxis Recommended
- Prostatic surgery
- Cystoscopy
- Urethral dilitation
B. Prophylaxis Not Recommended
- Vaginal and C-section deliveries
- In uninfected tissues:
a. Urethral catheterization
b. Uterine dilitation and curettage
c. sterilization procedures
d. insertion or removal of intrauterine devices
- Circumcision
- IV. Other Procedures Not Needing Prophylaxis:
- 1. Cardiac Catheterization
- 2. Biopsy of surgically scrubbed skin
Antibiotics
For genitourinary and gastrointestinal procedures, the prophylactic antibiotics
will almost always be given intravenously, so I won't be discussing these.
However, most parents of children who need prophylaxis have to give a dose
of an oral antibiotic prior to dental, oral or respiratory tract procedures.
The main change in these recommendations has been to eliminate the
6-hour post-procedure dose, and to remove erythromycin form the list of
antibiotics used. (Erythromycin was dropped due to GI side effects
and the variability between forms of the antibiotic.)
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Prophylaxis for Dental, Oral or Respiratory Procedures
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Situation
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Antibiotic
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Regimen
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Standard general
prophylaxis
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Amoxicillin
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Orally 1 hour before procedure
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Unable to take
oral medications
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Ampicillin
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Intramuscularly or Intravenously
Within 30 minutes before procedure
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Allergic to penicillin
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Clindamycin
or
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Orally 1 hour before procedure
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Cephalexin or
Cefadroxil
or
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Azithromycin or
Clarithromycin
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Allergic to penicillin
and unable to take
oral medications
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Clindamycin
or
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Intramuscularly or Intravenously
Within 30 minutes before procedure
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Cefazolin
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Reminder: Consult your pediatrician or cardiologist if you have any questions about your child's particular status or procedure. While blanket recommendations are good in that they may help optimize medical care,
not every child may be covered exactly by these recommendations.
Reference: Dajani AS et al. Prevention of bacterial endocarditis:
Recommendations by the American Heart Association. JAMA, 277(22): 1794-1801,
June 11, 1997.
Recommended Websites:
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Contact autor
| Sourcing:http://www.ds-health.com/endocard.htm |
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