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Chapter 187: Antibiotics

Angela Lee

BASIC PRINCIPLES

Surgical site infections (SSIs) occur within 30 days of surgery or within 90 days if a prosthetic implant. Antibiotic prophylaxis reduces microorganisms at the operative site during surgery. Cefazolin is the drug of choice for many surgeries because it is effective against streptococcus, methicillin susceptible staphylococci, and some gram-negative bacteria. Second-generation cephalosporins have broader coverage against gram-negative organisms than cefazolin. Cefoxitin and cefotetan also cover some anaerobes. The role of vancomycin in SSI prophylaxis is in the methicillin-resistant staphylococci colonized patient. Antimicrobial therapy should be administered within 60 minutes prior to surgical incision and within 2 hours if vancomycin or a fluoroquinolone is indicated.

In 2007, the American Heart Association simplified its recommendations for infective endocarditis (IE) prophylaxis. Routine prophylaxis solely to prevent IE for genitourinary and gastrointestinal procedures is not recommended. IE prophylaxis is not recommended based solely on an increased risk of endocarditis during the patient’s lifetime. Rather, IE prophylaxis for dental procedures is recommended only in those patients with cardiac lesions with the highest risk of adverse outcome from IE (Tables 187-1 and 187-2). IE prophylaxis is administered as a single dose before the procedure and can be administered up to 2 hours after the procedure, if no preprocedure IE prophylaxis was administered.

TABLE 187-1Cardiac Conditions Associated with the Highest Risk of Adverse Outcome from Endocarditis for which Dental Procedure Prophylaxis is Reasonable
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TABLE 187-1 Cardiac Conditions Associated with the Highest Risk of Adverse Outcome from Endocarditis for which Dental Procedure Prophylaxis is Reasonable

Prosthetic cardiac valve or prosthetic material used for cardiac valve repair

Previous IE

Congenital heart disease (CHD)*

  • Unrepaired cyanotic CHD, including palliative shunts and conduits

  • Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure†

  • Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization)

Cardiac transplantation recipients who develop cardiac valvulopathy

* Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD.

† Prophylaxis is reasonable because endothelialization of prosthetic material occurs within 6 months after the procedure.

TABLE 187-2Recommended Antibiotic Regimen for Dental Procedures
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TABLE 187-2 Recommended Antibiotic Regimen for Dental Procedures
Situation Antibiotic Single Dose 30–60 min Before Incision
    Adults Children
Oral Amoxicillin 2 g 50 mg/kg
Unable to take oral medication

Ampicillin

Cefazolin or ceftriaxone

2 g IM or IV

1 g IM or IV

50 mg/kg IM or IV

50 mg/kg IM or IV
Allergic to penicillins or ampicillin—oral

Cephalexin*,†

Clindamycin

Azithromycin or clarithromycin

2 g

600 mg

500 mg

50 mg/kg

20 mg/kg

15 mg/kg
Allergic to penicillins or ampicillin and unable to take ...

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