Antibiotic Premedication (Cardiac Conditions)

Added to Handbook: February 2010
Updated: February 2016

PURPOSE

To provide guidelines on antibiotic premedication for clients with specific cardiac conditions.

BACKGROUND

Current medical practice indicates that dental clients who are at risk for infective endocarditis (IE) should have prophylactic antibiotic premedication prior to specific dental procedures, including procedures regularly performed by dental hygienists during the assessment, implementation and evaluation phases of clinical client care. Regimens updated and published by the American Heart Association (2007) are adopted as the standard for prophylactic antibiotic premedication.

Registrants are encouraged to visit the following websites for current guidelines on antibiotic premedication:

Following consideration of a client's medical status and any co-morbidities that may increase their risk of infection, a client's cardiologist, physician, or dentist may prescribe prophylactic antibiotic premedication for clients with heart conditions prior to specific dental procedures.

Current indications for prophylactic antibiotics include a client with a history of any of the following:

  1. A prosthetic cardiac valve or prosthetic material used for a cardiac valve repair
  2. A history of infective endocarditis
  3. Certain heart conditions present from birth including:
    1. unrepaired or incompletely repaired cyanotic congenital heart disease, including those with palliative shunts and conduits.
    2. a completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention. In this case, prophylactic antibiotics are only required during the first six months after the procedure.
    3. any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device.
  4. A cardiac transplantation that develops cardiac valvulopathy (valve disorder or disease).

Current contra-indications for prophylactic antibiotics include a client with a history of:

  • Mitral valve prolapse
  • Rheumatic heart disease
  • Bicuspid valve disease
  • Calcified aortic stenosis
  • Congenital heart conditions such as ventricular septal defect, atrial septal defect and hypertrophic cardiomyopathy
  • Surgical repair of atrial septal defect, ventricular septal defect or patent ductus arteriosus (without residue beyond 6 months)
  • Previous coronary artery bypass surgery
  • Heart murmurs
  • Previous Kawasaki disease
  • Cardiac pacemakers and implanted defibrillators (intravascular and epicardial)
  • Coronary artery disease

When prophylactic antibiotics are recommended, the following dental hygiene procedures are considered to have the greatest potential to produce a bacteremia (i.e. procedures which manipulate the gingival tissues and which may cause bleeding and the presence of viable bacteria in the blood):

  • Periodontal procedures including surgery, scaling, root planing and probing
  • Intraligamentary anesthesia injections
  • Subgingival placement of antiobiotic fibres or strips
  • Polishing of teeth or implants, where bleeding is anticipated
  • Initial placement of orthodontic bands, but not brackets

Prophylactic antibiotics are not recommended for the following dental hygiene procedures:

  • Local anesthesia injections (other than intraligamentary)
  • Placement of rubber dam
  • Suture removal
  • Placement of removable prosthodontic or orthodontic appliances
  • Impressions
  • Intra-oral radiographs

The current prophylactic regimens (2007) are:

Regimen: Single Dose 30-60 min Before Procedure
Situation Agent Adults Children
Oral Amoxicillin 2g 50mg/kg
Unable to take oral medication Ampicillin 2g IM or IV 50mg/kg IM or IV
OR    
Cefazolin or ceftriaxone 1g IM or IV 50mg/kg IM or IV
Allergic to penicillin or ampicillin - oral Cephalexin*✝ 2g 50mg/kg
OR    
Clindamycin 600mg 20mg/kg
OR    
Azithromycin or clarithromycin 500mg 15mg/kg
Allergic to penicillins or ampicillin and unable to take oral medication Cefazolin or ceftriaxone✝ 1g IM or IV 50 mg/kg IM or IV
OR    
Clindamycin 600mg IM or IV 20 mg/kg IM or IV

IM indicates intramuscular; IV, intravenous
*Or other first-or second-generation oral cephalosporin in equivalent adult or pediatric dosage
✝Cephalosporins should not be used in an individual with a history of anaphylaxis, angioedema, or urticaria with penicillins or ampicillin.

From: Wilson et al. Prevention of Endocarditis, Circulation 2007;116;1736-1754; originally published online Apr 19, 2007

Timing of Antibiotic Administration

An antibiotic for prophylaxis of a cardiac condition should be administered in a single dose before the procedure. If the dosage of antibiotic is inadvertently not administered before the procedure, the dosage may be administered up to 2 hours after the procedure. However, administration of the dosage after the procedure should be considered only when the client did not receive the pre-procedure dose (Wilson et al., 2007). Therefore, this protocol should be reserved for emergency situations and may not be used simply for the convenience of the office or the dental hygienist.

POLICY

In order to meet CDHBC Practice Standards, dental hygienists are required to use current knowledge in their practice and to assess the client to determine whether special precautions are necessary. Ideally dental hygienists will consult with the client's cardiologist to determine the need for antibiotic prophylaxis prior to invasive dental hygiene procedures. If the dental hygienist is unable to consult with the cardiologist, a collaborative approach with the client's physician or dentist should take place to determine the client's need. Should the physician or dentist elect to take responsibility for making this determination, the direction provided must be clearly documented in the client's chart.

If a determination recommending antibiotic prophylaxis is made in a dental office setting, it is recommended that a letter be provided to the client to take to their treating physician informing them of the prophylactic coverage and directions that were provided.

REFERENCES

  • American Academy Of Paediatric Dentistry. Guideline On Antibiotic Prophylaxis For Dental Patients At Risk For Infection [Internet]. 2014. [cited 2016 February 17]. Available from:
    AAPD Antibiotic Prophylaxis (pdf)
  • Wilson W Et Al. American Heart Association Guideline: Prevention Of Infective Endocarditis. Circulation. 2007: 116:1736-1754. Available from:
    AHA Prevention of Infective Endocarditis (pdf)