TABLE 33-4 -Procedures for which bacterial endocarditis prophylaxis is or is not recommended

Endocarditis prophylaxis recommended²	Endocarditis prophylaxis not recommended
1. Dental Dental extractions Periodontal procedures Dental implant placement or reimplantation Endodontic (root canal) instrumentation or surgery only beyond the apex Subgingival placement of antibiotic fibers or strips Initial placement of orthodontic bands but not brackets Postoperative suture removal Intraligamentary local anesthetic injections Prophylactic cleaning of teeth or implants where bleeding is anticipated Orthodontic appliance adjustment	1. Dental Restorative dentistry (filling cavities, operative and prosthodontic) with or without retraction cord⁴ Local anesthetic injections (nonintraligamentary) Intracanal endodontic treatment; post placement and buildup Placement of rubber dams, removable prosthodontic, or orthodontic appliances Taking of oral impression Fluoride treatments
2. Respiratory tract Tonsillectomy, adenoidectomy Surgical operations that involve intestinal or respiratory mucosa Bronchoscopy with a rigid bronchoscope	2. Respiratory tract Endotracheal intubation Bronchoscopy with a flexible bronchoscope, with or without biopsy⁵ Tympanostomy (insertion)
3. Gastrointestinal tract³ Sclerotherapy for esophageal varices Esophageal stricture dilation Endoscopic retrograde cholangiography with biliary obstruction Vaginal hysterectomy⁵ Biliary tract surgery Surgical operations that involve intestinal mucosa	Gastrointestinal tract Transesophageal echocardiography⁵ Endoscopy with or without gastrointestinal biopsy⁵
4. Genitourinary tract Prostatic surgery Cystoscopy Urethral dilation	4. Genitourinary tract Vaginal delivery⁵ Cesarean section In the absence of infection: urethral catheterization, uterine dilation and curettage, therapeutic abortion, sterilization procedures, insertion or removal of intrauterine devices
	5. Other Cardiac catheterization, including balloon angioplasty; implanting cardiac pacemakers or defibrillators and coronary stents; incision or biopsy of surgically scrubbed skin; circumcision

Reproduced, with permission, from Dajani AS et al: Prevention of bacterial endocarditis. Recommendation by the American Heart Association. JAMA 1997;277:1794. Copyright © 1997 by American Medical Association.

¹This table lists selected procedures but is not meant to be all-inclusive.

²Recommended for individuals with high- and moderate-risk cardiac conditions

³Prophylaxis is recommended for high-risk patients, optional for moderate-risk patients.

⁴Clinical judgment may indicate antibiotic use in selected circumstances that may create significant bleeding.

⁵Prophylaxis is optional for high-risk patients.

Endocarditis prophylaxis recommended²	Endocarditis prophylaxis not recommended
1. Dental Dental extractions Periodontal procedures Dental implant placement or reimplantation Endodontic (root canal) instrumentation or surgery only beyond the apex Subgingival placement of antibiotic fibers or strips Initial placement of orthodontic bands but not brackets Postoperative suture removal Intraligamentary local anesthetic injections Prophylactic cleaning of teeth or implants where bleeding is anticipated Orthodontic appliance adjustment	1. Dental Restorative dentistry (filling cavities, operative and prosthodontic) with or without retraction cord⁴ Local anesthetic injections (nonintraligamentary) Intracanal endodontic treatment; post placement and buildup Placement of rubber dams, removable prosthodontic, or orthodontic appliances Taking of oral impression Fluoride treatments
2. Respiratory tract Tonsillectomy, adenoidectomy Surgical operations that involve intestinal or respiratory mucosa Bronchoscopy with a rigid bronchoscope	2. Respiratory tract Endotracheal intubation Bronchoscopy with a flexible bronchoscope, with or without biopsy⁵ Tympanostomy (insertion)
3. Gastrointestinal tract³ Sclerotherapy for esophageal varices Esophageal stricture dilation Endoscopic retrograde cholangiography with biliary obstruction Vaginal hysterectomy⁵ Biliary tract surgery Surgical operations that involve intestinal mucosa	Gastrointestinal tract Transesophageal echocardiography⁵ Endoscopy with or without gastrointestinal biopsy⁵
4. Genitourinary tract Prostatic surgery Cystoscopy Urethral dilation	4. Genitourinary tract Vaginal delivery⁵ Cesarean section In the absence of infection: urethral catheterization, uterine dilation and curettage, therapeutic abortion, sterilization procedures, insertion or removal of intrauterine devices
	5. Other Cardiac catheterization, including balloon angioplasty; implanting cardiac pacemakers or defibrillators and coronary stents; incision or biopsy of surgically scrubbed skin; circumcision