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Revised AHA Guidelines for Prevention of Infective Endocarditis

The 2007 guidelines reflect questions about the effectiveness of antimicrobial prophylaxis for IE associated with dental, GI, or GU tract procedures.

Sponsoring Organizations: American Heart Association, American Dental Association, Infectious Diseases Society of America, Pediatric Infectious Diseases Society

Background and Purpose: Morbidity and mortality associated with infective endocarditis (IE) remain high despite great advances in medicine and surgery. Prevention of IE has therefore been a priority for the American Heart Association for more than 50 years. The 2007 document updates the AHA’s guidelines, last revised in 1997. The key rationale for the current revision is to address the persistent question of whether antimicrobial prophylaxis effectively prevents IE associated with dental, gastrointestinal, or genitourinary (GU) tract procedures.

Key Points:
1. Prophylactic antibiotics based on a patient’s lifetime risk for acquiring IE are no longer recommended for dental, GI, or GU tract procedures. This recommendation follows from the observation that most cases of IE result from bacteremia caused by routine activities such as chewing food, brushing teeth, and flossing. Moreover, no published data clearly indicate that prophylaxis prevents IE from invasive procedures.

2. Dental disease may increase IE risk, but emphasis should shift from antibiotic prophylaxis for dental procedures to improved dental care and oral health in patients with conditions that carry the highest risk for IE.

3. IE prophylaxis is reasonable (Class IIb, level of evidence C) for dental procedures that involve gingival tissues or the periapical region of a tooth and for procedures that perforate the oral mucosa, in patients with cardiac conditions associated with the highest risk for adverse outcomes from IE:

• prosthetic cardiac valve
  
• previous IE
  
• unrepaired congenital heart disease (including palliative shunts and conduits)
  
• completely repaired congenital heart defect with prosthetic material or device, during the first 6 months after the procedure
  
• repaired congenital heart disease with residual defects at the site or adjacent to the site of a prosthetic patch or device
  
• cardiac transplantation recipients who develop cardiac valvulopathy
  

4. IE prophylaxis is no longer recommended for patients with mitral valve prolapse.

5. If administered, antibiotics should be given in a single dose before the procedure. The preferred antibiotic is amoxicillin (2 g in adults and 50 mg/kg in children).

6. IE prophylaxis is not strongly recommended for respiratory tract procedures and not recommended at all for bronchoscopy, unless incision of the respiratory tract mucosa is necessary.

7. IE prophylaxis is not recommended for GU or GI procedures.

Comment: These guidelines represent a marked change in approach to IE prevention, limiting the situations in which antimicrobial prophylaxis is considered reasonable and eschewing strong endorsement of prophylaxis in any setting (the guidelines contain no Class I recommendations). The shift is away from antibiotics and toward dental health. The authors also called for further studies so that future recommendations may be built on a stronger evidence base.

— Harlan M. Krumholz, MD, SM

Published in Journal Watch Cardiology May 30, 2007

Citation(s):

Wilson W et al. Prevention of infective endocarditis. Guidelines from the American Heart Association. A guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 2007 Apr 19; [e-pub ahead of print]. (http://dx.doi.org/10.1161/CIRCULATIONAHA.106.183095)