APPENDIX

PROPHYLAXIS OF BACTERIAL ENDOCARDITIS IN PATIENTS WITH CONGENITAL OR ACQUIRED HEART DISEASE
(in agreement with the recommendations of the "American Heart Association", Circulation 1997; 96: 358-366)

The infection of one or several structures of the heart could result from the passage into the bloodstream of a few germs after some medical procedures. A few forms of heart disease have a higher risk of developing endocarditis versus the general population.

THOSE PATIENTS WHO SHOULD PERFORM THE PROPHYLAXIS

High-risk patients: moderate-risk patients:
valvular prosthesis, including

Patency of arterial duct, defect of bioprosthesis and interventricular homografts atrioventricular canal, surgical pulmonary systemic shunts valvular disease, bicuspid aortic valve valvulated ducts obstructive hypertrophic cardiomyopathy.
Complex congenital cyanogenic heart diseases Prolapse of mitral valve with heart failure (situations of single ventricle), Fallot tetralogy, congenital traumatic A-V fistulae Surgical transposition of the large arteries (hemodialysis) Previous bacterial endocarditis

MEDICAL PROCEDURES WHERE THE PROPHYLAXIS SHOULD BE CARRIED OUT

dental apparatus:

Tooth extractions
Periodontal procedures, professional dental hygiene, smoothing of the roots, parodontal probing
Dental implantation, re-implantation of avulsed teeth
Channel treatments, apical surgery

Subgengival positioning of antibiotic fibers or strips
Initial application of orthodontic bands (not of the attachments)
Intraligamental injection of local anesthetic agents

Respiratory system:

Tonsillectomy and/or adenoidectomy
Surgical interventions involving the respiratory mucous membranes
Bronchoscopy with rigid bronchoscope

Gastrointestinal apparatus:

Sclerotherapy for esophageal varices
Dilation of esophageal stenoses
Retrograde endoscopic cholangiography with biliary obstruction
Surgery on the bileways
Surgical interventions involving the intestinal mucous membrane

Urogenital system

Prostatic surgery
Cystoscopy
Urethral dilation

DRUGS TO BE EMPLOYED

In case of procedures on teeth, mouth, airways or esophagus:

Standard: Amoxicillina 50 mg/Kg (massimo 2 g) per os, one hour before the procedure.

In patients allergic to penicillin: Clindamycin 20 mg/Kg (max 600 mg) per os, one hour before the procedure, or Cefalexin or Cefadroxil 50 mg/Kg (max 2 g) per os, one hour before the procedure, or Azitromycin or Clarithromycin 15 mg/Kg (max 500 mg) per os, one hour before the procedure.

Patients unable to take drugs per os: Ampicillin 50 mg/Kg (max 2 g) i.m. or i.v. 30 minutes before the procedure.

Patients unable to take drugs per os and allergic to penicillin: Clindamycin 20 mg/Kg (max 600) i.v. 30 minutes before the procedure, or Cefazolin 25 mg/Kg (max 1 g) i.m. or i.v. 30 minutes before the procedure

In case of urogenital and gastrointestinal procedures (excluding the esophageal ones):

A) High-risk patients: Ampicillin 50 mg/Kg (max 2 g) i.m. or i.v. plus Gentamycin 1.5 mg/Kg (max 120 mg). The administration should be completed 30 minutes before the beginning of the procedure. Six hours after the first dose, Ampicillin 25 mg/Kg (max 1 g) i.m. or i.v. or Amoxicillin 25 mg/Kg per os.

High-risk patients allergic to ampicillin/amoxicillin.
Vancomycin 20 mg/Kg (max 1 g) i.v. in 1-2 hours plus gentamycin 1.5 mg/Kg (max 120 mg) i.m. or i.v. The administration should be completed 30 minutes before the beginning of the procedure.

B) Moderate-risk patients. Amoxicillin 50 mg/Kg (max 2 g) per os one hour before the procedure or ampicillin 50 mg/Kg (max 2 g) i.m. or i.v. 30 minutes before the procedure.

Moderate-risk patients and patients allergic to ampicillin/amoxicillin.
Vancomycin 20 mg/Kg (max 1 g) i.v. in 1-2 hours. The infusion should be completed 30 minutes before the procedure.

PROCEDURES NOT REQUIRING THE PROPHYLAXIS

Dental apparatus

Conservative dentistry and injection of local anesthetic agents
Positioning of pins
Positioning of a rubber dam
Removal of post-operative sutures
Dental casts
Positioning of removable orthodontic appliances
Treatments with fluorine
Intraoral radiography

Adjustments of orthodontic appliances
Fall of deciduous teeth

Respiratory system

Tracheal intubation
Bronchoscopy with flexible bronchoscope, with or without biopsy*
Introduction of a tympanostomic tube

Gastrointestinal system

Trans-esophageal echocardiography *
Endoscopy with or without gastrointestinal biopsy*

Urogenital system

Intravaginal hysterectomy*
Vaginal delivery*

Caesarean section if tissues are not infected
Urethral catheterization
Dilation and revision of uterine cavity
Therapeutic abortion

Procedures of sterilization

Application or removal of intrauterine devices (IUD)

Other

Cardiac catheterization including balloon valvuloplasty
Pacemaker implantation of implantable defibrillators and coronary stents
Skin cut or biopsy, circumcision

* the prophylaxis is optional for high-risk patients

CARDIAC CONDITIONS NOT REQUIRING THE PROPHYLAXIS
(low risk, equal to the one the general population)

Interatrial defect type isolated ostium secundum
Interatrial defect, interventricular defect, patency of arterial ductus repaired surgically without residues, 6 months after surgery
Previous coronary by-pass surgery
Prolapse of the mitral valve without heart failure
Previous Kawasaki disease without valvular dysfunction
Previous rheumatic disease without valvular dysfunction
Pacemakers (intravascular and epicardic), implantable defibrillators.

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