Prophylactic Antibiotics for Procedures in Patients with Prior TAVR

Indications for Prophylaxis

The American Heart Association and American College of Cardiology recommend prophylactic antibiotics for patients with a history of TAVR when undergoing high-risk dental procedures that involve manipulation of gingival tissue or the periapical region of teeth 1
Antibiotic prophylaxis is indicated for dental procedures requiring manipulation of gingival tissue or the periapical region of teeth, or perforation of the oral mucosa, according to the European Heart Journal and Circulation 1, 2
Routine dental cleaning is included in the procedures that require antibiotic prophylaxis, as stated by Circulation 3

Gastrointestinal procedures, such as esophagogastroscopy and colonoscopy, do not require prophylaxis, according to the European Heart Journal and Journal of the American College of Cardiology 2, 4
Genitourinary procedures, such as cystoscopy, do not require prophylaxis, as stated by the European Heart Journal and Journal of the American College of Cardiology 2, 4
Respiratory tract procedures, such as bronchoscopy and transesophageal echocardiography, do not require prophylaxis, according to the European Heart Journal 2
Skin and soft tissue procedures do not require prophylaxis, as stated by the European Heart Journal 2

The 2017 AHA/ACC guidelines added transcatheter-implanted prosthetic valves to the highest-risk category requiring prophylaxis, due to the high risk of infective endocarditis 1
Infective endocarditis occurs after TAVR at rates equal to or exceeding surgical aortic valve replacement, with a high mortality rate, as stated by Circulation 1

The standard oral regimen for patients who can take oral medications is amoxicillin 2 grams orally, given 30-60 minutes before the procedure, as recommended by Circulation 3
For patients who cannot take oral medications, the alternative regimens are ampicillin 50 mg/kg IM or IV, or cefazolin or ceftriaxone 50 mg/kg IM or IV, as stated by Circulation 3
For patients with penicillin allergy, the alternative oral regimens are cephalexin 2 grams orally, clindamycin 600 mg orally, or azithromycin or clarithromycin 500 mg orally, as recommended by Circulation and Clinical Infectious Diseases 3, 5

The preoperative dose of antibiotics must be given 30-60 minutes before the procedure to ensure adequate antibiotic levels, as stated by Circulation 1, 3
Only a single dose of antibiotics is needed for dental procedures, and prophylaxis should not be continued beyond the procedure, according to the European Heart Journal 2
Optimal oral hygiene is paramount, and daily oral health maintenance and regular professional dental care are more important than prophylaxis for individual procedures, as recommended by Circulation and Clinical Infectious Diseases 1, 5, 6

The 2017 ACC Expert Consensus recommends encouraging optimal dental care as part of routine follow-up, and applying antibiotic prophylaxis per AHA/ACC guidelines for all dental procedures, as stated by the Journal of the American College of Cardiology 7, 8
Regular dental review is recommended to prevent infective endocarditis, according to the European Heart Journal 2