Endocarditis Prophylaxis (AHA) — Summary for Clinical Use

FOR USE BY MEDICAL PROFESSIONALS. This page summarizes AHA guidance on when antibiotic prophylaxis is reasonable and provides the standard single-dose dental regimens (adult + pediatric). Always individualize to allergy history, renal/hepatic function, local antimicrobial stewardship, and current labeling.

Quick index

Who needs prophylaxis (highest-risk cardiac conditions)

Restricted indication Antibiotic prophylaxis is reserved for patients at highest risk of adverse outcomes from infective endocarditis.

  • Prosthetic cardiac valves (including transcatheter-implanted prostheses and homografts)
  • Prosthetic material used for cardiac valve repair (e.g., annuloplasty rings, chords, clips)
  • Previous infective endocarditis
  • Unrepaired cyanotic CHD OR repaired CHD with residual shunts or valvular regurgitation at/adjacent to a prosthetic patch/device
  • Cardiac transplant with valve regurgitation due to a structurally abnormal valve

Except for the conditions above, prophylaxis before dental procedures is not recommended for other types of CHD.

Dental procedures: when prophylaxis is reasonable

Prophylaxis is reasonable (high-risk patients only) Before dental procedures that involve manipulation of gingival tissue, manipulation of the periapical region of teeth, or perforation of oral mucosa.

Not recommended Prophylaxis is not recommended for:

  • Routine anesthetic injections through noninfected tissue
  • Dental radiographs
  • Placement/adjustment of removable prosthodontic or orthodontic appliances
  • Placement/adjustment of orthodontic brackets
  • Shedding of deciduous teeth or bleeding from trauma to lips/oral mucosa

Antibiotic regimens (dental procedures)

Timing Single dose 30–60 minutes before the procedure.
Update Clindamycin is no longer recommended for dental prophylaxis.
Situation Agent Adults Children
Oral Amoxicillin 2 g PO 50 mg/kg PO
Unable to take oral meds Ampicillin 2 g IM or IV 50 mg/kg IM or IV
Cefazolin or Ceftriaxone 1 g IM or IV 50 mg/kg IM or IV
Penicillin/ampicillin allergy — oral regimen Cephalexin* 2 g PO 50 mg/kg PO
Azithromycin or Clarithromycin 500 mg PO 15 mg/kg PO
Doxycycline 100 mg PO <45 kg: 2.2 mg/kg PO
≥45 kg: 100 mg PO
Penicillin/ampicillin allergy + unable to take oral meds Cefazolin or Ceftriaxone† 1 g IM or IV 50 mg/kg IM or IV
* Or other first- or second-generation oral cephalosporin in equivalent adult/pediatric dosing.
† Cephalosporins should not be used in an individual with a history of anaphylaxis, angioedema, or urticaria with penicillin or ampicillin.

Non-dental procedures

AHA summary In patients at high risk of IE, antibiotic prophylaxis is not recommended for non-dental procedures in the absence of active infection.

  • TEE
  • EGD / colonoscopy
  • Cystoscopy

Respiratory / skin / GI-GU when infection present

Key principle For procedures involving active infection, choose antibiotics directed at likely pathogens (treatment of infection), rather than “IE prophylaxis.” Consider infectious diseases consultation for resistant organisms or complex cases.

Respiratory tract

  • Invasive procedures involving incision/biopsy of respiratory mucosa (e.g., tonsillectomy/adenoidectomy): use a regimen active against expected organisms (often aligns with dental regimens when IE-risk indication exists).
  • Not recommended: bronchoscopy unless it involves incision of respiratory tract mucosa.

Skin / skin structure / musculoskeletal tissue

  • If surgery involves infected tissue, antibiotic therapy should include activity against staphylococci and β-hemolytic streptococci.
  • Consider vancomycin or clindamycin for treatment (not dental prophylaxis) when β-lactams cannot be used or MRSA is suspected, per local antibiogram and clinical scenario.

GI / GU (including obstetric infections)

  • When a procedure involves infection of the GI/GU tract (e.g., chorioamnionitis, pyelonephritis), ensure the treatment regimen covers likely pathogens; for suspected/known enterococcal involvement, ampicillin/amoxicillin are typical first choices if susceptible.
  • IE prophylaxis is not recommended for vaginal delivery or cesarean section in the absence of infection.
Standard OBPharm/OBRx disclaimer THE INFORMATION IN THE OBPHARM/OBRx CONTENT IS INTENDED SOLELY FOR USE BY THE MEDICAL PROFESSION. IT IS NOT INTENDED FOR LAY PERSONS. The prescribing physician must be familiar with full product labeling and relevant medical literature prior to use.

UPDATED: 12/19/2025

References (click to expand)

References

  1. American Heart Association (AHA) wallet card: Prevention of Infective Endocarditis (antibiotic regimens and high-risk conditions; rev. 08/2024). PDF
  2. Wilson WR, et al. Prevention of Viridans Group Streptococcal Infective Endocarditis: A Scientific Statement From the AHA. Circulation. 2021;143:e963–e978. PubMed
  3. American Dental Association (ADA): Antibiotic prophylaxis prior to dental procedures (summary and update on clindamycin removal). Page