OfficialreprintfromUpToDate

www.uptodate.com2017UpToDate

Patienteducation:Antibioticsbeforeprocedures(Beyondthe
Basics)
Author SectionEditor DeputyEditor
DanielJSexton,MD StephenBCalderwood,MD ElinorLBaron,MD,DTMH

INTRODUCTION

Manypeoplearetoldthattheyneedtotakeanantibioticbeforehavingadental,surgical,orotherinvasivemedical
procedure.Thistopicdiscussesthebenefitoftakingapreprocedureantibiotic,whoshouldtakeantibiotics,and
providesanexplanationofwhenantibioticsareusuallyrecommended.

Certainprocedures,suchasarootcanalortoothextraction(asdiscussedbelow),mayallowbacteriafromthemouth
toenterthebloodstream.Rarely,thesebacteriacaninfecttheheartvalvesandliningoftheheart,causingthemto
becomeinflamed.Thisinflammationiscalledinfectiveendocarditis(IE).IEhasthepotentialtocausecatastrophic
medicalproblems,includingheartfailureandleakageoftheheartvalves.

Whentakenbeforeaprocedure,antibioticsmaypreventbacteriafrombeingreleasedintothebloodstream.Thisis
knownasantibioticprophylaxis.

Theguidelinesprovidedbelowmaynotapplytoeverysituation.Theremaybeinstancesinwhichapersonhasahigh
ormoderateriskofIEandantibioticsarenotrecommended.Insuchcases,itisimportanttounderstandtherisksand
benefitsoftakingversusnottakingpreventiveantibiotics.Youshoulddiscusstheseissueswithyourhealthcare
providerbeforetheprocedure.

INFECTIVEENDOCARDITIS

Infectiveendocarditis(IE)isaninfectionoftheliningofheartchambersorvalveswithbacteria,fungi,orother
organisms.IEoccursmostcommonlyinpeoplewhohaveabnormalheartvalvesorhadpreviousheartsurgeryless
commonly,itcanoccurinotherwisehealthypeoplewhohavedonothaveheartdisease.(See'Guidelinesforantibiotic
prophylaxis'below.)

IEdevelopsfollowingasequenceofevents:

Bacteriacirculateinthebloodstreamandsticktotheliningorvalvesoftheheart,usuallyatasiteofprevious
injuryorsurfaceirregularityorabnormality.

Thebacteriathengrowonthevalvesurface,formingasmallmass(calledavegetation)ontheheartvalvesor
lining.Thevalveorsurfacethatisinfectedmaythenbecomesecondarilydamaged.

IEcandevelopinaverysmallpercentageofpeoplewhoundergodentalorothermedicalproceduresthatcancause
bacteriatobetransientlyreleasedintothebloodstream.Antibioticsarecommonlygiventopeopleundergoingdental
procedureswhohavepreexistingheartmurmursorknownproblemswiththeirheartvalves,althoughtheevidencethat
theseantibioticsarealwaysnecessaryoreffectiveisnotconclusive.Somestudiesshowthatantibioticscanhelpto
preventIE,whileothersshownobenefit.

GuidelinesforantibioticprophylaxisInthepast,AmericanHeartAssociationguidelinesrecommendedthatmost
patientswithaheartmurmurreceiveantibioticspriortoalmostanydentalprocedure,evenminorones.However,these
guidelineshavechangedconsiderablyovertimeasmoreinformationhasbecomeavailableabouttheactualriskof
dentalproceduresforpatientswithheartconditions.Reviewofstudiesperformedbetween1950and2006,which
includedthousandsofpatients,hasshownthattherewasnobenefitofusingpreventiveantibiotics,exceptinthe
highestriskpatients[1].
 HighestriskPeoplewiththefollowingconditionsareconsideredtobeatthehighestriskofdevelopingIE.
Preventiveantibioticsaregenerallyrecommendedforpeoplewiththefollowingconditionsbeforecertainprocedures:

Aprostheticheartvalve

Valverepairwithprostheticmaterial

ApriorhistoryofIE

Unrepairedcyanoticcongenitalheartdisease,includingpalliativeshuntsandconduits

Completelyrepairedcongenitalheartdefectswithprostheticmaterialordeviceduringthefirstsixmonthsafter
theprocedure(whetherplacedbysurgeryorbycatheterintervention)

Repairedcongenitalheartdiseasewithresidualdefectsatthesiteoradjacenttothesiteoftheprostheticpatch
orprostheticdevice

Proceduresthatrequirepretreatmentwithantibioticsarelistedbelow.(See'Antibioticrecommendations'below.)

ModerateriskPeoplewiththefollowingconditionsareconsideredtobeatmoderateriskofdevelopingIE.
AntibioticprophylaxisisNOTgenerallyrecommendedforpeoplewithmoderateriskconditions.Thisisanimportant
changefrompriorrecommendations[1].

Valverepairwithoutprostheticmaterial

Hypertrophiccardiomyopathy

Mitralvalveprolapsewithvalvularregurgitationand/orvalvularthickening

Mostothercongenitalcardiacabnormalitiesnotlistedabove

Unrepairedventricularseptaldefect,unrepairedpatentductusarteriosus

Acquiredvalvulardysfunction(eg,mitraloraorticregurgitationorstenosis)

LowriskPeoplewiththefollowingconditionsarethoughttohavealowriskofIE.Antibioticshaveneverbeen
recommendedforpeoplewiththeseconditions:

Physiologic,functional,orinnocentheartmurmurs

Mitralvalveprolapsewithoutregurgitationorvalvularleafletthickening

Mildtricuspidregurgitation

Coronaryarterydisease(includingpreviouscoronaryarterybypassgraftsurgery)

Simpleatrialseptaldefect

Atrialseptaldefect,ventricularseptaldefect,orpatentductusarteriosusthatwassuccessfullyclosed(either
surgicallyorwithacatheterbasedprocedure)morethansixmonthspreviously

PreviousrheumaticfeverorKawasakidiseasewithoutvalvulardysfunction

Peoplewithpacemakersordefibrillators

Preventativeantibioticsarerecommendedforhighriskpatients(asoutlinedabove)undergoingdentalproceduresthat
involvemanipulationofthetissueofthegums,theperiapicalregionoftheteeth,orperforationoftheliningmembranes
ofthegumssuchastoothextractions,routinedentalcleaning(scaling),ordrainageofadentalabscess.

Otherproceduressuchasanestheticinjections,dentalXrays,placementoforthodonticorprosthodonticsappliances,
lossofbabyteeth,orbleedingfromtraumatothelipsorcheeksdonotrequireantibioticseveninhighriskpatients.

DentalcarerecommendationsAnyonewhoisatriskofdevelopingIEshouldfollowaprogramofcarefulmouth
andtoothcare.Thisincludesaprofessionalcleaningeverysixmonths,twicedailytoothbrushing,anddailyflossing.
Thesemeasurescanhelptopreventplaqueandbacteriafrombuildinguparoundthegumsandteeth.
ANTIBIOTICRECOMMENDATIONS

ThefollowingtreatmentsuggestionscomefromtheAmericanHeartAssociation'sguidelinesonantibioticprophylaxis.

Dental,oral,orupperrespiratorytractproceduresPeoplewhoareathighestriskforinfectiveendocarditis(IE)
(see'Highestrisk'above)shouldtakeonedoseofanantibioticbymouth(pillsorliquid)onehourbeforecertaindental,
oral,orupperrespiratorytractproceduresaseconddoseisnotnecessary.

PeopleallergictopenicillinPeoplewhoareallergictopenicillincanbetreatedonehourbeforetheprocedure
withanalternateantibiotic.

PeopleunabletotakeoralmedicationsPeoplewhoareunabletotakeoralmedicationscanbetreatedwithan
antibioticinjection30minutesbeforetheprocedure.

GenitourinaryorgastrointestinalproceduresTheAmericanHeartAssociationdoesnotconsidersurgeriesor
proceduresonthedigestiveorurinarysystemtohaveahighriskofcausingIE.Thisincludescolonoscopy,
sigmoidoscopy,cystoscopy,andmanyotherprocedures.

Antibioticsarenolongerroutinelyrecommendedbeforetheseprocedures,eveninpeoplewiththehighestriskheart
conditions[1].

PatientswithprostheticjointsPatientswithprostheticjointsdonotrequireantibiotictherapypriortodental
procedures.Althoughantibioticswerecommonlygiveninthepastinsuchcircumstances,theAmericanAcademyof
OralMedicine,theAmericanDentalAssociation,theAmericanAcademyofOrthopedicSurgery,andtheBritish
SocietyforAntimicrobialChemotherapyalladviseagainsttheroutineuseofantibioticspriortoteethcleaning,teeth
scaling,orroutineproceduressuchasfillingofadentalcavity.However,activedentalinfectionsinpatientswith
prostheticjointsshouldbetreatedpromptly,andgoodoralhygieneshouldbemaintained.

PatientswithbreastimplantsTherearenodatatosupportadministrationofprophylacticantibioticstowomenwith
prostheticbreastimplantspriortodentalprocedures,andwedonotrecommendit.

PregnancyPregnantwomenwhoareathighestriskforIE(see'Highestrisk'above)shouldtakeanantibiotic
beforecertaindental,oral,orupperrespiratorytractprocedures.

ApregnantwomanwhohasahighriskofIEdoesNOTusuallyneedantibioticprophylaxisbeforeanormalvaginal
deliveryorcesareansection.Antibioticsmayberecommendedbeforelabororcesareansectionforotherreasons,
includingpreventionofcomplicationsrelatedtogroupBStreptococcus.(See"Patienteducation:GroupB
streptococcusandpregnancy(BeyondtheBasics)".)

ChildrenChildrenwithamoderateorhighriskofdevelopingIEareusuallygivenantibioticsbeforeselecteddental
andsurgicalprocedures.

WHERETOGETMOREINFORMATION

Yourhealthcareprovideristhebestsourceofinformationforquestionsandconcernsrelatedtoyourmedicalproblem.

Thisarticlewillbeupdatedasneededonourwebsite(www.uptodate.com/patients).Relatedtopicsforpatients,as
wellasselectedarticleswrittenforhealthcareprofessionals,arealsoavailable.Someofthemostrelevantarelisted
below.

PatientlevelinformationUpToDateofferstwotypesofpatienteducationmaterials.

TheBasicsTheBasicspatienteducationpiecesanswerthefourorfivekeyquestionsapatientmighthave
aboutagivencondition.Thesearticlesarebestforpatientswhowantageneraloverviewandwhoprefershort,easy
toreadmaterials.

Patienteducation:Mitralregurgitation(TheBasics)
Patienteducation:Mitralvalveprolapse(TheBasics)

Patienteducation:TetralogyofFallot(TheBasics)
 BeyondtheBasicsBeyondtheBasicspatienteducationpiecesarelonger,moresophisticated,andmore
detailed.Thesearticlesarebestforpatientswhowantindepthinformationandarecomfortablewithsomemedical
jargon.

Patienteducation:GroupBstreptococcusandpregnancy(BeyondtheBasics)

ProfessionallevelinformationProfessionallevelarticlesaredesignedtokeepdoctorsandotherhealth
professionalsuptodateonthelatestmedicalfindings.Thesearticlesarethorough,long,andcomplex,andthey
containmultiplereferencestotheresearchonwhichtheyarebased.Professionallevelarticlesarebestforpeoplewho
arecomfortablewithalotofmedicalterminologyandwhowanttoreadthesamematerialstheirdoctorsarereading.

Antithrombotictherapyinpatientswithinfectiveendocarditis
Antimicrobialprophylaxisforbacterialendocarditis
Antimicrobialtherapyofnativevalveendocarditis
Antimicrobialtherapyofprostheticvalveendocarditis
Candidaendocarditisandsuppurativethrombophlebitis
Complicationsandoutcomeofinfectiveendocarditis
ClinicalmanifestationsofStaphylococcusaureusinfectioninadults
Epidemiology,microbiology,anddiagnosisofculturenegativeendocarditis
Clinicalmanifestationsandevaluationofadultswithsuspectednativevalveendocarditis
Epidemiology,riskfactors,andmicrobiologyofinfectiveendocarditis
Infectionsinvolvingcardiacimplantableelectronicdevices
Infectiveendocarditisininjectiondrugusers
Pathogenesisofvegetationformationininfectiveendocarditis
Epidemiology,clinicalmanifestations,anddiagnosisofprostheticvalveendocarditis
Roleofechocardiographyininfectiveendocarditis
Surgeryforleftsidednativevalveinfectiveendocarditis
Surgeryforprostheticvalveendocarditis

Thefollowingorganizationsalsoprovidereliablehealthinformation.

NationalLibraryofMedicine

(www.nlm.nih.gov/medlineplus/endocarditis.html)

NationalHeart,Lung,andBloodInstitute

(www.nhlbi.nih.gov/)

AmericanHeartAssociation

(www.heart.org/HEARTORG/)

[14]

Literaturereviewcurrentthrough:May2017.|Thistopiclastupdated:Mar16,2017.

ThecontentontheUpToDatewebsiteisnotintendednorrecommendedasasubstituteformedicaladvice,diagnosis,ortreatment.Alwaysseekthe
adviceofyourownphysicianorotherqualifiedhealthcareprofessionalregardinganymedicalquestionsorconditions.Theuseofthiswebsiteis
governedbytheUpToDateTermsofUse2017UpToDate,Inc.

References
Top

1.WilsonW,TaubertKA,GewitzM,etal.Preventionofinfectiveendocarditis:guidelinesfromtheAmericanHeart
Association:aguidelinefromtheAmericanHeartAssociationRheumaticFever,Endocarditis,andKawasaki
DiseaseCommittee,CouncilonCardiovascularDiseaseintheYoung,andtheCouncilonClinicalCardiology,
CouncilonCardiovascularSurgeryandAnesthesia,andtheQualityofCareandOutcomesResearch
InterdisciplinaryWorkingGroup.Circulation2007116:1736.
2.DuvalX,AllaF,HoenB,etal.Estimatedriskofendocarditisinadultswithpredisposingcardiacconditions
undergoingdentalprocedureswithorwithoutantibioticprophylaxis.ClinInfectDis200642:e102.
3.NishimuraRA,OttoCM,BonowRO,etal.2014AHA/ACCguidelineforthemanagementofpatientswith
valvularheartdisease:areportoftheAmericanCollegeofCardiology/AmericanHeartAssociationTaskForce
onPracticeGuidelines.JAmCollCardiol201463:e57.
4.NishimuraRA,OttoCM,BonowRO,etal.2017AHA/ACCFocusedUpdateofthe2014AHA/ACCGuidelinefor
theManagementofPatientsWithValvularHeartDisease:AReportoftheAmericanCollegeof
Cardiology/AmericanHeartAssociationTaskForceonClinicalPracticeGuidelines.Circulation2017.