**YES** **Antibiotic prophylaxis for** **endocarditis** **MAY BE required.** **See Box 2.** | **NO** | **Antibiotic prophylaxis for** endocarditis **NOT required.** | | :--- | :--- | **Surgical Antimicrobial Prophylaxis Guidelines** **Appendix 2:** Antibiotic Prophylaxis for Prevention of Endocarditis in High Risk Patients **Preoperative Considerations** Antibiotic prophylaxis to prevent endocarditis is **ONLY recommended for patients with cardiac conditions associated with the HIGHEST RISK** of adverse outcomes from endocarditis (See Box 1) and only for certain procedures (See Box 2). **Box 1:** **Cardiac conditions for which antibiotic prophylaxis to prevent endocarditis is recommended** > Prosthetic heart valve, including mechanic, bioprosthetic, and homograft valves (transcatheter-implanted as well as surgically implanted) > Prosthetic material used for cardiac valve repair (e.g. annuloplasty rings and chords) > Previous infective endocarditis > Cardiac transplantation with the subsequent development of cardiac valvulopathy (consult cardiologist) > Rheumatic heart disease in all populations > Congenital heart disease, only if it involves: >> i) unrepaired cyanotic defects, including palliative shunts and conduits; >> ii) repaired defects with residual defects at or adjacent to the site of a prosthetic patch or device (which inhibit endothelialisation). **Box 2:** **Procedures where antibiotic prophylaxis for endocarditis may or may not be required** | | | | :--- | :--- | | **Endocarditis Prophylaxis ALWAYS REQUIRED** | **Endocarditis Prophylaxis IS NOT REQUIRED** (list is not exhaustive) | | **DENTAL PROCEDURES:** > Procedures involving manipulation of the gingival or periapical tissue or perforation of the oral mucosa (e.g. tooth extraction, matrix band placement, subgingival rubber dam and clamp, implant placement, biopsy, removal of soft tissue or bone, subgingival scaling and root planning, replanting avulsed teeth, apicectomy, six-point pocket charting in diseased tissue, root canal treatment before establishment of an apical stop) **RESPIRATORY TRACT OR EAR, NOSE & THROAT PROCEDURES:** > tonsillectomy/ adenoidectomy > any invasive procedure to treat an established infection (e.g. drainage of abscess) **GENITOURINARY AND GASTROINTESTINAL PROCEDURES:** > any genitourinary procedure in the presence of a genitourinary infection unless already treating enterococci (for elective cystoscopy or urinary tract manipulations, obtain a urine culture and treat any bacteriuria beforehand) > any gastrointestinal procedure in the presence of infection or colonisation unless already treating enterococci > sclerotherapy for oesophageal varices. **OTHER PROCEDURES:** > Procedures involving infected skin, skin structures or musculoskeletal tissues (e.g. incision and drainage of local abscess, epidural, lung, orbital, perirectal, pyogenic liver) > Percutaneous endoscopic gastrostomy, PEJ | **ALL OTHER DENTAL PROCEDURES NOT LISTED IN GREEN BOX:** > oral examination > infiltration and block local anaesthetic injection through non-infected tissue > restorative dentistry > supragingival rubber dam clamping and placement of rubber dam > intracanal endodontic procedures > removal of sutures > impressions and construction of dentures > orthodontic bracket placement and adjustment of fixed appliances > application of gels > dental radiography > supragingival plaque removal **RESPIRATORY TRACT OR EAR, NOSE & THROAT PROCEDURES:** > endotracheal intubation > rigid or flexible bronchoscopy with or without incision or biopsy > transoesophageal echocardiography **GENITOURINARY AND GASTROINTESTINAL PROCEDURES:** > urethral catheterisation > transervical procedures (e.g. uterine dilation and curettage, sterilisation procedures, insertion or removal of intrauterine device) > obstetric procedures including surgical termination of pregnancy > endoscopy (with or without gastrointestinal biopsy including colonoscopy) | ![](R7 Surgical Antibiotic Prophylaxis_figures/img_927b1a493850e207.webp) ![](R7 Surgical Antibiotic Prophylaxis_figures/img_aeed4870422428a0.webp) **YES** **Antibiotic prophylaxis for** **endocarditis** **MAY BE required.** **See Box 2.** | **NO** | **Antibiotic prophylaxis for** endocarditis **NOT required.** | | :--- | :--- | **Surgical Antimicrobial Prophylaxis Guidelines** **Appendix 2:** Antibiotic Prophylaxis for Prevention of Endocarditis in High Risk Patients **Preoperative Considerations** Antibiotic prophylaxis to prevent endocarditis is **ONLY recommended for patients with cardiac conditions associated with the HIGHEST RISK** of adverse outcomes from endocarditis (See Box 1) and only for certain procedures (See Box 2). **Box 1:** **Cardiac conditions for which antibiotic prophylaxis to prevent endocarditis is recommended** > Prosthetic heart valve, including mechanic, bioprosthetic, and homograft valves (transcatheter-implanted as well as surgically implanted) > Prosthetic material used for cardiac valve repair (e.g. annuloplasty rings and chords) > Previous infective endocarditis > Cardiac transplantation with the subsequent development of cardiac valvulopathy (consult cardiologist) > Rheumatic heart disease in all populations > Congenital heart disease, only if it involves: >> i) unrepaired cyanotic defects, including palliative shunts and conduits; >> ii) repaired defects with residual defects at or adjacent to the site of a prosthetic patch or device (which inhibit endothelialisation). **Box 2:** **Procedures where antibiotic prophylaxis for endocarditis may or may not be required** | | | | :--- | :--- | | **Endocarditis Prophylaxis ALWAYS REQUIRED** | **Endocarditis Prophylaxis IS NOT REQUIRED** (list is not exhaustive) | | **DENTAL PROCEDURES:** > Procedures involving manipulation of the gingival or periapical tissue or perforation of the oral mucosa (e.g. tooth extraction, matrix band placement, subgingival rubber dam and clamp, implant placement, biopsy, removal of soft tissue or bone, subgingival scaling and root planning, replanting avulsed teeth, apicectomy, six-point pocket charting in diseased tissue, root canal treatment before establishment of an apical stop) **RESPIRATORY TRACT OR EAR, NOSE & THROAT PROCEDURES:** > tonsillectomy/ adenoidectomy > any invasive procedure to treat an established infection (e.g. drainage of abscess) **GENITOURINARY AND GASTROINTESTINAL PROCEDURES:** > any genitourinary procedure in the presence of a genitourinary infection unless already treating enterococci (for elective cystoscopy or urinary tract manipulations, obtain a urine culture and treat any bacteriuria beforehand) > any gastrointestinal procedure in the presence of infection or colonisation unless already treating enterococci > sclerotherapy for oesophageal varices. **OTHER PROCEDURES:** > Procedures involving infected skin, skin structures or musculoskeletal tissues (e.g. incision and drainage of local abscess, epidural, lung, orbital, perirectal, pyogenic liver) > Percutaneous endoscopic gastrostomy, PEJ | **ALL OTHER DENTAL PROCEDURES NOT LISTED IN GREEN BOX:** > oral examination > infiltration and block local anaesthetic injection through non-infected tissue > restorative dentistry > supragingival rubber dam clamping and placement of rubber dam > intracanal endodontic procedures > removal of sutures > impressions and construction of dentures > orthodontic bracket placement and adjustment of fixed appliances > application of gels > dental radiography > supragingival plaque removal **RESPIRATORY TRACT OR EAR, NOSE & THROAT PROCEDURES:** > endotracheal intubation > rigid or flexible bronchoscopy with or without incision or biopsy > transoesophageal echocardiography **GENITOURINARY AND GASTROINTESTINAL PROCEDURES:** > urethral catheterisation > transervical procedures (e.g. uterine dilation and curettage, sterilisation procedures, insertion or removal of intrauterine device) > obstetric procedures including surgical termination of pregnancy > endoscopy (with or without gastrointestinal biopsy including colonoscopy) | Flowchart decision tree for determining antibiotic prophylaxis requirements. The central node asks 'Does the patient have any of the conditions listed in box 1?'. A 'YES' path leads to a green box stating 'Antibiotic prophylaxis for endocarditis MAY BE required. See Box 2.' A 'NO' path leads to a pinkish box stating 'Antibiotic prophylaxis for endocarditis NOT required.' Table titled 'Box 2: Procedures where antibiotic prophylaxis for endocarditis may or may not be required'. It is split into two columns: 'Endocarditis Prophylaxis ALWAYS REQUIRED' (green header) and 'Endocarditis Prophylaxis IS NOT REQUIRED' (pink header). The table lists specific medical procedures under categories such as DENTAL PROCEDURES, RESPIRATORY TRACT OR EAR, NOSE & THROAT PROCEDURES, GENITOURINARY AND GASTROINTESTINAL PROCEDURES, and OTHER PROCEDURES. ```html <table border="1"> <tr> <th rowspan="2" style="width: 15%">Procedure</th> <th rowspan="2" style="width: 35%">Recommended Prophylaxis</th> <th rowspan="2" style="width: 35%">Penicillin / Cephalosporin Allergy</th> </tr> <tr> <th></th> </tr> <tr> <td>Dental procedures</td> <td>amoxicillin 2g orally (child: 50mg/kg up to 2g) 60 minutes prior to procedure</td> <td rowspan="3"></td> </tr> <tr> <td>Tonsillectomy</td> <td>OR if oral administration not possible: amoxicillin 2g IV (child: 50mg/kg up to 2g)</td> <td rowspan="6">^ Moderate risk penicillin allergy: cefalexin 2g orally (child: 50mg/kg up to 2g) 60 minutes prior to procedure OR if oral administration not possible: cefazolin 2g IV (child: 30mg/kg up to 2g) *High risk penicillin/cephalosporin allergy: clindamycin 600mg orally (child: 20mg/kg up to 600mg) 60 to 120 minutes prior to procedure OR if oral administration not possible: clindamycin 600mg IV infusion (child: 20mg/kg up to 600mg)</td> </tr> <tr> <td>Adenoidectomy</td> <td></td> </tr> <tr> <td>All other procedures</td> <td>amoxicillin 2g IV (child: 50mg/kg up to 2g)</td> <td>vancomycin 1g IV infusion (1.5g for adult patients more than 80kg actual body weight) (child: 30mg/kg up to 1.5g)#</td> </tr> <tr> <td></td> <td></td> <td></td> </tr> <tr> <td></td> <td></td> <td></td> </tr> <tr> <td></td> <td></td> <td></td> </tr> <tr> <td></td> <td></td> <td></td> </tr> </table> AMS Antimicrobial Stewardship ID Infectious Diseases PO Per oral Definitions / Acronyms DRESS Drug rash with eosinophilia and systemic symptoms IV Intravenous SJS / TEN Stevens-Johnson syndrome / Toxic epidermal necrolysis ^ Moderate risk penicillin allergy: History suggestive of moderate risk (e.g. delayed rash which is NOT urticarial or DRESS/SJS/TEN) *High risk penicillin/cephalosporin allergy: History suggestive of high risk (e.g. anaphylaxis, angioedema, bronchospasm, urticaria, DRESS/SJS/TEN) #For patients colonised or infected with vancomycin-resistant enterococci, seek advice from ID about an appropriate regimen References Antibiotic Expert Groups (2019). Therapeutic Guidelines: Antibiotic. Version 16. Melbourne, Therapeutic Guidelines Limited. Australian Injectable Drugs Handbook (2020) 8th ed. Collingwood, VIC (online). Bakhsh, A, et al (2020). "A review of guidelines for antibiotic prophylaxis before invasive dental treatments." Applied Sciences 11,311: 1-11. Glenny AM, Oliver R, et al (2013). "Antibiotics for the prophylaxis of bacterial endocarditis in dentistry". Cochrane Database of Systematic Reviews, Issue 10. Art. No.:CD003813. DOI: 10.1002/14651858.CD003813.pub4. Habib G, Lancelotti P, Antunes MJ, et al (2015). "ESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Eur Heart J. 36:3075-128 Nishimura, RA., et al (2017). "AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Report of theAmerican College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 70 (2): 252-89. Sexton DJ., Chu VH (2020). "Antimicrobial prophylaxis for bacterial endocarditis". In: Otto, C (ed), UpToDate, Waltham, WA. [www.uptodate.com] Accessed February 2021 Wilson, W., et al (2007). " Prevention of infective endocarditis: guidelines from the American Heart Association ". Circulation 116 (15): 1736-54. RHD Australia (ARF/RHD writing group). The 2020 Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (3rd ed); 2020. Endorsed by South Australian expert Advisolr Group on Antibiotic Resistance (SAAGAR). Last reviewed and amended December 2021. SAAGAR has endeavoured to ensure that the information in this publication is accurate at the time of writing; however, it makes no representation or warranty to this effect. SAAGAR disclaims all liability for any claims, losses, damages, costs and expenses suffered or incurred as a result of reliance on this publication. ``` ![](R7 Surgical Antibiotic Prophylaxis_figures/img_74c2392a1599a63f.webp) ```html <table border="1"> <tr> <th rowspan="2" style="width: 15%">Procedure</th> <th rowspan="2" style="width: 35%">Recommended Prophylaxis</th> <th rowspan="2" style="width: 35%">Penicillin / Cephalosporin Allergy</th> </tr> <tr> <th></th> </tr> <tr> <td>Dental procedures</td> <td>amoxicillin 2g orally (child: 50mg/kg up to 2g) 60 minutes prior to procedure</td> <td rowspan="3"></td> </tr> <tr> <td>Tonsillectomy</td> <td>OR if oral administration not possible: amoxicillin 2g IV (child: 50mg/kg up to 2g)</td> <td rowspan="6">^ Moderate risk penicillin allergy: cefalexin 2g orally (child: 50mg/kg up to 2g) 60 minutes prior to procedure OR if oral administration not possible: cefazolin 2g IV (child: 30mg/kg up to 2g) *High risk penicillin/cephalosporin allergy: clindamycin 600mg orally (child: 20mg/kg up to 600mg) 60 to 120 minutes prior to procedure OR if oral administration not possible: clindamycin 600mg IV infusion (child: 20mg/kg up to 600mg)</td> </tr> <tr> <td>Adenoidectomy</td> <td></td> </tr> <tr> <td>All other procedures</td> <td>amoxicillin 2g IV (child: 50mg/kg up to 2g)</td> <td>vancomycin 1g IV infusion (1.5g for adult patients more than 80kg actual body weight) (child: 30mg/kg up to 1.5g)#</td> </tr> <tr> <td></td> <td></td> <td></td> </tr> <tr> <td></td> <td></td> <td></td> </tr> <tr> <td></td> <td></td> <td></td> </tr> <tr> <td></td> <td></td> <td></td> </tr> </table> AMS Antimicrobial Stewardship ID Infectious Diseases PO Per oral Definitions / Acronyms DRESS Drug rash with eosinophilia and systemic symptoms IV Intravenous SJS / TEN Stevens-Johnson syndrome / Toxic epidermal necrolysis ^ Moderate risk penicillin allergy: History suggestive of moderate risk (e.g. delayed rash which is NOT urticarial or DRESS/SJS/TEN) *High risk penicillin/cephalosporin allergy: History suggestive of high risk (e.g. anaphylaxis, angioedema, bronchospasm, urticaria, DRESS/SJS/TEN) #For patients colonised or infected with vancomycin-resistant enterococci, seek advice from ID about an appropriate regimen References Antibiotic Expert Groups (2019). Therapeutic Guidelines: Antibiotic. Version 16. Melbourne, Therapeutic Guidelines Limited. Australian Injectable Drugs Handbook (2020) 8th ed. Collingwood, VIC (online). Bakhsh, A, et al (2020). "A review of guidelines for antibiotic prophylaxis before invasive dental treatments." Applied Sciences 11,311: 1-11. Glenny AM, Oliver R, et al (2013). "Antibiotics for the prophylaxis of bacterial endocarditis in dentistry". Cochrane Database of Systematic Reviews, Issue 10. Art. No.:CD003813. DOI: 10.1002/14651858.CD003813.pub4. Habib G, Lancelotti P, Antunes MJ, et al (2015). "ESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Eur Heart J. 36:3075-128 Nishimura, RA., et al (2017). "AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Report of theAmerican College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 70 (2): 252-89. Sexton DJ., Chu VH (2020). "Antimicrobial prophylaxis for bacterial endocarditis". In: Otto, C (ed), UpToDate, Waltham, WA. [www.uptodate.com] Accessed February 2021 Wilson, W., et al (2007). " Prevention of infective endocarditis: guidelines from the American Heart Association ". Circulation 116 (15): 1736-54. RHD Australia (ARF/RHD writing group). The 2020 Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (3rd ed); 2020. Endorsed by South Australian expert Advisolr Group on Antibiotic Resistance (SAAGAR). Last reviewed and amended December 2021. SAAGAR has endeavoured to ensure that the information in this publication is accurate at the time of writing; however, it makes no representation or warranty to this effect. SAAGAR disclaims all liability for any claims, losses, damages, costs and expenses suffered or incurred as a result of reliance on this publication. ``` A table titled 'Recommended Prophylaxis' with columns for Procedure, Recommended Prophylaxis, and Penicillin / Cephalosporin Allergy. It lists procedures such as Dental procedures, Tonsillectomy, Adenoidectomy, and All other procedures, along with their corresponding antibiotic regimens. The Penicillin / Cephalosporin Allergy column provides alternative dosages for moderate and high-risk allergies. [^1]: Original PDF page 1: [[R7 Surgical Antibiotic Prophylaxis.pdf#page=1|R7 Surgical Antibiotic Prophylaxis, p.1]] [^2]: Original PDF page 2: [[R7 Surgical Antibiotic Prophylaxis.pdf#page=2|R7 Surgical Antibiotic Prophylaxis, p.2]]