Infective endocarditis prevention

Red Flags

Patient with prosthetic valve, prior IE, or unrepaired cyanotic congenital heart disease undergoing high-risk dental procedure — confirm prophylaxis indication and regimen before procedure^[2]
Penicillin allergy with anaphylaxis history — choose macrolide alternative (azithromycin, clarithromycin); avoid clindamycin where alternatives available (C. difficile signal per ADA 2024)^[2]
Suspected odontogenic infection (facial swelling, dysphagia, drooling, trismus) — admit for IV antibiotic and surgical drainage; risk of airway compromise (Ludwig's angina)^[2]
Recurrent dental infection in immunocompromised or diabetic patient — investigate underlying cause; multidisciplinary care^[2]

First-line treatment

Interventions

Restrict prophylaxis to highest-risk patients^[2]
Same as AHA 2007: prosthetic valve, prior IE, unrepaired cyanotic congenital heart disease, repaired with residual defect, cardiac transplant valvulopathy. Lower-risk conditions no longer require routine prophylaxis
Limit prophylaxis to high-risk dental procedures^[2]
Gingival/periapical manipulation, oral mucosa perforation. Routine fillings, fluoride application, X-rays, orthodontic appliance adjustment do NOT require prophylaxis
Daily oral health and twice-yearly dental review as primary prevention^[2]
Brushing twice daily with fluoride toothpaste, daily flossing, twice-yearly dental review with prophylaxis cleaning; treat caries and periodontitis proactively; daily bacteraemia from poor oral hygiene exceeds procedural risk
Patient communication and shared decision making^[2]
Wallet card with cardiac status and prophylaxis regimen; counsel about red flags (fever, weight loss, new heart murmur); coordinate with cardiology for shared decisions in atypical cases

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
Amoxicillin (oral)^[2]	Aminopenicillin	2 g PO 30–60 min before procedure	50 mg/kg PO 30–60 min before procedure (max 2 g)	First-line; if missed, may give within 2 h post-procedure; 30–60 min timing maximises serum concentration during transient bacteraemia
Cephalexin (penicillin allergy without anaphylaxis)^[2]	First-generation cephalosporin	2 g PO 30–60 min before procedure	50 mg/kg PO (max 2 g)	Non-severe penicillin allergy; cross-reactivity rare; avoid in immediate hypersensitivity (urticaria, angioedema, anaphylaxis)
Azithromycin or clarithromycin (severe penicillin allergy)^[2]	Macrolide	500 mg PO 30–60 min before procedure	15 mg/kg PO (max 500 mg)	Severe penicillin allergy with anaphylaxis history; ADA 2024 update prefers macrolides over clindamycin (C. difficile signal); QTc caution with concurrent QT-prolonging agents
Doxycycline (alternative penicillin allergy)^[2]	Tetracycline	100 mg PO 30–60 min before procedure	Children >8 years: 2.2 mg/kg (max 100 mg)	Per AHA 2021/ADA 2024 update; alternative for severe penicillin allergy; avoid in pregnancy and children <8 years
Ampicillin (parenteral, when oral not possible)^[2]	Aminopenicillin	2 g IV/IM 30–60 min before procedure	50 mg/kg IV/IM (max 2 g)	Alternative if oral route unavailable; cefazolin or ceftriaxone same dose where penicillin not contraindicated

Amoxicillin (oral)^[2]

Aminopenicillin

Adult: 2 g PO 30–60 min before procedure
Paediatric: 50 mg/kg PO 30–60 min before procedure (max 2 g)

First-line; if missed, may give within 2 h post-procedure; 30–60 min timing maximises serum concentration during transient bacteraemia

Cephalexin (penicillin allergy without anaphylaxis)^[2]

First-generation cephalosporin

Adult: 2 g PO 30–60 min before procedure
Paediatric: 50 mg/kg PO (max 2 g)

Non-severe penicillin allergy; cross-reactivity rare; avoid in immediate hypersensitivity (urticaria, angioedema, anaphylaxis)

Azithromycin or clarithromycin (severe penicillin allergy)^[2]

Macrolide

Adult: 500 mg PO 30–60 min before procedure
Paediatric: 15 mg/kg PO (max 500 mg)

Severe penicillin allergy with anaphylaxis history; ADA 2024 update prefers macrolides over clindamycin (C. difficile signal); QTc caution with concurrent QT-prolonging agents

Doxycycline (alternative penicillin allergy)^[2]

Tetracycline

Adult: 100 mg PO 30–60 min before procedure
Paediatric: Children >8 years: 2.2 mg/kg (max 100 mg)

Per AHA 2021/ADA 2024 update; alternative for severe penicillin allergy; avoid in pregnancy and children <8 years

Ampicillin (parenteral, when oral not possible)^[2]

Aminopenicillin

Adult: 2 g IV/IM 30–60 min before procedure
Paediatric: 50 mg/kg IV/IM (max 2 g)

Alternative if oral route unavailable; cefazolin or ceftriaxone same dose where penicillin not contraindicated

Safety-net

Daily oral hygiene and twice-yearly dental review prevent more endocarditis than any antibiotic — make these your priority^[2]
Tell every clinician (dentist, GP, surgeon, pharmacist) about your prosthetic valve, prior IE, or congenital heart disease — informs procedure planning^[2]
Unexplained fever, fatigue, weight loss, or new heart murmur — same-day medical review with blood cultures BEFORE empiric antibiotic^[2]

Referral criteria

Suspected infective endocarditisCardiology with blood cultures, echocardiogram, infectious diseases^[2]
Pre-cardiac surgery or pre-prosthetic valve placementDental review for clearance and oral health optimisation^[2]
Recurrent IE despite optimal preventionTertiary cardiac and infectious diseases multidisciplinary team^[2]
Severe odontogenic infection or Ludwig's anginaEmergency department; oral and maxillofacial surgery for drainage^[2]

Clinical summary

Risk-based dental antibiotic prophylaxis and oral hygiene-focused prevention of infective endocarditis from the dental practice perspective.

References

1.ADA Council on Scientific Affairs Guideline on Use of Antibiotic Prophylaxis for Patients at Risk of Infection Associated with Dental Procedures (2015, with 2024 update) (2024)
2.ADA Guideline on Use of Antibiotic Prophylaxis for Patients at Risk of Infection Associated with Dental Procedures. Journal of the American Dental Association (2024)

Drug

Class

Adult

Paediatric

Notes

Amoxicillin (oral)^[2]

Aminopenicillin

2 g PO 30–60 min before procedure

50 mg/kg PO 30–60 min before procedure (max 2 g)

First-line; if missed, may give within 2 h post-procedure; 30–60 min timing maximises serum concentration during transient bacteraemia

Cephalexin (penicillin allergy without anaphylaxis)^[2]

First-generation cephalosporin

2 g PO 30–60 min before procedure

50 mg/kg PO (max 2 g)

Non-severe penicillin allergy; cross-reactivity rare; avoid in immediate hypersensitivity (urticaria, angioedema, anaphylaxis)

Azithromycin or clarithromycin (severe penicillin allergy)^[2]

Macrolide

500 mg PO 30–60 min before procedure

15 mg/kg PO (max 500 mg)

Severe penicillin allergy with anaphylaxis history; ADA 2024 update prefers macrolides over clindamycin (C. difficile signal); QTc caution with concurrent QT-prolonging agents

Doxycycline (alternative penicillin allergy)^[2]

Tetracycline

100 mg PO 30–60 min before procedure

Children >8 years: 2.2 mg/kg (max 100 mg)

Per AHA 2021/ADA 2024 update; alternative for severe penicillin allergy; avoid in pregnancy and children <8 years

Ampicillin (parenteral, when oral not possible)^[2]

Aminopenicillin

2 g IV/IM 30–60 min before procedure

50 mg/kg IV/IM (max 2 g)

Alternative if oral route unavailable; cefazolin or ceftriaxone same dose where penicillin not contraindicated

References

1.ADA Council on Scientific Affairs Guideline on Use of Antibiotic Prophylaxis for Patients at Risk of Infection Associated with Dental Procedures (2015, with 2024 update) (2024)

2.ADA Guideline on Use of Antibiotic Prophylaxis for Patients at Risk of Infection Associated with Dental Procedures. Journal of the American Dental Association (2024)