The new American Heart Association guidelines on the prevention of infective endocarditis: culmination of a long process of thought

Despite recent advances in its diagnosis and treatment, infective endocarditis (IE) remains a disease with a high mortality rate, with an overall in-hospital mortality rate of 20% and a 5-year mortality rate of 40%, reported in recent large studies.1 Every effort should be made to reduce the incidence of a disease which carries such a heavy burden of morbidity and mortality. Although its efficacy has not been demonstrated in humans, antibiotic prophylaxis of IE has been recommended for subjects with predisposing cardiac conditions (PCC) since 1955.2 During the last decade, however, several factors have challenged the principles underlying these recommendations.3 The American Heart Association (AHA) has just modified its recommendations on IE prevention.4 The new recommendations represent a radical change from the previous ones: antibiotic prophylaxis using a 2 g single oral dose of amoxicillin is no longer recommended prior to dental procedure except for patients with the highest risk of adverse outcome resulting from IE (ie, previous IE, prosthetic cardiac valve, congenital heart disease with persistent risk of IE, cardiac transplantation recipients with cardiac valve diseases) and undergoing “any dental procedure that involves manipulation of the oral mucosa”. Prophylaxis is thus abandoned in patients at intermediate risk of IE, such as those with a history of aortic …