GOOD MORNING

ANTIBIOTIC PROPHYLAXIS IN
DENTISTRY: Problems in Paradise
SEMINAR
ANTIBIOTIC PROPHYLAXIS IN
DENTISTRY
ANTIBIOTICS CURED
PATIENTS AND ANTIBIOTICS
PREVENTED INFECTIONS.
In 1928, Fleming discovered that the fungus
Penicillium notatum produced a substance which
killed the bacteria responsible for such infections.
It was the first antibiotic and he called it penicillin
Sir Alexander Fleming
Inside History
Definition of Antibiotics !
It is a chemical substance derivable from a mold or
bacterium that kills micro-organisms and cures
infections.
Antibiotics Wonder Drugs
Antibiotics may be informally defined as
the sub-group of anti- infectives that are
derived from bacterial sources and are used
to treat bacterial infections
Antibiotic is a chemical substance produced
by micro-organism having property of inhibiting
the growth of or destroying other m/o in high
dilution. Waksman in 1944
Antibiotics are the substances produced by
m/o, which suppress the growth of or kill other
m/o at very low concentration.
Tripathi, 5
th
ed.

Antibiotics are the substances produced by
various species of m/o that suppress the
growth of other m/o.
Goodman and Gillmans
Pharmacological Basis of Therapeutics, 10
th
ed.
Definition of Antibiotics !
How do Antibiotics work?
Define Antibiotic Prophylaxis:-
It is the use of antibiotics to prevent the
infections and is based on the assumption that if
antibiotics are useful in treating infections, then
they will prevent the infections.
Thomas J. Pallasch
It is defined as the use of an antimicrobial
agent before any infection has occurred for
the purpose of preventing a subsequent
infection.
Gerding DN, 1996
Uses of Antibiotic Prophylaxis:
As Drugs
of Fear
Prevent
Metastatic
Infections
Reduce infections
associated
with surgery
USES
Principles of Antibiotic prophylaxis **
Acc. To Waddel TK et al., 1994

Cost-Benefit Ratios
High concentration at target site
Loading Dose
Active against single micro-organism
Continued as long as microbial contamination
Adverse effects of Antibiotic prophylaxis ---
Allergy and Toxicity
Cutaneous eruptions (rash, urticaria, exfoliative
dermatitis)
Serum sickness (immune complex reactions)
Immediate hypersensitivity (penicillin anaphylaxis)
Super infections
Selection of Antibiotic Resistant micro-organisms
Induction of resistance gene transfer
Pallasch TJ et al, 2003
Contraindications:
Few Unusual Contraindications


Factors complicating antibiotic
prophylaxis:
No. of different organisms may be involved
Organisms involved have variable virulence
Organisms may originate from multiple sites
Organisms may have different sensitivity to
given antibiotics
Random physiologic bacteremia may occur
No controlled studies exist to show the
efficacy of antibiotic prophylaxis.
Thomas J Pallasch, 1989
AHA Recommendations:
In 1955
Oral: Low Loading Dose
Parenteral Oral: None
Parenteral: Single IM Injection
Penicillin Allergy Protection: None
Special: None
IN 1943-------
250,000 U Pen G
four times a day
AHA Recommendations:
In 1960
Oral: None
Parenteral Oral: Oral, 2 days
before, day of, 2 days following IM
loading dose.
Parenteral: IM Injections one on each of 2
days before and 2 days following IM loading
dose on day of procedure.
Penicillin Allergy Protection: Erythromycin
Special: None
AHA Recommendations:
Oral: Start 1 hr before; Low dosage 3 days
Parenteral Oral: None
Parenteral: Single IM Injection
Penicillin Allergy Protection: Erythromycin
Special: None

In 1965
AHA Recommendations:
Oral: Start 1 hr before; Extra loading dose;
Low dose 3 days following.
Parenteral Oral: None
Parenteral: Three IM Injections, Reduced
aqueous dosage, 1 hr before and 2 days
following.
Penicillin Allergy Protection: Erythromycin
Special: None
In 1972 -
AHA Recommendations:
Oral: High loading dose; Moderate dosage; About 2
days.
Parenteral Oral: High IM loading dose;
Moderate oral dose; About 2 days.
Parenteral: None
Penicillin Allergy Protection: Erythromycin;
High loading dose; Moderate following dose.
Special: IM penicillin & Streptomycin plus
penicillin IV or vancomycin plus oral erythromycin.
In 1977 -
1977 Recommendations:
High risk patients
Not allergic to penicillin.
Oral Parenteral & Oral

2gm Pen. V 30-60 mins 1million U Aq. Pen. G
before procedure. 600,000 U Procaine Pen. G
1 gm Streptomycin
500 mg Pen. V every 500mg Pen. V every 6hrs
6 hrs for 8 doses.
Allergic to Pen
1gm Vancomycin i/v over 30 mins period just before procedure.
500 mg Erythromycin every 6 hrs for 8 doses.

AHA Recommendations:
Oral: High loading dose; Single following
dose; Less than 1 day.
Parenteral Oral: None
Parenteral: High IM loading dose followed
by IM dose 6hrs later; Only aqueous.
Penicillin Allergy Protection:
Erythromycin; High loading dose; Single
following dose; Less than one day.
Special: IM or IV ampicillin, gentamycin plus
single-dose oral penicillin; IV vancomycin only.
In 1984 -
1984 Recommendations:
Patients who cannot take oral penicillin

Low moderate risk
2 million U Aq. Pen G i/m 30-60 mins before
followed by 1 million units of Aq. Pen G i/m 6 hrs
later

High risk
1-2 gm Ampicillin i/m or i/v 1 hr. before followed by
1gm Pen V orally 6 hrs later
AHA Recommendations:
Oral: High loading dose; Single following
dose; Less than 1 day.
Parenteral Oral: None
Parenteral: None
Penicillin Allergy Protection: Clindamycin
or Erythromycin; High loading dose; Single
following dose less than one day.
Special: IM or IV ampicillin, gentamycin plus
single following dose oral penicillin; IV
vancomycin only
In 1990 -
AHA Recommendations:
In 1990

Erythromycin ethylsuccinate
800mg initial oral dose followed 6hrs later
by 400mg.
Erythromycin stearate
1gm initial oral dose followed by 6hrs later by
500mg.

Patients unable to tolerate erythromycin
Clindamycin 300mg 1hr before and 150mg
6hrs after the procedure.
AHA Recommendations:
Most cases of endocarditis are not
attributable to invasive dental procedures
Committee stated that approach for
endocarditis prophylaxis should consider
Level of risk
Risk of bacteremia
Adverse reactions with antibiotic selected
Cost-benefit aspects

In 1997 -
Conditions considered for Antibiotic
Prophylaxis by AHA:
High Risk Conditions

Prosthetic cardiac
valves
Bioprosthetics
Homograft
Previous Bacterial
Endocarditis
Complex cyanotic
CHD
Surgically constructed
systemic pulmonary
shunts
Moderate Risk Conditions

Other congenital cardiac
malformations
Acquired valve
dysfunction
Hypertrophic
cardiomyopathy
Mitral Valve prolapse
with valvar regurgitation
Antibiotic prophylaxis recommended
Circulation 1997; 96: 358-66.
Conditions considered for Antibiotic
Prophylaxis by AHA:
Low or Negligible Risk Conditions :

Isolated scundum atrial septal defect
Ventricular septal defect
Patent ductus arteriosus
Previous coronary artery bypass graft surgery
Mitral valve prolapse without valvar regurgitations
Physiologic, functional, or innocent heart murmurs
Previous Kawasaki disease without valvar dysfunction
Previous rheumatic fever without valvar dysfunction
Cardiac pacemakers and implanted defibrillators





Antibiotic prophylaxis recommended
Circulation 1997; 96: 358-66.
Recommendations by AHA regarding dental
procedures and antibiotic prophylaxis:
Endocarditis prophylaxis recommended:

Dental extractions
Periodontal Surgery, scaling, root planning, probing
and recall maintenance
Placement of dental implants
Reimplantation of avulsed teeth
Endodontic instrumentation or surgery only beyond
the apex of teeth
Subgingival placement of orthodontic fibers/strips
Initial placement of orthodontic bands but not
brackets
Intraligamentary local anesthetic injections
Prophylactic cleaning of teeth or implants where
bleeding is anticipated
Circulation 1997; 96: 358-66.
Recommendations by AHA regarding dental
procedures and antibiotic prophylaxis:
Endocarditis prophylaxis not recommended:

Restorative dentistry
Local anesthetic injections
Intracanal endodontic treatment, post placement,
and crown build up
Placement of rubber dams
Post operative suture removal
Placement of removable prosthodontic or orthodontic
appliances
Taking oral impressions
Fluoride treatments
Taking oral radiographs
Orthodontic appliance adjustment
Shedding of primary teeth

Circulation 1997; 96: 358-66.
Antibiotic prophylaxis Guidelines for the
Prevention of Bacterial Endocarditis:
Standard Regimen (Oral)

Adults
Amoxicillin 2g, 1hr before procedure.
Children
Amoxicillin 50mg/kg, 1 hr before procedure.

Penicillin Allergy (Oral)

Adults
Clindamycin 600mg, 1 hr before procedure.
Cephalexin or Cefadroxil 2g, 1 hr before procedure.
Clarithromycin or Azithromycin 500mg, 1 hr before procedure.
JAMA 277: 1794-1801, 1997.
Antibiotic prophylaxis Guidelines for the
Prevention of Bacterial Endocarditis:
Penicillin Allergy (Oral)

Children
Clindamycin 20mg/kg, 1 hr before procedure.
Cephalexin or Cefadroxil 50mg/kg, 1 hr before
procedure.
Clarithromycin or Azithromycin 15mg/kg, 1 hr before
procedure.

Unable to Take Oral Medications
Adults
Ampicillin 2g IM or IV 30 min before procedure.
Children
50mg/kg IM or IV 30 min before procedure.
JAMA 277: 1794-1801, 1997.
Antibiotic prophylaxis Guidelines for the
Prevention of Bacterial Endocarditis:
Penicillin Allergy and Unable to take Oral
Medications:

Adults
Clindamycin 600 mg IV 30 min before
procedure
Cefazolin 1g IM or IV 30 min before
procedure

Children
Clindamycin 20mg/kg IV 30 min before
procedure
Cefazolin 25mg/kg IM or IV 30 min before
procedure
JAMA 277: 1794-1801, 1997.
After the AHA recommendations in
1997 were published number of
questions arose regarding some of the
specifics that could not be included in
original document; these questions
were answered in 1999??
QUESTIONS ????
Answers
Procedures associated with significant bleeding
If large no. of sutures are involved
Dental matrix bands and gingival retraction
cords
If patients forget to take the antibiotics
If dentist did not anticipate significant
bleeding
A 9-14 interval is advised between
appointments
If only short interval exists between
appointments
If multiple appointments are necessary
Therapeutic Guidelines 2000
Standard Oral
Amoxicillin orally 1 hr preop
Adult 2gm Child 50mg/kg
Parenteral
Ampicillin/Amoxicillin IV immediately or IM 30 min preop
Adult 2gm Child 50mg/kg
Non-penicillin Oral
Clindamycin orally 1 hr preop
Adult 600mg Child 10mg/kg
Cephalexin orally 1 hr preop
Adult 2gm Child 50mg/kg

Spicer J et al 2000
ADA Recommendations
Non-penicillin Parenteral
Clindamycin IV infused over 30min preop
Adult 600mg Child 10mg/kg
Lincomycin IV immediately
Adult 600mg Child 15mg/kg
Tiecoplanin IV immediately preop
Adult 400mg Child 10mg/kg
Vancomycin IV infused over 30 min preop
Adult 1gm Child 20mg/kg
Spicer J et al 2000
Therapeutic Guidelines 2000
ADA Recommendations
Rationale behind recommendations:
Both ADA and AHA recommend

Amoxicillin as drug of first choice
Use of Amoxicillin 1 hr preoperatively
Reduced dose of Amoxicillin from 3gms to
2gms
2
nd
dose of Amoxicillin 6hrs post operatively
In patients allergic to Amoxicillin, Clindamycin is
recommended
Erythromycin no longer used..

Rouse MS et al, 1997
Rationale behind recommendations:
Both ADA and AHA recommend

Clarithromycin and Azithromycin as Amoxicillin
alternatives
Cephalexin
Cephalosporins should not be given to patients with
history of immediate Type 1 hypersensitivity
No longer recommend combination of Amoxycillin
and Gentamycin
Morreilon P et al, 1996
AHA no longer recommends Vancomycin but
however ADA recommends Vancomycin for Pen
allergic patients unable to take oral medication

Review-
2
6
8
10
12
4
14
2 gm Amoxicillin
600mg Clindamycin
MIC 90
Adapted by Dajani 1997
Vermot 1996
mg/L
Hours
1 6
Serum conc. following 2gm oral Amoxicillin and 600mg Clindamycin
MIC 90 - Minimum inhibitory serum conc. effective against 90% of
m/o exposed to antimicrobials.
ADA Risk Categories:
At-risk patient

All acquired Valvular heart diseases
Hypertrophic Cardiomyopathy
Mitral valve prolapse with regurgitation
Most congenital heart diseases
Prosthetic heart valve
Previous episode of IE
Surgically constructed shunts
Aust. Dent. J 2001; 46(3): 220-5
ADA Risk Categories:
Non-risk patients

Coronary bypass
Isolated atrio-ventricular defects
Kawasaki disease without Valvular dysfunction
Mitral valve prolapse without regurgitation
Pacemakers and implanted defibrillators
Physiological/innocent heart murmur
Rheumatic fever without Valvular dysfunction
Surgical repair of heart defects after six months


Aust. Dent. J 2001; 46(3): 220-5
ADA Risk Procedures:
1. Dental prophylaxis
2. Endodontic surgery
3. Extractions
4. Implant placement
5. Instrumentation beyond the apex
6. Intra- ligamentary injections
7. Osteotomy
8. Periodontal procedures
9. Placing orthodontic bands
10. Reimplantation of avulsed teeth
11. Surgical drainage of abscess
12. Surgical repair of jaw fracture

RISK PROCEDURES
Aust. Dent. J 2001;
46(3): 220-5

1. Exfoliation of deciduous teeth
2. Intra-canal instrumentation
3. Local anaesthesia (except intra-ligamentary )
4. Orthodontic adjustments
5. Radiographs
6. Removal of sutures
7. Restorative dental procedures
8. Rubber dam placement
9. Taking impressions

NON-RISK PROCEDURES
Aust. Dent. J 2001;
46(3): 220-5
ADA Risk Procedures:
Clinical Situations considered for
Antibiotic Prophylaxis:
Prevention of metastatic infections
Bacterial Endocarditis
Surgical Antibiotic Prophylaxis
Potential Antibiotic Prophylaxis Situations
Prosthetic joints
Brain Abscess
Nonvalvular cardiovascular devices
Hemodialysis
Solid organ transplants
Diabetes
Immunocompromised patients
Collagen Diseases and other disorders
Pharmacology & Therapeutics for
Dentistry, 5
th
ed.
Clinical Situations considered for
Antibiotic Prophylaxis:
Infective Endocarditis
Dwelling catheters, neurosurgical
shunts and other implants
Prevention of local infection in surgical
or operative sites in the mouth
Prevention of generalized spread of
infections in patients with compromised
immune system

JADA 2000; 131: 366-374
Exudative and Proliferative inflammatory
alteration of the endocardium.
FIRST SUGGESTION OF THE LINK BETWEEN IE
AND ORAL BACTERIA WAS RAISED IN 1909 BY
HORDER TJ.

IE is uncommon with prevalence rate of 15-30
cases per1 million per year.

Certain studies challenge the practice of antibiotic
prophylaxis to prevent IE:

Vandermeet JT et al, 1992
Storm BL et al 1998
Infective Endocarditis:
Certain controversies regarding
association of Dentistry with IE :
Is IE caused by dental procedure-induced
bacteremia or from spontaneous bacteremia ?
Which patients are at risk of IE ?
Which procedures require antibiotic coverage ?
Are the risk of providing such coverage greater
than the risk for contracting IE ?
Are antibiotic regimens effective ?
DCNA 2002; 46: 635-51
Infective Endocarditis:
Antibiotic prophylaxis to prevent
endocarditis 1955
Bacteremia and Oral Cavity
Incidence of Bacteremia
Dental Extraction 40%-89%
Periodontal Surgery 36%-88%
Simple Prophylaxis 0%-40%
Buccal Anesthetic Injection 16%
Intraligamentary Injection 97%
Rubber Dam/Matrix/Wedge 9%-32%
Non-Surgical Endodontic t/t 0%-15%
Infective Endocarditis:
Incidence of Bacteremia
Activities of Daily Living
Tooth Brushing : 0%-26%
Dental Flossing : 20%-58%
Wooden Cleansing Devices :20%-40%
Water Irrigation Devices : 7%-50%
Mastication : 17%-51%
Int J Oral Max Surg 1995; 24(3): 239-242.
DCNA 2003; 47: 665-79.
Oral Microorganisms and Endocarditis:
S. Viridans
Most common causative organism
Gram negative bacilli
Neonates and Immunocompromised patients
Prosthetic valves
Within first year of surgery: Coag-negative staph
After first year: similar to native valve endocarditis
HACEK organisms
Hemophilus, Actinobacillus, Cardiobacterium,
Eikenella, Kingella
Frequently affect damaged valves and can
cause emboli
Oral Microorganisms and Endocarditis:
25% cases by VGS
Cabell CH et al., 2002
102 cases by A. actinomycetemcomitans
Paturel L et al., 2003
2 cases by P. oralis
Quaglio G et al., 1999
5 cases by Veillonella
Houston S et al., 1997
1 case by P. bivia, B. melaninogenicus
Kentos A et al., 1994
Risk of Endocarditis due to dental
procedures:
8% cases by periodontal/other dental diseases
Drangshott MT et al., 1998
19% to 35% by dental treatment procedures
Droz D et al., 1997

No association between dental treatment and
endocarditis
Strom BL et al., 1998
Houston S et al., 1997
Lacassin F et al., 1995

Blaming a dentist for endocarditis would be like
blaming the cardiologist for myocardial infarction.
Guntheroth, 1984
Infective Endocarditis:
Evertt ED et al., 1977
Bender IB et al., 1984
Guntherhoth WG et al., 1984
Roberts GJ et al., 1999

Dentists are Innocent! Everyday bacteremia is
the real culprit.
DCNA 2003; 47: 665-79.
Infective Endocarditis:
AHA recommendations significantly changed in
respect to various cardiac conditions

Understanding of disease process

Amoxicillin dosage reduced from 3gm to2gm.

recommending that follow up dose should be
discontinued and replacement of
erythromycin.
Committee stated that:
Wynn R. et al
Gen Dent 1997; 45: 426-34
Antibiotic Prophylaxis and Bacteremia
Reduction:
Pallash TJ et al., 2000
antibiotic prophylaxis reduces
bacteremias after onset of dental treatment.

No explanation as to how drugs that work so
slowly eliminate bacteremia so quickly?


Durack DT et al., 1995 & Hall G et al., 1996


- Lysis filtration method
- Preventing the adherence of
microbes to the valvular vegetations
Other conditions requiring antibiotic
prophylaxis:
Prosthetic Joint replacements:
Jacobson JJ et al., 1988
CONTENTIOUS ISSUE!!

- Does dental induced bacteremia cause hematogenous
infections in patients with joint prosthesis?

- Does antibiotic prophylaxis prevent such infections?

- What is the cost-risk benefit to provide such cover?

In the current consensus, ADA have recommended the use
of antibiotic prophylaxis only patients with total joint
replacements and compromised immune system.


R.A. Seymour et al 2003

Patients at Risk Include:
JADA 1997; 128(7): 1004-8
Suggested Antibiotic Prophylaxis Regime:
JADA 1997; 128(7): 1004-8
Hip and Joint Prosthesis:
Early Infections Surgical Procedures
Late infections Hematogenous Spread

Is there any evidence ??
Ainscow DAP et al., 1984
Thyne GM et al., 1991
Deacon JM et al., 1996
Guidelines from Professional Bodies:
BSAC in 1992
ADA/AAOS in 1997
BOA

Overview:
Synopsis of evidence to date
Staphylococcal origin
Joint infection arising spontaneously from patients oral
hygiene
No evidence to support efficacy of antibiotic prophylaxis
Risk with antibiotic prophylaxis is high
Patients dentally fit
Limited evidence..
Any perceived potential benefit of antibiotic
prophylaxis must be weighed against the known
risks of antibiotic toxicity; allergy; and
development, selection and transmission of
microbial resistance.
Patients with Renal diseases :
Arteriovenous shunts and fistulas are commonly
used to access the patient's bloodstream in
hemodialysis.

Carl and Wood (1976) suggested that patients
receive dental treatment just before undergoing
hemodialysis since they are free of anticoagulants
at that time and at decreased risk of bleeding.

Common infectious agents are staphylococcal and
streptococcal species.
Contaminate dialysis vascular
access sites/infection in
immunocompromised transplant
patients
Arterio-Venous Connections

On one hand, patients with
central lines and synthetic
grafts for haemodialysis

Infection at the access site

Bacteremia and possible
endocarditis


The synthetic graft or
catheter can be colonized
and thus become a
subsequent source for
bacteremia.
However, on a broader
scale, one may consider
renal patients


Immunocompromised
Argue

Antibiotic prophylaxis
for dental procedures is
not to cover a prosthesis
or foreign material but
to prevent systemic
infection and sepsis in an
immunocompromised
individuals.
Controversy exists over the principles
of antibiotic prophylaxis in renal patients:
Antibacterial Regime:
- Vancomycin (1.0 g) infused over one hour during
dialysis the day before dental treatment
- Amoxicillin (3.0 g per mouth) one hour before the
dental procedure; a second dose is not needed
- Erythromycin ethylsuccinate (800 mg) or
erythromycin stearate (1.0 g by mouth) two
hours before the dental procedure, then one-
half the dose six hours after the initial dose
- Clindamycin (300 mg by mouth) one hour before
the dental procedure, then 150 mg six hours
after the initial dose

JADA 1996; 127: 211-19
Recent Study:
Forty-one per cent of clinicians do not routinely give
antibiotic prophylaxis to haemodialysis patients prior to
dental surgery, but a majority (53%) would consider
antibiotic prophylaxis if the patient had a synthetic
arteriovenous fistula. The majority of clinicians follow the
American Heart Association (AHA) guidelines with a
single oral preoperative dose of 2 g Amoxycillin or 600
mg clindamycin if patients are allergic to penicillin.


DARRYL C TONG
Nephrology 2004; 9: 167-70

History of rheumatic fever is important
Inflammatory Rheumatic Carditis

Cardiac Valve Damage

Mitral Valve Prolapse

With regurgitation Without regurgitation

Require Antibiotic Not required
prophylaxis
Rheumatic Heart Disease:

AHA
Darryl C. Tong
JADA 2000; 131: 366-74
SUGGESTED ANTIBIOTIC PROPHYLAXIS REGIMENS:


Patients not allergic to penicillin:
Cephalexin, Cephradine or Amoxicillin, 2 grams
orally, one hour before dental procedure
Patients not allergic to penicillin and unable to take
oral medications:
Cefazolin (1 g) or Ampicillin (2 g) intramuscularly or
intravenously, one hour before dental procedure
Patients allergic to penicillin:
Clindamycin, 600 milligrams orally, one hour before
dental procedure
Patients allergic to penicillin and unable to take oral
medications:
Clindamycin, 600 mg intravenously, one hour before
dental procedure

JADA 1999; 130: 689-697
Nonvalvular Cardiovascular Devices:
Pacemakers, implantable cardioverter defibrillators,
peripheral and cardiac vascular stents, prosthetic
vascular grafts, and Dacron carotid patches.

Evidence for hematogenous infection with these
devices is extremely rare, with no documentation of
dental treatment causation.
AHA review concludes that
Baddour LM et al
Circulation 108: 2015-31, 2003
Other conditions requiring antibiotic
prophylaxis:
Prevention of local infection in surgical site
Clean Contaminated Highly contaminated
-Routine exodontia - Periodontal Surgery
-Third molar surgery
-Orthognathic surgery
Prevention of generalised spread of infections
in patients with compromised immune system
At high risk of developing bacteremias
Undergoing chemotherapy
HIV infected patients
Diabetics
Other Conditions:
Brain Abscess:
- 3
rd
metastatic infections after B.E. and joint
infections.
- VGS likely causative agent
- Rare, 1 per 10,000 hospital admissions
- Absolute risk is 1 in 1 million to 10 million
Pallasch TJ et al, 2003
Splenectomy
No clinical studies evaluate the efficacy
of antibiotic prophylaxis prior to dental
t/t in splenetic patients.
Waghorn DJ et al, 2001
Solid Organ Transplants
Petri WA et al, 1994
Paterson DL et al, 1998
Immunocompromised patients
- HIV patients
Pallasch TJ et al 1997-
Darryl C Tong et al 2003-
- Diabetic patients
No data support use of antibiotic prophylaxis
in controlled non-ketotic diabetic patients.
Alexander RE et al, 1999
Lockhart PB et al 2002-
Little JW et al 1993-
- Neutropenic patients
- Chronic I/V drug abusers

Other Conditions:
Associated Unsolved Problems ?
By Pallasch T J et al 2003
High financial cost
Risk of Bacteremia
Extreme rarity of endocarditis
Extremely low absolute risk
Dental Treatments rarely
Antibiotic prophylaxis does not significantly reduce
Contribution of Antibiotic prophylaxis
Mortality rate is greater