Infectious Disease Compendium

Endocarditis Prophylaxis


With the US have 30% of the worlds lawyers, or so I have been told, there is no reason not to follow the AHA Guidelines to the letter (even if the data is suggestive that it does not work).

At best the risks of developing IE are estimated at 1 in 46,000 for unprotected procedures (antibiotics not condoms) (1 in 10,700 (prosthetic valve) and 1 in 54,300 (native valve) and 1 in 150,000 for protected procedures (PubMed). But does dental procedures increase the risk of endocarditis? Maybe not so much (PubMed), but follow the guidelines.

In England they abandoned all antibiotic prophylaxis for dental work and most other procedures. Guess what? No increase in endocarditis (PubMed). Or was there?  A 2014 study shows an increase in endocarditis since stopping widespread prophylaxis (PubMed).The lack of increase in endocarditis with less prophylaxis has been demonstrated in several studies (PubMed).

You do NOT NOT NOT need to prophylax for joints. There is a study (PubMed), and I quote, "Dental procedures were not risk factors for subsequent total hip or knee infection. The use of antibiotic prophylaxis prior to dental procedures did not decrease the risk of subsequent total hip or knee infection." Ha! And the Guidelines were updated in 2012 to add this.

From the 2007 Guidelines Antibiotic prophylaxis with dental procedures is recommended only for patients with cardiac conditions associated with the highest risk of adverse outcomes from endocarditis, including:

  • Prosthetic cardiac valve,
  • Previous endocarditis,
  • Cardiac transplantation recipients with cardiac valvular disease,
  • Congenital heart disease only in the following categories:

- Unrepaired cyanotic congenital heart disease, including those with palliative shunts and conduits.

- Completely repaired congenital heart disease with prosthetic material or device, whether placed by surgery or catheter intervention, during the first six months after the procedure (prophylaxis is recommended because endothelialization of prosthetic material occurs within six months after the procedure

- Repaired congenital heart disease with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization).

Dental procedures for which prophylaxis is recommended in patients with cardiac conditions listed above: All dental procedures that involve manipulation of gingival tissue or the periapical region of teeth, or perforation of the oral mucosa.

Antibiotic prophylaxis is NOT recommended for the following dental procedures or events: routine anesthetic injections through noninfected tissue; taking dental radiographs; placement of removable prosthodontic or orthodontic appliances; adjustment of orthodontic appliances; placement of orthodontic brackets; and shedding of deciduous teeth and bleeding from trauma to the lips or oral mucosa.

The Committee no longer recommends administering antibiotics solely to prevent BE in patients who undergo a GI or GU tract procedure.


Antibiotic Prophylactic Regimens Recommended for Dental Procedures
Situation Single dose 30–60 minutes before procedure Adults Children
Oral amoxicillin 2 gm 50 mg/kg
Can't take oral

cefazolin or ceftriaxone IM or IV

1 gm 50 mg/kg
Allergic to Penicillin





azithromycin or clarithromycin:

2 gm

600 mg

500 mg




Allergic to Penicillin and can't take oral

cefazolin or ceftriaxone IM or IV


clindamycin IM or IV

1 gm

600 mg



Curious Cases

Relevant links to my Medscape blog

Post hoc ergo propter hoc

Last Update: 06/26/18.