Dental Procedures and Heart Operations: Prophylaxis against infective endocarditis
is a very common question that many patients who had cardiac surgery are faced with, every time thy visit their dentist : “do I need to
have/give antibiotics before dental procedures?” Various committees across the the world, including those for Europe (led by the European Society of Cardiology [ESC]) and North America (led by the American Heart Association [AHA]) feel that the risks associated with infection to the heart (native valves or prosthetic valve, known as infective endocarditis [IE]) in the highest risk groups (those more likely to have a bad outcome if they developed IE, as well as those more likely to develop it), are likely to exceed the risks associated with adverse drug reactions of using prophylactic antibiotics during dental procedures.
In the absence of clear evidence either for or against antibiotic prophylaxis, it is probably reasonable to recommend prophylactic antibiotic before dental procedures that involves manipulation of gingival tissue, manipulation of the peri-apical region of teeth or perforation of the oral mucosa in patients with valvular heart disease (patients with a previous history of IE, prosthetic heart valve-rings-chords-clips or valve repaired with prosthetic material, unrepaired cyanotic congenital heart disease, or certain repaired congenital heart defects, cardiac transplant with valve regurgitation)
In July 2016 NICE (UK) made a small but extremely important change to Clinical Guideline 64 (CG64), ‘Prophylaxis against infective endocarditis:
antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures’ Recommendation 1.1.3, ‘Antibiotic prophylaxis against infective endocarditis is not recommended for people undergoing dental procedures’ (or other non-dental procedures) has now been changed to ‘Antibiotic prophylaxis against infective endocarditis is not recommended routinely for people undergoing dental procedures.’ This change was precipitated by recent publications stating that it is inappropriate to withhold antibiotic prophylaxis from patients at high-risk of developing infective endocarditis, particularly in light of a recent change in the law concerning informed consent.
The change in wording now allows clinicians to comply with the new GMC recommendation on consent which states that ‘Doctors and dentists should offer the most appropriate treatment options, in consultation with the patient and/or their carer or guardian. In doing so, they should take account of the recommendations in this guideline and the values and preferences of patients and apply their clinical judgment’. These changes have made it necessary for dentists to explain to their patients the differences between NICE recommendations and recommendations from other guidelines with regards to the use of antibiotic prophylaxis during dental work
When a patient has undergone a heart operation with the use of prosthetic material, which means that they are now in the high risk category of infective endocarditis (patients with a previous history of IE, prosthetic heart valve or valve repaired with prosthetic material, unrepaired cyanotic congenital heart disease, or certain repaired congenital heart defects), it is my recommendation that the patient should be counselled and consented towards prophylactic use of antibiotics during dental work, as per advice below.
| Situation | Antibiotic | Single-dose 30-60 minutes before procedure | ||
| Adults | Children | |||
| No allergy to penicillin or ampicillin | Amoxicillin or ampicillin1 | 2 g orally2 or IV | 50 mg/kg orally or IV | |
| Allergy to penicillin or ampicillin | Clindamycin | 600 mg orally or IV | 20 mg/kg orally or IV | |
| This table has been adapted from the 2015 ESC Guidelines for the management of infective endocarditis | ||||
| Note 1: Alternatively, Cephalexin 2g IV for adults or 50 mg/kg IV for children, Cefazolin or Ceftriaxone 1 g IV for adults or 50 mg/kg IV for children. Cephalosporins should not be used, however, in patients with anaphylaxis, angio-oedema or urticaria after intake of Penicillin or Ampicillin due to cross-sensitivity.
Note 2: In the UK, a practical alternative is the 3 g Amoxicillin oral powder sachet to be made up with water.
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Relevant literature
2015 ESC Guidelines for the management of infective endocarditis: The ask Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC) Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM)
2016 NICE update (UK): Prophylaxis against infective endocarditis: antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures
2017 Guidelines on prophylaxis to prevent infective endocarditis
2017 ESC/EACTS Guidelines for the management of valvular heart disease
2020 AHA/ACC Guidlines for the management of patients with valvular heart disease
