Antibiotic prophylaxis. Part II: recommendations of the American Heart Association and related committees.
The American Heart Association's (AHA) Rheumatic Fever rheumatic fever (rmăt`ĭk), systemic inflammatory disease, extremely variable in its manifestation, severity, duration, and aftereffects. , Endocarditis endocarditis (ĕn'dōkärdī`tĭs), bacterial or fungal infection of the endocardium (inner lining of the heart) that can be either acute or subacute. , and Kawasaki Disease Ka·wa·sa·ki disease
See mucocutaneous lymph node syndrome.
Kawasaki disease Mucocutaneous lymph node syndromeA disease of children < age 5 that often follows a 1-2 wk prodrome Etiology Uncertain; bugs implicated Committee; the Council on Cardiovascular Disease Cardiovascular disease
Disease that affects the heart and blood vessels.
Mentioned in: Lipoproteins Test
cardiovascular disease in the Young; and the Council on Clinical Cardiology, Council on Cardiovascular Surgery cardiovascular surgery Heart surgery An operation for repairing structural defects of the cardiovascular system Examples CABG, repair of congenital heart defects, varicose veins, aortic aneurysms, ventricular remodeling, transmyocardial and Anesthesia, and Quality of Care and Outcomes Research Interdisciplinary Working Group recently published guidelines for antibiotic prophylaxis prophylaxis (prō'fĭlăk`sĭs), measures designed to prevent the occurrence of disease or its dissemination. Some examples of prophylaxis are immunization against serious diseases such as smallpox or diphtheria; quarantine to confine prior to dental procedures, respiratory tract respiratory tract
The air passages from the nose to the pulmonary alveoli, including the pharynx, larynx, trachea, and bronchi.
Respiratory tract procedures and gastrointestinal (GI) or genitourinary genitourinary /gen·i·to·uri·nary/ (jen?i-to-u´ri-nar-e) pertaining to the genital and urinary organs.
adj. Abbr. (GU) tract procedures. The groups of committees were instructed to use the systematic review process to develop new guidelines to assist oral-health and other health professionals. Major changes include (1) cardiac conditions indicated for prophylaxis pertain only to those that carry the highest risk of developing infective endocarditis infective endocarditis
See infectious endocarditis.
infective endocarditis Acute endocarditis; bacterial endocarditis; subacute endocarditis Cardiology An infection of the endocardium which may involve the valves (EI); (2) dental procedures requiring prophylaxis in these conditions include any procedure requiring tooth manipulation rather than procedures that are associated with significant bleeding; and (3) timing of the antibiotic is to administer a single dose 30 to 60 minutes prior to the dental procedure rather than the previous 60-minute requirement. The recommendation for a pre-procedural antimicrobial rinse was eliminated. The antibiotics recommended for prophylaxis were not changed.
Le Rheumatic Fever, Endocarditis and Kawasaki Disease Committee, le Council on Cardiovascular Disease in the Young, le Council on Clinical Cardiology, le Council on Cardiovascular Surgery and Anesthesia et le Quality of Care and Outcomes Research Interdisciplinary Working Group de l'American Heart Association (AHA) ont publie dernierement des directives sur l'antibioprophylaxie prealable aux interventions dentaires et aux interventions touchant les voies respiratoires, le tractus gastro-intestinal et l'appareil genitourinaire. Les groupes de comites devaient appliquer un mecanisme de revision systematique pour elaborer de nouvelles directives d'aide aux professionnels de la sante dentaire et autres professionnels de la sante. Les principaux changements sont, notamment : 1) les troubles cardiaques indiques pour la prophylaxie sont uniquement ceux qui presentent le risque ris·qué
Suggestive of or bordering on indelicacy or impropriety.
[French, from past participle of risquer, to risk, from risque, risk; see risk.]
Adj. le plus eleve de developper une endocardite infectieuse; 2) les interventions dentaires necessitant une prophylaxie dans ces conditions incluent toute intervention exigeant une manipulation dentaire plutot que les interventions associees a un saignement abondant; 3) l'antibiotique doit etre administre sous forme forme (form) pl. formes [Fr.] form.
forme fruste (froost) pl. formes frustes an atypical, especially a mild or incomplete, form, as of a disease. de dose unique entre 30 et 60 minutes avant les interventions dentaires au lieu de 60 minutes, comme auparavant. Le rincage antimicrobien pre-intervention qui etait recommande a ete elimine. Les antibiotiques recommandes pour la prophylaxie demeurent les memes.
THE AMERICAN HEART ASSOCIATION'S (AHA) Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee; the Council on Cardiovascular Disease in the Young; and the Council on Clinical Cardiology, Council on Cardiovascular surgery and Anesthesia, and Quality of Care and Outcomes Research Interdisciplinary Working Group recently published new guidelines to assist oral-health and other health professionals in the use of antibiotic prophylaxis prior to dental, respiratory tract and gastrointestinal (GI) or genitourinary (GU) tract procedures. (1) The British Antimicrobial Society (BAS BAS
1. Bachelor of Agricultural Science
2. Bachelor of Applied Science ) updated their recommendations in 2006. Both the BAS and the AHA, which are equivalent authorities in their respective countries, used the systematic review process to develop the new guidelines. Antibiotic Prophylaxis, Part 1: Recommendations of the British Society for Antimicrobial Chemotherapy Working Party, published in the May-June 2007 issue of this journal, reviewed relevant scientific evidence and clinical studies used by the Working Party of the BAS to establish recommendations for dental-health professionals when making judgments related to antibiotic prophylaxis to prevent infective endocarditis (IE). The AHA's recommendations for using antibiotic prophylaxis are discussed in this article, representing Part II of the issue. As well, this article discusses the differences between the two professional recommendations. The writing group of the AHA Committee reported the recent changes are intended to define more clearly those situations when endocarditis prophylaxis is or is not recommended and to provide more uniform and consistent global recommendations.
SYSTEMATIC REVIEW LEVELS OF EVIDENCE
The AHA Committee, Councils and Working Group were charged with the task of assessing the evidence and giving a classification of recommendations and a level of evidence (LOE LOE Ley Orgánica de Educación (Spanish)
LOE Level Of Effort
LOE Limited Objective Experiment
LOE Letter of Explanation
LOE Language Other than English. ) to each recommendation. The group used the American College of Cardiology/American Heart Association classification system (Boxl) (1) and determined their recommendations over the past 50 years to be Class IIb, LOE C.
HISTORY OF AHA RECOMMENDATIONS FOR PREVENTION OF IE
The AHA has made recommendations for the prevention of IE for more than 50 years, beginning with the first guidelines in 1955. (2) The recommendations for the use of antibiotic prophylaxis prior to dental treatment were made based on the significant morbidity and mortality Morbidity and Mortality can refer to:
The part of the mouth behind the teeth and gums that is bounded above by the hard and soft palates and below by the tongue and the mucous membrane connecting it with the inner part of the mandible. (viridans group streptococci Streptococcus (plural, streptococci)
A genus of spherical-shaped anaerobic bacteria occurring in pairs or chains. Sydenham's chorea is considered a complication of a streptococcal throat infection. ) were the most common microorganisms cultured from early cases. (2) The 1965 guidelines recognized for the first time the role of enterococci enterococci
bacteria in the genus Enterococcus. in bacteremias following GI- or GU-tract procedures. (3) Recommendations published in 1972 were endorsed for the first time by the American Dental Association American Dental Association (ADA),
n.pr a nonprofit professional association whose membership is dental professionals in the United States. Its purpose is to assist its members in providing the highest professional and ethical care to the citizens of the (ADA Ada, city, United States
Ada (ā`ə), city (1990 pop. 15,820), seat of Pontotoc co., S central Okla.; inc. 1904. It is a large cattle market and the center of a rich oil and ranch area. ) and emphasized the importance of maintaining good oral hygiene Oral Hygiene Definition
Oral hygiene is the practice of keeping the mouth clean and healthy by brushing and flossing to prevent tooth decay and gum disease. . (4) Subsequent recommendations attempted to simplify prophylactic regimens and address the growing problem with antibiotic resistance antibiotic resistance,
n the ability of certain strains of microorganisms to develop resistance to antibiotics.
antibiotic resistance until the 1997 recommendations stratified stratified /strat·i·fied/ (strat´i-fid) formed or arranged in layers.
Arranged in the form of layers or strata. cardiac conditions into high-, moderate-, and low-risk categories, advising not to provide antibiotic prophylaxis for low-risk cardiac conditions and to limit pre-procedure dosing to a single dose. (5) The fundamental principles that led to the formulation of the AHA's new guidelines and the nine previous sets of guidelines are that (1) IE is an uncommon but life-threatening disease and prevention is preferable to treatment of an established infection; (2) certain underlying cardiac conditions predispose pre·dis·pose
To make susceptible, as to a disease. to IE; (3) bacteremia bacteremia: see septicemia.
Presence of bacteria in the blood. Short-term bacteremia follows dental or surgical procedures, especially if local infection or very high-risk surgery releases bacteria from isolated sites. with organisms known to cause IE occurs commonly in association with invasive dental, GI- or GU-tract procedures; (4) antimicrobial prophylaxis has proven to be effective in preventing experimental IE in animals; and (5) antimicrobial prophylaxis is thought to be effective in humans for prevention of IE associated with dental, GI- or GU-tract procedures. (1) The 2007 guidelines are based on the results of a large body of evidence published in numerous studies over the past two decades. The guidelines are intended to be in the best interest of clients and care providers, are considered to be reasonable and prudent and represent the collective wisdom of many experts on IE and relevant national and international societies.
RATIONALE FOR REVISING THE 1997 GUIDELINES
The AHA Committee explained that the 1997 guidelines were based largely on expert opinion and what seemed to be a rational and prudent attempt to prevent a life-threatening infection. They report the basis for former recommendations for endocarditis prophylaxis was not well established and the quality of evidence was limited to a few case-control studies or was based on clinical experience and descriptive studies that utilized surrogate measures of risk. (1) Although many dental and dental-hygiene professionals believed that (based on AHA guidelines) antibiotic prophylaxis prior to dental procedures was effective to prevent endocarditis, research published prior to and following the 1997 guidelines questioned the effectiveness of the then-recommended regimen to prevent IE associated with oral procedures and dental treatment. (6,7,8,9) The primary reasons for the current revision of guidelines for antibiotic prophylaxis to prevent IE are that (1) IE is much more likely to result from frequent exposure to random bacteremias associated with daily activities than from bacteremia caused by a dental, GI- or GU-tract procedure; (2) only a small number of cases of IE, if any, would be prevented with prophylaxis prior to a dental, GI- or GU-tract procedure; (3) the risk of antibiotic-associated adverse events exceeds the benefit, if any, from prophylactic antibiotic therapy prophylactic antibiotic therapy Administration of antimicrobials in absence of a known infection, a standard practice to ↓ risk of surgical wound infection Common surgical wound pathogens Staphylococcus aureus, Bacteroides fragilis, ; and (4) maintenance of oral health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics prior to a dental procedure to reduce the risk of IE.
ROLE OF ORAL HEALTH AND HYGIENE
Oral health and the absence of periodontal periodontal /peri·odon·tal/ (per?e-o-don´t'l)
1. pertaining to the periodontal ligament or periodontium.
2. near or around a tooth.
1. inflammation and bleeding have been considered important to reduce bacteremias from the oral cavity. The AHA Committee noted that this presumed relationship is controversial, (10,11,12,13) however available evidence supports an emphasis on maintaining good oral hygiene and eradicating dental disease to decrease the frequency of bacteremia from routine daily activities. (14,15,16,17) Because study results vary, the AHA Committee concluded that a precise determination of the relative risk of bacteremia that result from a specific dental procedure in clients with or without dental disease is probably not possible. (18,19,20).
Results are contradictory with regard to the efficacy of the use of topical antiseptics in reducing the frequency of bacteremia associated with dental procedures, but the preponderance of evidence A standard of proof that must be met by a plaintiff if he or she is to win a civil action.
In a civil case, the plaintiff has the burden of proving the facts and claims asserted in the complaint. suggests there is no clear benefit. (6,21,22,23) The collective published data suggests that the vast majority of dental treatments result in some degree of bacteremia; however, there is no evidence-based method to decide which procedures should require prophylaxis, because no data shows that the incidence, magnitude or duration of bacteremia from any dental procedure increase the risk of IE. In past regimens a pre-procedural use of chlorhexidine chlorhexidine /chlor·hex·i·dine/ (klor-heks´i-den) an antibacterial effective against a wide variety of gram-negative and gram-positive organisms; used also as the acetate ester, as a preservative for eyedrops, and as the gluconate or was recommended, but the current regimen does not recommend an antiseptic rinse because there is no evidence that demonstrates the practice will prevent IE.
POTENTIAL CONSEQUENCES OF CHANGES IN GUIDELINES
The AHA Committee's writing group recognized that changes in the new guidelines could be confusing to both practitioner and client, because they might violate longstanding expectations and practice patterns. The changes would likely cause concern among clients who previously received antibiotic prophylaxis before dental or other procedures and would now be advised that such prophylaxis is unnecessary. The Committee agrees that for 50 years, since the publication of the first AHA guidelines on the prevention of IE, clients and health-care providers assumed that antibiotics administered in association with a bacteremia-producing procedure effectively prevented IE in clients with underlying cardiac risk factors. Receiving antibiotic prophylaxis may have given clients with underlying cardiac defects a sense of reassurance and comfort that IE would be prevented. Oral health-care providers need to understand the reasons for the changes and communicate this information to those clients who are affected.
Part 1 of the discussion on antibiotic prophylaxis included a sample information sheet, which the BAS proposed to provide to clients, explaining the changes in the new recommendations. The AHA also has a client information sheet that can be printed and provided to clients explaining the changes in the new guidelines and identifying those clients who should have antibiotic prophylaxis prior to dental procedures (http://www.americanheart.org/presenter.jhtml?identifier=11086).
RECOMMENDED GUIDELINES FOR ANTIBIOTIC PROPHYLAXIS (1)
The cardiac conditions recommended for antibiotic prophylaxis prior to dental procedures include those that carry the highest risk of an adverse outcome from IE (Box 2). Although it has been reported that IV-drug users represent a group who are very likely to develop IE, the AHA Committee did not include this group in their 2007 recommendations. The AHA Committee recommendation is to be applied to "community-acquired" IE and endocarditis resulting from IV-drug use is not in this category. In the high-risk cardiac conditions identified by the new guidelines, dental procedures that require prophylaxis include all procedures that involve manipulation of gingival gingival (jin´jv tissue or the periapical region of teeth or perforation per·fo·ra·tion
1. The act of perforating or the state of being perforated.
2. An abnormal opening in a hollow organ or viscus, as one made by rupture or injury.
A hole. of the oral mucosa. The appropriate antibiotic should be administered in a single dose 30 minutes to one hour before the procedure. If the dose is inadvertently not taken before the dental appointment it may be administered up to two hours after the procedure. This should only be considered if the client failed to take the antibiotic prior to the appointment. Table 1 illustrates the antibiotics recommended for prophylaxis and alterations to the oral-dose regimen for individuals who cannot swallow oral-dose forms. Amoxicillin amoxicillin /amox·i·cil·lin/ (ah-mok?si-sil´in) a semisynthetic derivative of ampicillin effective against a broad spectrum of gram-positive and gram-negative bacteria.
n. is the preferred choice for oral therapy because it is well absorbed from the GI tract and provides a rapid and sustained serum concentration serum concentration Therapeutics The amount of a drug or other compound in the circulation, both bound to proteins and unbound, the latter of which generally corresponds to the theraepeutically active fraction of antibiotic. For situations in which the client is currently taking amoxicillin an alternate drug from a different class in Table 1 should be selected for prophylaxis. The current regimen does not discuss situations in which multiple dental appointments are needed, however the AHA Committee states that waiting 10 days after an antibiotic has been taken may allow sufficient time for the usual oral flora to be reestablished. Applying this principle to multiple dental appointments for the individual at high risk of IE, spacing appointments 10 days apart can be considered, as well as selecting an antibiotic from a different class. For example, when treatment needs to be completed within a two-week time period and four quadrants of periodontal therapy are required (and no allergy to antibiotics is reported in the health history), amoxicillin is the drug of first choice for the initial appointment, followed by clindamycin for the second appointment of less than 10 days later, followed by a macrolide for the third appointment of less than 10 days later, and so on.
Other special situations addressed in the updated recommendations include avoiding intramuscular injections for IE prophylaxis when anticoagulant anticoagulant (ăn'tēkōăg`yələnt), any of several substances that inhibit blood clot formation (see blood clotting). medication is being taken (Class I, LOE A). In addition, clients who are scheduled to undergo cardiac surgery should have a careful preoperative pre·op·er·a·tive
Preceding a surgical operation.
preceding an operation.
the preparation of a patient before operation. dental evaluation and the recommended treatment should be completed, whenever possible, before cardiac valve cardiac valve
Any of the valves regulating the flow of blood through and from the heart, consisting of the aortic valve, the left and right atrioventricular valves, and the pulmonary valve. surgery or replacement or repair of coronary heart disease coronary heart disease: see coronary artery disease.
coronary heart disease
or ischemic heart disease
Progressive reduction of blood supply to the heart muscle due to narrowing or blocking of a coronary artery (see atherosclerosis). (CHD CHD coronary heart disease.
Latin Chirurgiae Doctor (Doctor of Surgery)
n.pr See disease, coronary heart.
canine hip dysplasia. ). There is no evidence that coronary artery bypass graft surgery Coronary Artery Bypass Graft Surgery Definition
Coronary artery bypass graft surgery is a surgical procedure in which one or more blocked coronary arteries are bypassed by a blood vessel graft to restore normal blood flow to the heart. is associated with a long-term risk of infection, therefore, antibiotic prophylaxis for dental procedures is not necessary in clients who have undergone this surgery. As well, antibiotic prophylaxis prior to dental procedures is not recommended for clients with coronary artery coronary artery
1. An artery with origin in the right aortic sinus; with distribution to the right side of the heart in the coronary sulcus, and with branches to the right atrium and ventricle, including the atrioventricular branches and stents (Class III, LOE C). However, endocarditis in a client with a heart transplant is associated with a high risk of adverse outcome, (24) so antibiotic prophylaxis is recommended for clients who develop valvular valvular /val·vu·lar/ (val´vu-ler) pertaining to, affecting, or of the nature of a valve.
Relating to, having, or operating by means of valves or valvelike parts. dysfunction after transplantation.
The Committees concluded major changes in the updated guidelines that include the following: (1) only an extremely small number of cases of IE might be prevented by antibiotic prophylaxis prior to dental procedures even if such prophylactic therapy were 100-percent effective; (2) IE prophylaxis for dental procedures should be recommended only for clients with underlying cardiac conditions associated with the highest risk of adverse outcome from IE; (3) when these underlying cardiac conditions are present, antibiotic prophylaxis is recommended for all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa; (4) prophylaxis is not recommended based solely on an increased lifetime risk of acquisition of IE; (5) bacteremia resulting from daily activities is much more likely to cause IE than bacteremia associated with a dental procedure; and (6) administration of antibiotics solely to prevent endocarditis is not recommended for clients who undergo genitourinary- or gastrointestinal-tract procedures. The Committees reaffirmed those procedures noted in the 1997 prophylaxis guidelines for which endocarditis prophylaxis is not recommended and extended this prohibition to other common procedures, including ear and body piercing body piercing Body image A disruption of a mucocutaneous surface with jewelry or dangling artifices. See Tattoos. , tattooing, and vaginal delivery and hysterectomy hysterectomy (hĭstərĕk`təmē), surgical removal of the uterus. A hysterectomy may involve removal of the uterus only or additional removal of the cervix (base of the uterus), fallopian tubes (salpingectomy), and ovaries . In former recommendations the AHA Committee used the term "bacterial endocarditis bacterial endocarditis
Infectious endocarditis caused by the direct invasion of bacteria and leading to deformity of the heart valves.
bacterial endocarditis " because the antibiotic regimen only covered bacteria, not fungi or nonbacterial cardiac infections. For the first time, the 2007 guidelines terminology was changed to "infective endocarditis" as this is a currently accepted term for the condition.
DIFFERENCES FROM THE BRITISH ANTIMICROBIAL SOCIETY RECOMMENDATIONS
The AHA and BAS regimens are very similar. The cardiac conditions recommended for prophylaxis are similar in both sets of guidelines, however the BAS does not include congenital cardiac conditions nor the heart-transplant client who develops valvular dysfunction. The AHA continues to recommend a two-gram single dose of amoxicillin, whereas the BAS now recommends a three-gram single dose. The AHA does not address multiple dental visits, while the BAS recommends a regimen when multiple dental visits are needed. The AHA does recommend spacing dental appointments 10 days apart to avoid antibiotic resistance and to select an antibiotic from another class when the client is currently taking an antibiotic in the regimen. The AHA does not include a pre-procedure antiseptic mouthrinse in their new guidelines, whereas the BAS recommends this practice. Both sets of guidelines stress the importance of oral health and that clients with cardiac disease should be educated to maintain periodontal and dental health to reduce the risk of IE.
In the past, it was assumed that taking an antibiotic prior to dental procedures would reduce the formation of a bacteremia and reduce the risk for IE, however no evidence-based studies have verified this assumption. The collective published evidence suggests that antibiotic prophylaxis, if it is effective, would reduce the condition in only a very few cases. The majority of IE cases caused by oral microflora microflora /mi·cro·flo·ra/ (-flor´ah) the microscopic vegetable organisms of a special region.
The bacterial population in the intestine. likely develop from routine daily activities, such as chewing, toothbrushing, flossing flossing,
n the mechanical cleansing of interproximal tooth surfaces with stringlike, waxed or unwaxed dental floss or tape.
n. and using toothpicks. Dental and periodontal disease Periodontal Disease Definition
Periodontal diseases are a group of diseases that affect the tissues that support and anchor the teeth. Left untreated, periodontal disease results in the destruction of the gums, alveolar bone (the part of the jaws where may increase the risk of bacteremia and maintaining good oral health is felt to be important to reduce IE. The AHA Committee recognizes a shift is needed away from antibiotic prophylaxis and toward a greater emphasis on improved access to dental care in order to eliminate oral infection and on maintaining good periodontal health in individuals with underlying cardiac conditions associated with the highest risk of IE.
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one of the voices of cattle. Usually refers to the arrogant call of the bull used to announce territorial rights. Abnormalities of the voice include hoarseness as in rabies, or continuous repetition as in nervous acetonemia. See also low, moo. MT, Breese BB, Kuttner AG, McCarty M, Rammelkamp CH (Committee on Prevention of Rheumatic Fever and Bacterial Endocarditis, American Heart Association). Prevention of rheumatic fever and bacterial endocarditis through control of streptococcal infections Streptococcal Infections Definition
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3. Wannamaker LW, Denny FW, Diehl A, Jawetz E, Kirby WMM WMM Windows Movie Maker (Microsoft)
WMM Women Make Movies (New York, NY non profit feminist film productions)
WMM Wireless Multimedia
WMM World Magnetic Model
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8. van der Meer Van der Meer is a Dutch surname that simply means the phrase 'from the lake' in English. Many years ago, descendants would have lived from a lake in the Netherlands which is how the name first originated. JTM JTM Je T'aime (French: I Love You)
JTM Job Transfer & Manipulation
JTM Joint Technical Manual
JTM Jackass the Movie (movie)
JTM Jack T. , van Wijk W, Thompson J, Vandenbroucke JP. Efficacy of antibiotic prophylaxis for prevention of nativevalve endocarditis. Lancet 1992;339:135-39.
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21. MacFarlane MacFarlane or Macfarlane is a surname shared by:
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Heart transplantation, also called cardiac transplantation, is the replacement of a patient's diseased or injured heart with a healthy donor heart. : 10 cases and a review of the literature. Transpl Infect Dis 2004;6:165-70.
By Frieda Pickett, RDH RDH
Registered Dental Hygienist
n an abbreviation for registered dental hygienist. , MS
Class 1: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is beneficial, useful and effective. Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment. Class lla: Weight of evidence/opinion is in favor of usefulness/efficacy. Class llb: Usefulness/efficacy is less well established by evidence/opinion. Class III: Conditions for which there is evidence and/or general agreement that a procedure/treatment is not useful/effective and in some cases may be harmful. Level of Evidence (LOE): LOE A: Data derived from multiple randomized clinical trials or meta-analyses. LOE B: Data derived from a single randomized trial or nonrandomized studies. LOE C: Only consensus opinion of experts, case studies, or standard of care. Source: Wilson W et al. J Am Dent Assoc 2007; 1 38(6):740 Box 1. ACC/AHA classification of recommendations and levels of evidence Prosthetic cardiac valve Previous history of IE Congenital heart disease (CHD) * Unrepaired cyanotic CHD, including palliative shunts and conduits * Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the procedure * Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit epithelialization) Cardiac transplantation recipients who develop cardiac valvulopathy Source: Wilson et al. Prevention of Infective Endocarditis. Circulation May 8, 2007:10. Box 2. High-risk cardiac conditions for which prophylaxis prior to dental procedures is recommended Situation Antibiotic Adult dose* Child dose* Able to take oral amoxicillin 2 g 50 mg/kg med Unable to take Ampicillin 2 g IM or IV 50 mg/kg IM or IV oral med Cefazolin or 1 g IM or IV 50 mg/kg IM or IV ceftriaxone Allergic to Clindamycin or 600 mg 20 mg/kg penicillin-- Azithromycin or 500 mg 15 mg/kg able to take clarithromycin 2 g 50 mg/kg oral med Cephalexin+ Allergic to Clindamycin or 600 mg IM or 20 mg/kg IM or penicillin and Cefazolin or IV 1 g IM or IV IV 50 mg/kg IM or unable to take ceftriaxone+ IV oral med e*taken 30 to 60 min before dental procedure + do not use cephalosporin if individual has history of anaphylaxis, angioedema or urticaria with penicillin on thIM = intramuscular; IV = intravenous Source: Wilson et al. Prevention of Infective Endocarditis. Circulation. May 8, 2007:12. Table 1. Antibiotic Regimens for Dental Procedure in those at high-risk for IE