Indications for endocarditis prophylaxis

Antibiotic prophylaxis against infective endocarditis is recommended only for patients who meet both of the following criteria:

have a cardiac condition associated with an increased risk of developing infective endocarditis and the highest risk of adverse outcomes from endocarditis (see here)
are undergoing a procedure associated with a high risk of a bacteraemia that is associated with endocarditis (see here).

A printable version of these recommendations is available here.

Endocarditis prophylaxis is not recommended for situations other than those covered in this topic.

Figure 1. Cardiac conditions for which endocarditis prophylaxis is recommended for patients undergoing a procedure listed in the figure below

Endocarditis prophylaxis is recommended only for patients with the following cardiac conditions (that are associated with an increased risk of developing infective endocarditis and the highest risk of adverse outcomes from endocarditis) who are undergoing a procedure listed below [NB1] [NB2]:

prosthetic cardiac valve, including transcatheter-implanted prosthesis or homograft
prosthetic material used for cardiac valve repair, such as annuloplasty rings and chords
previous infective endocarditis
congenital heart disease but only if it involves:
- unrepaired cyanotic defects, including palliative shunts and conduits
- repaired defects with residual defects at or adjacent to the site of a prosthetic patch or device (which inhibit endothelialisation)
rheumatic heart disease [NB3].

Note:

NB1: Endocarditis prophylaxis is not recommended for patients with forms of valvular or structural heart disease not listed in this box, including patients with mitral valve prolapse, septal defects or cardiac implantable electronic devices.

NB2: Patients with a heart transplant who have developed cardiac valvulopathy may also be at high risk of adverse outcomes from endocarditis; consult the patient’s cardiologist for specific recommendations.

NB3: See text below for discussion of patients with rheumatic heart disease.

Figure 2. Procedures for which endocarditis prophylaxis is recommended for patients with a cardiac condition listed in the figure above.

[NB1]

Endocarditis prophylaxis is recommended only for patients with a cardiac condition listed above who are undergoing one of the following procedures associated with a high risk of a bacteraemia that is associated with infective endocarditis:

Dental procedures —only those involving manipulation of the gingival or periapical tissue or perforation of the oral mucosa (eg extraction, implant placement, biopsy, removal of soft tissue or bone, subgingival scaling and root planing, replanting avulsed teeth).
Dermatological or musculoskeletal procedures —only those involving infected skin, skin structures or musculoskeletal tissues.
Respiratory tract or ear, nose and throat procedures —only for tonsillectomy or adenoidectomy, or invasive respiratory tract or ear, nose and throat procedures to treat an established infection (eg drainage of abscess).
Genitourinary and gastrointestinal tract procedures—only if surgical antibiotic prophylaxis is required or for patients with an established infection [NB2].

Note:

NB1: Endocarditis prophylaxis is not recommended for procedures other than those covered in this topic. However, surgical prophylaxis may be indicated even if endocarditis prophylaxis is not—see Surgical antibiotic prophylaxis for specific procedures.

NB2: In these guidelines, obstetric procedures (eg caesarean section) are not considered to be genitourinary procedures.

Infective endocarditis prophylaxis was previously only recommended for rheumatic heart disease in Aboriginal and Torres Strait Islander peoples or considered for those at significant socioeconomic disadvantage. However, studies have demonstrated that rheumatic heart disease is an independent risk factor for infective endocarditis and adverse outcomes from this disease. As such, it is now recommended that all patients with rheumatic heart disease be offered prophylaxis when undergoing certain procedures. Ensure the diagnosis of rheumatic heart disease has been confirmed on echocardiography to avoid unnecessary use of antibiotics in patients with normal valves or nonrheumatic valvular heart disease.