PREVENTION OF BACTERIAL-ENDOCARDITIS - RECOMMENDATIONS BY THE AMERICAN-HEART-ASSOCIATION

Objective. To update recommendations issued by the American Heart Asso ciation last published in 1990 for the prevention of bacterial endocar ditis in individuals at risk for this disease. Participants. An ad hoc writing group appointed by the American Heart Association for their e xpertise in endocarditis and treatment with liaison members representi ng the American Dental Association, the Infectious Diseases Society of America, the American Academy of Pediatrics, and the American Society for Gastrointestinal Endoscopy. Evidence. The recommendations in this article reflect analyses of relevant literature regarding procedure-r elated endocarditis, in vitro susceptibility data of pathogens causing endocarditis, results of prophylactic studies in animal models of end ocarditis, and retrospective analyses of human endocarditis cases in t erms of antibiotic prophylaxis usage patterns and apparent prophylaxis failures. MEDLINE database searches from 1936 through 1996 were done using the root words endocarditis, bacteremia, and antibiotic prophyla xis. Recommendations in this document fall into evidence level III of the US Preventive Services Task Force categories of evidence. Consensu s Process. The recommendations were formulated by the writing group af ter specific therapeutic regimens were discussed. The consensus statem ent was subsequently reviewed by outside experts not affiliated with t he writing group and by the Science Advisory and Coordinating Committe e of the American Heart Association. These guidelines are meant to aid practitioners but are not intended as the standard of care or as a su bstitute for clinical judgment. Conclusions. Major changes in the upda ted recommendations include the following: 1) emphasis that most cases of endocarditis are not attributable to an invasive procedure; 2) car diac conditions are stratified into high-, moderate-, and negligible-r isk categories based on potential outcome if endocarditis develops; 3) procedures that may cause bacteremia and for which prophylaxis is rec ommended are more clearly specified; 4) an algorithm was developed to more clearly define when prophylaxis is recommended for patients with mitral valve prolapse; 5) for oral or dental procedures the initial am oxicillin dose is reduced to 2 g, a follow-up antibiotic dose is no lo nger recommended, erythromycin is no longer recommended for penicillin -allergic individuals, but clindamycin and other alternatives are offe red; and 6) for gastrointestinal or genitourinary procedures, the prop hylactic regimens have been simplified. These changes were instituted to more clearly define when prophylaxis is or is not recommended, impr ove practitioner and patient compliance, reduce cost and potential gas trointestinal adverse effects, and approach more uniform worldwide rec ommendations.