Endocarditis prophylaxis

Antibiotic prophylaxis to prevent endocarditis is a controversial area. While NICE advises against any routine use of prophylaxis against endocarditis, European (ESC) and American (AHA) guidelines restrict the use to the population with highest risk.

High-risk individuals are [NICE]

• acquired valvular heart disease with stenosis or regurgitation
• valve replacement
• structural congenital heart disease, including surgically corrected or palliated structural conditions, but excluding isolated atrial septal defect, fully repaired ventricular septal defect or fully repaired patent ductus arteriosus, and closure devices that are judged to be endothelialised
• previous infective endocarditis
• hypertrophic cardiomyopathy.

Advise to the patients

  • Risk and benefit of prophylaxis; why prophylaxis is not routinely available.

  • Maintain good oral health.

  • Symptoms that indicate endocarditis, and to seek expert advice.

  • risks of undergoing invasive procedures, including non-medical procedures such as body piercing or tattooing.

Prophylaxis

  • Routine antibiotic prophylaxis is not recommended

  • Chlorhexidine mouthwash should not be offered as prophylaxis.

In cases of infection

  • Any infection in patients with endocarditis should be promptly identified and treated.

  • If a person at risk of endocarditis is receiving antibiotic because they are undergoing a genitourinary/gastrointestinal procedure at a site with infection - antibiotic should cover potential endocarditis pathogens.

Combining NICE, AHA and ESC

Individuals with a high risk of endocarditis:

  1. Valvular heart disease

  • Acquired valvular heart disease with stenosis or regurgitation.

  • Cardiac valvulopathy in a cardiac transplant recipient. [AHA recommendation]

  • Prosthetic heart valve, including transcatheter-implanted prostheses and homograft.

  • Structural congenital heart disease -
    - Patients with cyanotic congenital heart defects.
    - Patients for the first six months after surgical or percutaneous repair of congenital heart disease [excluding isolated atrial septal defect] with a prosthetic material - palliative shunts, conduits or other prostheses (indefinitely in case of a residual shunt or valvular regurgitation).

  • Previous infective endocarditis

  • hypertrophic cardiomyopathy

Following conditions are not associated with risk of endocarditis

• isolated atrial septal defect
• repaired ventricular septal defect
• repaired patent ductus arteriosus
• closure devices that are judged to be endothelialised.

Patients with prosthetic valve endocarditis have higher rates of in-hospital mortality compared with those with native valve endocarditis

ESC

Risk groups


Antibiotic prophylaxis is not recommended for patients at intermediate risk of IE, i.e. any other form of native valve disease (including the most commonly identified conditions: bicuspid aortic valve, mitral valve prolapse and calcific aortic stenosis)