ACC/AHA: Fewer patients require prophylaxis for endocarditis

Clinical Question

Who should receive prophylaxis against infective endocarditis?

Bottom Line

Most patients going to the dentist no longer require prophylaxis. The new American College of Cardiology/American Heart Association guidelines for the prevention of endocarditis greatly reduces the groups of patients who require prophylaxis and decreases the number of procedures that require prophylaxis. See the full summary for specific recommendations. These new guidelines are a significant departure from decades of complex decision making and regimens that were not based on quality research. They also no longer jibe with European Society of Cardiology guidelines. (LOE = 2a)


Nishimura RA, Carabello BA, Faxon DP, et al. ACC/AHA 2008 guideline update on valvular heart disease: Focused update on infective endocarditis: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J A Coll Cardiol 2008;52(8):676-685.  [PMID:18702976]

Study Design

Practice guideline




Various (guideline)


This report is an update of the 2006 guideline issued by the same groups on the role of prophylaxis to prevent endocarditis in at-risk patients. This revision is based on accumulated published and unpublished data evaluated by an expert group and subjected to peer review. The major change in directive is to treat only the groups with the highest risk of adverse outcomes from endocarditis, not simply everyone with a higher lifetime risk of developing endocarditis. The update: The task force nixed endocarditis prophylaxis for most patients and most dental procedures. Only patients with prosthetic cardiac valves or prosthetic material used for valve repair, patients with previous infective endocarditis, patients with congenital heart disease, and cardiac transplant patients with valve regurgitation should receive prophylaxis, and only if the dental procedure involves manipulation of the gingival tissue or periapical region of the teeth, or perforation of the oral mucosa. Patients who do not require prophylaxis include those who have undergone valve repair without prosthetic material, patients with hypertrophic cardiomyopathy with obstruction, and patients with mitral valve prolapse, as well as whose who receive routine anesthetic injections or radiographs, and those who have bleeding from trauma to the lips or oral mucosa. Prophylaxis is not recommended for nondental procedures, such as transesophageal echocardiogram, and gastrointestinal or genitourinary procedures. Prophylactic regimens for dental procedures include a single dose of amoxicillin or cephalexin (2 g in adults, 50 mg/kg in children), clindamycin (600 mg or 20 mg/kg), or azithromycin or clarithromycin (500 mg or 15 mg/kg).