Antibiotic Premedication (Cardiac Conditions)

Added to Handbook: February 2010
Updated: February 2018

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 and the American College of Cardiology Foundation (2017) are adopted as the standard for prophylactic antibiotic premedication within this interpretation guideline.
 
Registrants are encouraged to visit the following websites for current guidelines on antibiotic premedication:
              
               The American Heart Association: www.americanheart.org
               The American College of Cardiology: www.acc.org
               The Canadian Dental Association: www.cda-adc.ca
               The American Dental Association: www.ada.org      
              
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, prior to dental/dental hygiene procedures that involve manipulation of gingival tissue or the periapical region of teeth, and/or perforation of the oral mucosa, are for clients with a history of any of the following:1
 

  • Prosthetic cardiac valves, including transcatheter implanted prostheses and homografts.
  • Prosthetic material used for cardiac valve repair, such as annuloplasty rings and chords.
  • Previous infective endocarditis.
  • Unrepaired cyanotic congenital heart disease or repaired congenital heart disease, with residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch or prosthetic device.
  • Cardiac transplant with valve regurgitation due to a structurally abnormal valve. 

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 antibiotic fibers 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 through non-infected tissues (other than intraligamentary)
  • Placement of rubber dam
  • Suture removal
  • Placement of removable prosthodontic or orthodontic appliances
  • Adjustment of orthodontic appliances
  • Impressions
  • Intra-oral radiographs


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.2 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. 

Clients Already Receiving Antibiotics
The 2007 guidelines state that if the client is already taking an antibiotic that is recommended for IE for another reason, rather than increasing the dose, an antibiotic from a different class should be prescribed.2
 
Prophylactic Regimen:2
Situation Agent Regimen - Single Dose 30 - 60 minutes before procedure
Oral Amoxicillin Adults: 2.0 g
Children: 50 mg/kg 
orally, 1 hour before procedure
Unable to take oral medication Ampicillin or
Cefazolin or Ceftriaxone
Adults: 2.0 g IM or IV* (ampicillin) 1.0 g IM or IV (cefazoline or ceftriaxone)
Children: 50 mg/kg IM or IV
30 minutes prior to procedure
Allergy to oral penicillin or ampicillin Cephalexin**✝ Adults: 2.0 g
Children: 50 mg/kg
orally, 1 hour before procedure
Clindamycin Adults: 600 mg
Children: 20 mg/kg
orally, 1 hour before procedure
Azithromycin or Clarithromycin Adults: 500 mg
Children: 15 mg/kg
orally, 1 hour before procedure
Allergic to penicillin or ampicillin
and unable to take oral medication
Cefazolin or Ceftriaxone✝ Adults: 1.0 g IM or IV
Children: 50 mg/kg IM or IV
30 minutes before procedure
Clindamycin Adults: 600mg IV
Children: 20 mg/kg
IM or IV 30 minutes before procedure
*IM indicates intramuscular; IV, intravenous
**Or other first or second generation oral cephalosporin in equivalent adult or pediatric dosages
Cephalosporins should not be used with individuals with a history of anaphylaxis, angioedema or urticaria, to penicillins or ampicillin
From: Wilson et al. Prevention of Endocarditis, Circulation 2007;116;1736-1754; originally published online April 19, 2007. Available from: http://circ.ahajournals.org/content/116/15/1736.full.pdf+html  


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.
 
It is recommended that the dental hygiene professional encourage clients who are at high risk for developing infective endocarditis to maintain optimal oral health to prevent bacterial seeding. This is through oral hygiene instruction to ensure effective home oral self-care and through regular professional dental hygiene maintenance appointments. Dental hygiene appointments must also ensure strict infection prevention and control measures are upheld.

REFERENCES

  1. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP 3rd, Fleisher LA, Jneid H, Mack MJ, McLeod CJ, O’Gara PT, Rigolin VH, Sundt TM 3rd, Thompson A. 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task force on Clinical Practice Guidelines. J Am Coll Cardiol 2017;70:252-89. Available from: http://www.onlinejacc.org/content/accj/70/2/252.full.pdf  
 
  1. Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et al. Prevention of infective endocarditis: Guidelines 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;116:1736-1754. Available from: http://circ.ahajournals.org/content/116/15/1736.full.pdf+html 
 
  1. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP III, Guyton RA, O’Gara PT, Ruiz CE, Skubas NJ, Soraiga P, Sundt TM III, Thomas JD, 2014 AHA/ACC guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014;129:2440-2492. Available from: http://circ.ahajournals.org/content/129/23/2440.long
 
  1. American Academy of Pediatric Dentistry. Clinical Practice Guidelines, Council on Clinical Affairs. Guideline on antibiotic prophylaxis for dental clients at risk for infection. Chicago (IL): American Academy of Pediatric Dentistry (AAPD); 2014;38 (6) 16/17 available from: http://www.aapd.org/assets/1/7/G_AntibioticProphylaxis1.PDF
 
  1. American Dental Association. Oral Health Topics: Antibiotic Prophylaxis Prior to Dental Procedures. [www.ada.org]. c 2017. Updated September 14, 2017. Available from: http://www.ada.org/en/member-center/oral-health-topics/antibiotic-prophylaxis