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Antibiotic Recommendations
LE T T E R S
TO
THE
E D IT O R
Antibiotic recommendations □ Cards are available from the American Heart Association for patients who re quire antibiotic prophylaxes when u n dergoing treatment. O n these cards, reg imens are listed for patients who require antibiotics for dental procedures, tonsil lectomy, or bronchoscopy, as well as for those patients with heart disease, bacte rial endocarditis, severe gingival disease,
Name
___________________________________
poor dental hygiene, rheumatic fever, or other conditions. Patients can also in d i cate allergies to penicillin. Each regimen recom m ended by the A m erican Heart A ssociation includes dosage and duration of administration of the antibiotic, and alternatives for pa tients allergic to penicillin. A number is a s s ig n e d to each re g im e n , a n d the num ber can be circled for easy reference by the dentist or physician.
ADULT SCHEDULE
Diagnosis: _________________________________________________
allergy? Yes
□
No Q Regimens recom m ended: For
dental or upper respiratory procedures
□ A-j
H. TODD WILLIAMSON. DDS PHILADELPHIA
PROPHYLAXIS FOR GU OR Gl SURGERY OR INSTRUMENTATION
D a t e _______
needs p ro te ctio n fro m bacterial endocarditis.
Penicillin
These cards can be folded into sizes that are convenient to carry in wallets. They can be obtained from the affiliate chapters (listed in local telephone d i rectories) of the American Heart Associa tion and distributed to patients w ho have special conditions or who are undergoing treatment.
□ A2
□ B
Augmented Intensified Regimens: For patie nts requiring prop h yla xis w h o are abo ut to underao low er gastrointestinal or gen ito u rin a ry procedures, o r w h o have obstetrical in fectio ns, o r in w h om one decides to "c o v e r” durin g c h ild b irth .
ADULT SCHEDULE
Aqueous crystalline p e n ic illin G (2,0 00,0 00 units I.M . o r I.V .) — or — A m p ic illin (1.0 gm I.V . or I.M .) — plus —
For patients w ho require p ro p h yla xis fo r dental procedures, tonsillec to m y , adenoidectom y, bronchoscopy, o r esophagoscopy w ith biopsy.
G entam icin (1.5 m g/kg, n o t to exceed 80 mg I.V . or I.M .) — or — S tre p to m ycin (1.0 gm I.M . o n ly)
□ C-j
OC2
For GI or GU procedures
Congenital and V a lvular Heart Disease Parenteral Oral Pe nicillin A llergy
DD
□
D
DE
In itia l dose 1 hou r before procedure. Repeat tw ice a t 8h ou r intervals if regimen contains gentam icin, or a t 12h ou r intervals if regimen contains s tre p to m ycin . N O TE: FO LLO W -UP DOSES M A Y H A V E TO BE AD JU S T E D IF R E N A L F U N C T IO N IS CO M PRO M ISED.
Prosthetic Heart Valve
Regimen A-j or B
Regimen B
Regimen A 2
Regimen B
Regimen C-j or C2
Regimen C 2
□
E
For patients allergic to penicillin. V a ncom ycin (1.0 gm I.V .) 1 hou r before procedure over 45 m inutes - plus S tre p to m ycin (1.0 gm 1.M).
Standard Regimens: For patients w ith congenital heart disease, rheum atic o r acquired val vular heart disease, and h yp e rtro p h ic subaortic stenosis.
Repeat 12 hours a fte r m ajor procedures. RE M IN D ER S Regimen A □
A^
- Penicillin Parenteral-O ral: Aqueous crystalline p e n icillin G (1,000,000 units) m ixed w ith procaine pen icillin G (600,000 units I.M .) 1 hour before the procedure; then pe n icillin V (500 mg o ra lly ) every 6 hours fo r 8 doses, or longer in the case o f delayed healing.
□
A2
O ral: p e n ic illin V (2.0 grams o ra lly ) 1 hou r p rio r to the procedure; then 500 mg o ra lly every 6 hours fo r 8 doses, o r longer in the case o f delayed healing.
□
C-j
For patients allergic to p e n ic illin . E ry th ro m y c in (1.0 gm o ra lly ) 1 -!4 to 2 hours before the procedure; then 500 mg p.o. every 6 hours fo r 8 doses, or longer in the case o f delayed healing.
Inten sified Regimens:
1.
N O P R O P H Y L A X IS is needed fo r: . . . shedding o f de cidu ou s teeth . . . sim p le a d ju s tm e n t o f o r th o d o n tic ap plia nce . . . liver o r bone m a rro w b io psy • . . cardiac c a th e te riz a tio n o r an gio grap hy . . . u n co m p lica te d secundum A S D . . pa te n t d u ctu s a fte r surgical rep air o r p o st-co ro n a ry a rte ry bypass w ith o u t valvu lar heart disease.
2
P ro p h yla xis m ay be in d ica te d in high risk p a tie n ts - especially those w ith p ro s th e tic valves fo r: . . . pe lvic e x a m in a tio n . . . u n com p lica te d vaginal d e liv e ry . . . ute rin e d ila tio n a n d cure tta ge . . u n co m p lica te d IU D in se rtio n or rem oval . . . G I endoscopy w ith o u t b io psy . . . p ro c to o r s ig m o id o scopy w ith o u t bio p sy . . . pa tie n ts w ith m itra l valve prolapse syn dro m e .
3.
Patients a t increased risk o f in fe c tiv e e n d o c a rd itis s h o u ld n o t take a n tib io tic s fo r m in o r illness, a n d sh o uld have a b lo o d c u ltu re done to e xclu de e n d o ca rd itis be fo re in s titu tin g a n tib io tic th erap y o f ba cte rial in fe c tio n .
4.
Patients w ith rh e u m a tic heart disease sh o uld be o n a regim en o f pro p h y la x is fo r pre ve n tion o f re cu rre n t g ro u p A strep to cocca l ph a ry n g itis in a d d itio n to these regim ens (C irc u la tio n 55.1 A 19771.
5.
M aintenance o f th e highest level o f ora l he a lth is im p o rta n t in p a tie n ts a t increased risk fo r e n d o ca rd itis. C om ple te eva lua tion and d e ntal re sto ra tio n s are in d ica te d b e fo re p ro s th e tic valve in s ertio n.
6
Physicians m ust prepare in advance if th ey plan to use th e p re ferred paren teral regim ens because pharm acies d o n o t usu a lly sto ck aqueous c ry s ta llin e p e n ic illin G , pro caine p e n ic illin G , s tre p to m y c in , o r g e n ta m ic in ; th e y can get these drugs w ith in 2 4 4 8 hours o n request.
7.
These re co m m en da tion s are based on th e 1977 sta tem e nt o f th e J o in t C o m m itte e (C irc u la tio n 5 6 .1 3 9 A , 1 9 7 7 ; J .A .D .A . 9 5 :6 0 0 , 19 77 ). R eco m m e nd atio ns regarding m o d ific a tio n o f subsequent doses of v a n co m ycin , s tre p to m y c in , and g e ntam icin fo r pa tien ts w ith renal fa ilu re m ay be fo u n d in C lin ica l N e p h ro lo g y , V o l. 7, pgs. 81 -84 , 1977.
For patients w ith pro sth e tic heart valves, previous endocarditis, severe gingival disease, p o o r dental hygiene o r on rheum atic fever prophylaxis. □
B
Regimen A-j plus stre p to m ycin 1 gm I.M . a t the tim e o f the in itia l injections.
□
C2
For patients allergic to p e n ic illin . V a ncom ycin (1 gm I.V .) 1 hou r before procedure over 45 m inutes, fo llo w e d by E ry th ro m y c in (500 mg o ra lly ) every 6 hours fo r 8 doses, or longer in the case o f delayed healing.
300 ■ JADA, Vol. 106, March 1983
Developed b y The A m erican H e art Association, Pennsylvania A ffilia te
TO
THE
E D IT O R
Antibiotic recommendations □ Cards are available from the American Heart Association for patients who re quire antibiotic prophylaxes when u n dergoing treatment. O n these cards, reg imens are listed for patients who require antibiotics for dental procedures, tonsil lectomy, or bronchoscopy, as well as for those patients with heart disease, bacte rial endocarditis, severe gingival disease,
Name
___________________________________
poor dental hygiene, rheumatic fever, or other conditions. Patients can also in d i cate allergies to penicillin. Each regimen recom m ended by the A m erican Heart A ssociation includes dosage and duration of administration of the antibiotic, and alternatives for pa tients allergic to penicillin. A number is a s s ig n e d to each re g im e n , a n d the num ber can be circled for easy reference by the dentist or physician.
ADULT SCHEDULE
Diagnosis: _________________________________________________
allergy? Yes
□
No Q Regimens recom m ended: For
dental or upper respiratory procedures
□ A-j
H. TODD WILLIAMSON. DDS PHILADELPHIA
PROPHYLAXIS FOR GU OR Gl SURGERY OR INSTRUMENTATION
D a t e _______
needs p ro te ctio n fro m bacterial endocarditis.
Penicillin
These cards can be folded into sizes that are convenient to carry in wallets. They can be obtained from the affiliate chapters (listed in local telephone d i rectories) of the American Heart Associa tion and distributed to patients w ho have special conditions or who are undergoing treatment.
□ A2
□ B
Augmented Intensified Regimens: For patie nts requiring prop h yla xis w h o are abo ut to underao low er gastrointestinal or gen ito u rin a ry procedures, o r w h o have obstetrical in fectio ns, o r in w h om one decides to "c o v e r” durin g c h ild b irth .
ADULT SCHEDULE
Aqueous crystalline p e n ic illin G (2,0 00,0 00 units I.M . o r I.V .) — or — A m p ic illin (1.0 gm I.V . or I.M .) — plus —
For patients w ho require p ro p h yla xis fo r dental procedures, tonsillec to m y , adenoidectom y, bronchoscopy, o r esophagoscopy w ith biopsy.
G entam icin (1.5 m g/kg, n o t to exceed 80 mg I.V . or I.M .) — or — S tre p to m ycin (1.0 gm I.M . o n ly)
□ C-j
OC2
For GI or GU procedures
Congenital and V a lvular Heart Disease Parenteral Oral Pe nicillin A llergy
DD
□
D
DE
In itia l dose 1 hou r before procedure. Repeat tw ice a t 8h ou r intervals if regimen contains gentam icin, or a t 12h ou r intervals if regimen contains s tre p to m ycin . N O TE: FO LLO W -UP DOSES M A Y H A V E TO BE AD JU S T E D IF R E N A L F U N C T IO N IS CO M PRO M ISED.
Prosthetic Heart Valve
Regimen A-j or B
Regimen B
Regimen A 2
Regimen B
Regimen C-j or C2
Regimen C 2
□
E
For patients allergic to penicillin. V a ncom ycin (1.0 gm I.V .) 1 hou r before procedure over 45 m inutes - plus S tre p to m ycin (1.0 gm 1.M).
Standard Regimens: For patients w ith congenital heart disease, rheum atic o r acquired val vular heart disease, and h yp e rtro p h ic subaortic stenosis.
Repeat 12 hours a fte r m ajor procedures. RE M IN D ER S Regimen A □
A^
- Penicillin Parenteral-O ral: Aqueous crystalline p e n icillin G (1,000,000 units) m ixed w ith procaine pen icillin G (600,000 units I.M .) 1 hour before the procedure; then pe n icillin V (500 mg o ra lly ) every 6 hours fo r 8 doses, or longer in the case o f delayed healing.
□
A2
O ral: p e n ic illin V (2.0 grams o ra lly ) 1 hou r p rio r to the procedure; then 500 mg o ra lly every 6 hours fo r 8 doses, o r longer in the case o f delayed healing.
□
C-j
For patients allergic to p e n ic illin . E ry th ro m y c in (1.0 gm o ra lly ) 1 -!4 to 2 hours before the procedure; then 500 mg p.o. every 6 hours fo r 8 doses, or longer in the case o f delayed healing.
Inten sified Regimens:
1.
N O P R O P H Y L A X IS is needed fo r: . . . shedding o f de cidu ou s teeth . . . sim p le a d ju s tm e n t o f o r th o d o n tic ap plia nce . . . liver o r bone m a rro w b io psy • . . cardiac c a th e te riz a tio n o r an gio grap hy . . . u n co m p lica te d secundum A S D . . pa te n t d u ctu s a fte r surgical rep air o r p o st-co ro n a ry a rte ry bypass w ith o u t valvu lar heart disease.
2
P ro p h yla xis m ay be in d ica te d in high risk p a tie n ts - especially those w ith p ro s th e tic valves fo r: . . . pe lvic e x a m in a tio n . . . u n com p lica te d vaginal d e liv e ry . . . ute rin e d ila tio n a n d cure tta ge . . u n co m p lica te d IU D in se rtio n or rem oval . . . G I endoscopy w ith o u t b io psy . . . p ro c to o r s ig m o id o scopy w ith o u t bio p sy . . . pa tie n ts w ith m itra l valve prolapse syn dro m e .
3.
Patients a t increased risk o f in fe c tiv e e n d o c a rd itis s h o u ld n o t take a n tib io tic s fo r m in o r illness, a n d sh o uld have a b lo o d c u ltu re done to e xclu de e n d o ca rd itis be fo re in s titu tin g a n tib io tic th erap y o f ba cte rial in fe c tio n .
4.
Patients w ith rh e u m a tic heart disease sh o uld be o n a regim en o f pro p h y la x is fo r pre ve n tion o f re cu rre n t g ro u p A strep to cocca l ph a ry n g itis in a d d itio n to these regim ens (C irc u la tio n 55.1 A 19771.
5.
M aintenance o f th e highest level o f ora l he a lth is im p o rta n t in p a tie n ts a t increased risk fo r e n d o ca rd itis. C om ple te eva lua tion and d e ntal re sto ra tio n s are in d ica te d b e fo re p ro s th e tic valve in s ertio n.
6
Physicians m ust prepare in advance if th ey plan to use th e p re ferred paren teral regim ens because pharm acies d o n o t usu a lly sto ck aqueous c ry s ta llin e p e n ic illin G , pro caine p e n ic illin G , s tre p to m y c in , o r g e n ta m ic in ; th e y can get these drugs w ith in 2 4 4 8 hours o n request.
7.
These re co m m en da tion s are based on th e 1977 sta tem e nt o f th e J o in t C o m m itte e (C irc u la tio n 5 6 .1 3 9 A , 1 9 7 7 ; J .A .D .A . 9 5 :6 0 0 , 19 77 ). R eco m m e nd atio ns regarding m o d ific a tio n o f subsequent doses of v a n co m ycin , s tre p to m y c in , and g e ntam icin fo r pa tien ts w ith renal fa ilu re m ay be fo u n d in C lin ica l N e p h ro lo g y , V o l. 7, pgs. 81 -84 , 1977.
For patients w ith pro sth e tic heart valves, previous endocarditis, severe gingival disease, p o o r dental hygiene o r on rheum atic fever prophylaxis. □
B
Regimen A-j plus stre p to m ycin 1 gm I.M . a t the tim e o f the in itia l injections.
□
C2
For patients allergic to p e n ic illin . V a ncom ycin (1 gm I.V .) 1 hou r before procedure over 45 m inutes, fo llo w e d by E ry th ro m y c in (500 mg o ra lly ) every 6 hours fo r 8 doses, or longer in the case o f delayed healing.
300 ■ JADA, Vol. 106, March 1983
Developed b y The A m erican H e art Association, Pennsylvania A ffilia te