Red Flags
- New murmur with fever in patient with prosthetic valve, prior IE, or unrepaired cyanotic congenital heart disease — admit; blood cultures × 3, echocardiography, urgent cardiology[1]
- Suspected IE during dental or invasive procedure period — culture and treat early; multidisciplinary review[1]
- Heart-brain embolic event in IE — emergency MDT (cardiology, cardiac surgery, neurology); valve surgery often indicated despite stroke[1]
- Prophylaxis failure or recurrent IE — investigate dental/other portals; cardiology and cardiothoracic surgery; oral health intensification[1]
First-line treatment
Interventions
- NICE position — antibiotic prophylaxis NOT routinely offered[1]NICE CG64 (2008, updated 2016) does not recommend routine antibiotic prophylaxis to prevent IE for dental or non-dental procedures, regardless of cardiac risk; emphasise oral hygiene as primary prevention. NB: 2016 update permits prophylaxis to be considered for specified high-risk individuals on case-by-case basis after shared decision making
- Oral health as primary prevention[1]Twice-yearly dental review, daily brushing and flossing, treat periodontitis and dental caries proactively; daily bacteraemia from poor oral hygiene exceeds procedure-related risk
- Discuss benefits and risks with high-risk patients[1]Patients with prosthetic valves, prior IE, congenital heart disease at risk should have informed discussion. NICE notes lack of definitive evidence either way; if patient values prophylaxis, discuss with cardiologist
- Patient and family education[1]Wallet card with cardiac risk status; counsel about red-flag symptoms (fever, weight loss, night sweats, new heart murmur) requiring same-day cardiology review with blood cultures BEFORE empiric antibiotic
- Avoid unnecessary procedures and reduce bacteraemia risk[1]Limit cardiac catheterisation in unprotected aortic stenosis where alternative imaging suffices; avoid IV drug use; manage piercings/tattoos with hygienic practice; daily oral hygiene throughout life
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Amoxicillin (selected high-risk, shared decision-making)[1] | Aminopenicillin | 3 g PO 30–60 min before procedure (NICE-permitted dose where prophylaxis selected by shared decision making) | Per local protocol | Used in patients who choose prophylaxis after informed discussion; NICE 2016 update permits this; use of higher 3 g dose was traditional UK practice |
| Clindamycin (penicillin allergy alternative)[1] | Lincosamide | 600 mg PO 30–60 min before procedure | 20 mg/kg PO (max 600 mg) | Where prophylaxis chosen and penicillin allergic; AHA 2021 update has moved toward azithromycin alternative due to C. difficile signal — UK practice variable |
| Azithromycin (penicillin allergy alternative)[1] | Macrolide | 500 mg PO 30–60 min before procedure | 15 mg/kg PO (max 500 mg) | Alternative for severe penicillin allergy with anaphylaxis history; QTc caution with concurrent QT-prolonging agents |
Amoxicillin (selected high-risk, shared decision-making)[1]
Aminopenicillin
- Adult
- 3 g PO 30–60 min before procedure (NICE-permitted dose where prophylaxis selected by shared decision making)
- Paediatric
- Per local protocol
Used in patients who choose prophylaxis after informed discussion; NICE 2016 update permits this; use of higher 3 g dose was traditional UK practice
Clindamycin (penicillin allergy alternative)[1]
Lincosamide
- Adult
- 600 mg PO 30–60 min before procedure
- Paediatric
- 20 mg/kg PO (max 600 mg)
Where prophylaxis chosen and penicillin allergic; AHA 2021 update has moved toward azithromycin alternative due to C. difficile signal — UK practice variable
Azithromycin (penicillin allergy alternative)[1]
Macrolide
- Adult
- 500 mg PO 30–60 min before procedure
- Paediatric
- 15 mg/kg PO (max 500 mg)
Alternative for severe penicillin allergy with anaphylaxis history; QTc caution with concurrent QT-prolonging agents
Safety-net
- Daily oral hygiene and regular dental review prevent more endocarditis than any antibiotic — make these your priority[1]
- Tell every dentist, GP, surgeon, and pharmacist about your prosthetic valve, prior IE, or congenital heart disease — informs procedure planning[1]
- Unexplained fever, fatigue, weight loss, or new heart murmur — same-day medical review with blood cultures BEFORE empiric antibiotic[1]
Referral criteria
- Suspected infective endocarditisCardiology with blood cultures, echocardiogram, infectious diseases[1]
- Pre-cardiac surgery or pre-prosthetic valve placementDental review for clearance and oral health optimisation[1]
- High-risk patient seeking informed prophylaxis discussionCardiology and dentistry shared decision-making review[1]
- Penicillin allergy requiring documentation/de-labellingAllergy clinic for risk assessment and possible delabelling[1]
Clinical summary
Risk-based antibiotic prophylaxis and oral health for adults at high risk of infective endocarditis undergoing dental and other procedures (NICE pathway).