Chapter 6.  Prophylaxis and Immunizations

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ENDOCARDITIS PROPHYLAXIS

Endocarditis prophylaxis is now recommended only for previous endocarditis, prosthetic­ cardiac valve or prosthetic cardiac valve material, congenital heart disease (CHD), unrepaired cyanotic CHD, including palliative shunts and conduits, completely repaired congenital heart defects with prosthetic material/devices (placed by surgery­ or by catheter intervention during the first 6 months post-procedure), repaired CHD with residual defects adjacent to the site of prosthetic patch/device, and cardiac transplantation with cardiac valvupathy.

Table 6.9. Previous Indications for Infective Endocarditis (IE) Prophylaxis*

		Prophylaxis Recommended		Prophylaxis Not Recommended
Subset		(Column A)		(Column B)
Cardiac conditions	•	Ostium primum ASD	• Isolated ostium secundum ASD
	•	Prosthetic heart valves,	• Surgical repair without residue
		including bioprosthetic and		beyond 6 months of ostium
		homograft valves		secundum ASD or PDA
	•	Previous infective endocarditis	• Previous coronary artery bypass
	•	Most congenital cardiac		surgery
		malformations	• MVP without valvular regurgitation
	•	Rheumatic valve disease	• Physiologic, functional, or innocent
	•	Hypertrophic cardiomyopathy		murmurs
	• MVP with significant valvular		• Previous Kawasaki’s cardiac disease
	•	regurgitation		or rheumatic fever without valve
		Calcific aortic stenosis		disease
Procedures	•	Dental procedures known	• Dental procedures not likely to
		to induce gingival/mucosal	•	induce gingival bleeding
		bleeding, including dental		Tympanostomy tube insertion
		cleaning	• Flexible bronchoscopy ± biopsy
	•	Tonsillectomy or	•	Endotracheal intubation
	•	adenoidectomy	•	Endoscopy ± gastrointestinal
		Surgical operations involving	•	biopsy
		intestinal or respiratory mucosa		Cesarean section
	• Cystoscopy or urethral dilation		• D & C, IUD insertion/removal, or
	•	Urethral catheterization or		therapeutic abortion in the absence
		urinary tract surgery if UTI is	•	of infection
	•	present		Cardiac pacemaker/defibrillator
		Prostate surgery		insertion

•I & D of infected tissue

*Wilson W, et al.. Prevention of Infective Endocarditis.. Circulation 116:1736–1754, 2007..

370	A n t i b i o t i c E s s e n t i a l s

Table 6.9. Previous Indications for Infective Endocarditis (IE) Prophylaxis* (cont’d)

		Prophylaxis Recommended		Prophylaxis Not Recommended
Subset		(Column A)		(Column B)
	• Biopsies of infected respiratory		•	Coronary stent implantation
		mucosa or infected skin/soft	•	Percutaneous transluminal coronary
	•	tissues	•	angioplasty (PTCA)
		Any surgical procedure		Cardiac catheterization
		involving an infected field

ASD = atrial septal defect, D & C = dilatation and curettage, I & D = incision and drain, IUD = intrauterine device, MVP = mitral valve prolapse, PDA = patent ductus arteriosus, UTI = urinary tract infection.

*Prophylaxis is indicated for patients with cardiac conditions in Column A undergoing procedures in Column A.. Prophylaxis is not recommended for patients or procedures in Column B.. See Tables 6..9 and 6..10 for prophylaxis regimens for above-the-waist and below-the-waist procedures, respectively..

Table 6.10. Endocarditis Prophylaxis for Above-the-Waist (Dental, Oral, Esophageal, Respiratory Tract) Procedures*

Prophylaxis	Reaction to Penicillin	Antibiotic Regimen
Oral prophylaxis	None	Amoxicillin 2 gm (PO) 1 hour pre-procedure†
	Non-anaphylactoid	Cephalexin 1 gm (PO) 1 hour pre-procedure
	Anaphylactoid	Clindamycin 300 mg (PO) 1 hour pre-procedure††
IV prophylaxis	None	Ampicillin 2 gm (IV) 30 minutes pre-procedure
	Non-anaphylactoid	Cefazolin 1 gm (IV) 15 minutes pre-procedure
	Anaphylactoid	Clindamycin 600 mg (IV) 30 minutes pre-procedure

*Endocarditis prophylaxis is directed against viridans streptococci, the usual SBE pathogen above the waist.. Macrolide regimens are less effective than other regimens; clarithromycin/azithromycin regimens (500 mg PO 1 hour pre-procedure) are of unproven efficacy..

†Some recommend a 3 gm dose of amoxicillin, which is excessive given the sensitivity of viridans streptococci to amoxicillin..

††Some recommend a 600 mg dose of clindamycin, but a 300 mg dose gives adequate blood levels and is better tolerated (less diarrhea)..

Table 6.11. Endocarditis Prophylaxis for Below-the-Waist (Genitourinary, Gastrointestinal) Procedures Involving an Infected Field*†

Prophylaxis	Reaction to Penicillin	Antibiotic Regimen
Oral prophylaxis	None	Amoxicillin 2 gm (PO) 1 hour pre-procedure
	Non-anaphylactoid,	Linezolid 600 mg (PO) 1 hour pre-procedure
	anaphylactoid