Guidelines for the prevention of Infective endocarditis with antibiotic prophylaxis

Contents
1. Contact details
2

2. Cardiac conditions for which prophylaxis is recommended 3 3. Cardiac conditions for which prophylaxis is 3 not recommended 4. Procedures for which prophylaxis is recommended
4.1 Prophylaxis in patients already on antibiotic therapy 4.2 Dental procedures 4.3 Respiratory tract procedures 4.4 Gastrointestinal tract procedures 4.5 Genitourinary tract procedures 4.6 Procedures involving infected skin, skin structures or musculoskeletal tissue

4 4 4 5 5 6 6 7

5. Prophylactic antibiotics

1. Contact details
Phone Medical enquiries Consultant Microbiologists Dr E Smyth Prof H Humphreys Dr F Fitzpatrick Ext 2017 Ext 3312 Ext 2938 Ext 2667/3320/3321 Bleep 319/443/323 Out of hours Consultant-on-call via switch Pharmacy enquiries Antimicrobial Senior Pharmacist Ms. Sarah Foley Bleep 046 sarahfoley2@beaumont.ie E mail edmondsmyth@beaumont.ie hilaryhumphreys@beaumont.ie fidelmafitzpatrick@beaumont.ie

Registrars office

*Please refer to the Antibiotic Prophylaxis in Surgery Guidelines for further information on appropriate antibiotic prophylaxis in surgical procedures **These guidelines have been devised by the Beaumont Hospital Antimicrobial Stewardship Committee in conjunction with the Beaumont Hospital Department of Cardiology and are based on the 2007 Prevention of infective endocarditis Guidelines from the American Heart Association (Circulation 2007;116:17361754) and the 2009 Guidelines from the European Society of Cardiology on the prevention, diagnosis and treatment of infective endocarditis (Eur Heart J. 2009 Aug 27)

2. Cardiac conditions for which endocarditis prophylaxis is recommended

1. Prosthetic cardiac valve (including bioprosthetic and homograft valves) or prosthetic material used for cardiac valve repair. 2. Previous bacterial endocarditis. 3. Serious congenital heart conditions including Unrepaired or incompletely repaired cyanotic congenital heart disease, including those with palliative shunts and conduits. Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or catheter intervention, during the first six months after the procedure. Following Patent Foramen Ovale (PFO) repair, during the first 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 endothelialisation). 4. Cardiac transplant recipients who develop cardiac valvulopathy. 5. Following left atrial appendage occlusion, during the first six months after the procedure.

3. Cardiac conditions for which endocarditis prophylaxis is not recommended

Moderate risk uncorrected cyanotic heart disease including Patent ductus arteriosius Ventricular septal defect Primum atrial septal defect Coarctation of the aorta* Bicuspid aortic valve Calcified aortic stenosis Acquired valvular dysfunction (Rheumatic heart disease) Hypertrophic cardiomyopathy Mitral valve prolapse with regurgitation and/or thickened leaflets *Contact cardiologist prior to prophylaxis

4. Procedures for which prophylaxis is recommended

4.1 Prophylaxis in patients already on antibiotic therapy
1. If a patient is already receiving long term antibiotic therapy with an antibiotic that is also recommended for prophylaxis, an antibiotic from a different class should be chosen for prophylaxis (Contact Microbiology for advice). 2. Patients receiving iv antibiotic therapy for the treatment of infective endocarditis should have the timing of the antibiotic dose adjusted to be administered 30 to 60 minutes before a procedure for which prophylaxis is required to ensure optimal serum concentrations.

4.2 Dental procedures requiring prophylaxis

Maintenance of optimal oral health and hygiene may reduce the incidence of bacteraemia from daily activities and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of IE. 1. All dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa* *the following procedures do not require prophylaxis: Routine anaesthetic injections through non - infected tissue Taking dental radiographs Placement of removable prosthodontic or orthodontic appliances Adjustment of orthodontic appliances Placement of orthodontic brackets Shedding of deciduous teeth Bleeding from trauma to the lips or oral mucosa

4.3 Respiratory tract procedures requiring prophylaxis

1. Invasive procedures of the respiratory tract that involve incision or biopsy of the respiratory mucosa e.g. tonsillectomy and adenoidectomy. 2. Prophylaxis only required for bronchoscopy if the procedure involves incision of the respiratory tract mucosa/biopsy. 3. Antibiotic regimens to treat patients undergoing drainage of an abscess or an empyema should include an agent active against viridans group streptococci (Contact Microbiology for advice).

4.4 Gastrointestinal tract/biliary tract procedures requiring prophylaxis

1. Prophylaxis is not recommended for any patient undergoing diagnostic oesophagogastroduodenoscopy, colonoscopy or sigmoidoscopy. 2. Patients with an established GI infection or those receiving antibiotic therapy to prevent surgical site (wound) infection or sepsis associated with a GI procedure should be given an antibiotic regimen that includes an antibiotic active against enterococci (Contact Microbiology for advice).

4.5 Genitourinary tract procedures requiring prophylaxis

1. Sterile urine Prophylaxis is not recommended for patients undergoing routine GU tract procedures. Antibiotic treatment to eradicate enterococci from urine before the procedure is advised in the case of elective cystoscopy or other urinary tract manipulation. (Contact Microbiology for advice)

2. Enterococcal UTI or colonization

3. Gram negative UTI

4. Urine culture results unknown If the procedure is not elective, the empiric antimicrobial regimen administered to the patient should contain an agent active against enterococci (Contact Microbiology for advice).

4.6 Procedures involving infected skin, skin structures or musculoskeletal tissue that require prophylaxis
1. No evidence of infection 2. Evidence of infected skin, skin structures or musculoskeletal tissue Prophylaxis not required Patients should be given an antibiotic regimen that contains an agent active against staphylococci and -haemolytic streptococci (Contact Microbiology for advice).

5. Prophylactic antibiotics
Regimen Single dose given 3060 minutes before the procedure
Adults Amoxicillin Amoxicillin or Clindamycin Clindamycin or Azithromycin Clindamycin* 3g PO 2g IM or IV 600mg IM or IV 600mg PO 500mg PO 600mg IM or IV Children 50mg/kg PO 50mg/kg IM or IV 20mg/kg IM or IV 20mg/kg PO 15mg/kg PO 20mg/kg IM or IV

Situation

Agent

Oral

Unable to take oral medications

Allergic to penicillins (oral)

Allergic to penicillin and unable to take oral medication

*Contact microbiology for advice on prophylactic antibiotic choice if allergic to Clindamycin