Bacterial Endocarditis Prophylaxis:
1997 Recommendations

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Bacterial Endocarditis Prophylaxis:
1997 Recommendations

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:
  1. Emphasis that most cases of endocarditis are not due to invasive procedures
  2. Cardiac conditions are now classified as to the likelihood of a bad outcome due to endocarditis
  3. Procedures that require prophylaxis are spelled out more clearly
  4. The post-oral procedure dose has been dropped, and erythromycin is no longer recommended as a substitute for penicillin
  5. Mitral valve prolapse is given an in-depth discussion (which I won't address here)
  6. 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
  1. Prosthetic cardiac valves
  2. Previous endocarditis
  3. Complex cyanotic congenital heart disease (single ventricle states, tetralogy of Fallot, transposition of the great arteries, etc.)
  4. Surgically constructed shunts or conduits
B. Moderate-risk category
  1. Most other cardiac malformations not listed above or below
  2. Acquired valvular dysfunction
  3. Mitral valve prolapse with regurgitation
  4. Hypertrophic cardiomyopathy

II. Prophylaxis Not Recommended
Negligible-risk category
  1. Isolated atrial septal defect
  2. Surgically repaired atrial septal defect, ventricular septal defect, or patent ductus arteriosus (if there is no cardiac residual problems 6 months after the surgery)
  3. Mitral valve prolapse without valvular dysfunction
  4. Physiologic, functional or innocent heart murmurs
  5. Previous Kawasaki Disease without valvular dysfunction
  6. Previous Rheumatic Fever without valvular dysfunction
  7. 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
  1. Tonsillectomy and/or adenoidectomy
  2. Surgical operations involving respiratory mucosa
  3. Bronchoscopy with a rigid bronchoscope

B. Prophylaxis Not Recommended
  1. Endotracheal intubation
  2. Bronchoscopy with flexible bronchoscope
  3. Tympanostomy ("P-E" or "vent") tube insertion

II. Gastrointestinal Tract
A. Prophylaxis Recommended (optional for medium-risk patients)
  1. Sclerotherapy for esophageal varices
  2. Esophageal stricture dilitation
  3. Endoscopic retrograde cholangiography
  4. Biliary tract surgery
  5. Surgical operations involving intestinal mucosa

B. Prophylaxis Not Recommended
  1. Endoscopy with or without biopsy (except high-risk patients)

III. Genitourinary Tract
A. Prophylaxis Recommended
  1. Prostatic surgery
  2. Cystoscopy
  3. Urethral dilitation

B. Prophylaxis Not Recommended
  1. Vaginal and C-section deliveries
  2. In uninfected tissues:
    a. Urethral catheterization
    b. Uterine dilitation and curettage
    c. sterilization procedures
    d. insertion or removal of intrauterine devices
  3. Circumcision

IV. Other Procedures Not Needing Prophylaxis:
1. Cardiac Catheterization
2. Biopsy of surgically scrubbed skin


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.)
Prophylaxis for Dental, Oral or Respiratory Procedures
Situation Antibiotic Regimen
Standard general
Amoxicillin Orally 1 hour before procedure
Unable to take
oral medications
Ampicillin Intramuscularly or Intravenously
Within 30 minutes before procedure
Allergic to penicillin Clindamycin
Orally 1 hour before procedure
Cephalexin or
Azithromycin or
Allergic to penicillin
and unable to take
oral medications
Intramuscularly or Intravenously
Within 30 minutes before procedure

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.

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