|IIa||C-LD||Prophylaxis against IE is reasonable before dental procedures that involve manipulation of gingival tissue, manipulation of the periapical region of teeth, or perforation of the oral mucosa in patients with the following (13,15,23–29):|
1. Prosthetic cardiac valves, including transcatheter-implanted prostheses and homografts.
2. Prosthetic material used for cardiac valve repair, such as annuloplasty rings and chords.
3. Previous IE.
4. 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.
5. Cardiac transplant with valve regurgitation due to a structurally abnormal valve.
|MODIFIED: LOE updated from B to C-LD. Patients with transcatheter prosthetic valves and patients with prosthetic material used for valve repair, such as annuloplasty rings and chords, were specifically identified as those to whom it is reasonable to give IE prophylaxis. This addition is based on observational studies demonstrating the increased risk of developing IE and high risk of adverse outcomes from IE in these subgroups. Categories were rearranged for clarity to the caregiver.|
|See Online Data Supplements 1 and 2.|
|The risk of developing IE is higher in patients with underlying VHD. However, even in patients at high risk of IE, evidence for the efficacy of antibiotic prophylaxis is lacking. The lack of supporting evidence, along with the risk of anaphylaxis and increasing bacterial resistance to antimicrobials, led to a revision in the 2007 AHA recommendations for prophylaxis limited to those patients at highest risk of adverse outcomes with IE (11). These included patients with a history of prosthetic valve replacement, patients with prior IE, select patients with congenital heart disease, and cardiac transplant recipients. IE has been reported to occur after TAVR at rates equal to or exceeding those associated with surgical aortic valve replacement (AVR) and is associated with a high 1-year mortality rate of 75% (30,31). IE may also occur after valve repair in which prosthetic material is used, usually necessitating urgent operation, which has high in-hospital and 1-year mortality rates (32,33). IE appears to be more common in heart transplant recipients than in the general population, according to limited data (23). The risk of IE is highest in the first 6 months after transplantation because of endothelial disruption, high-intensity immunosuppressive therapy, frequent central venous catheter access, and frequent endomyocardial biopsies (23). Persons at risk of developing bacterial IE should establish and maintain the best possible oral health to reduce potential sources of bacterial seeding. Optimal oral health is maintained through regular professional dental care and the use of appropriate dental products, such as manual, powered, and ultrasonic toothbrushes; dental floss; and other plaque-removal devices.|