Trip Answers

Question answered:29/03/07 Warning! this question is over two years old.

We found two guidelines discussing antibiotic prophylaxis for the prevention of bacterial endocarditis.  However, neither discuss the scenario of allergies to two antibiotics, they both focus on allergy to penicillin.  As such their recommendations might not be compatible with someone allergic to erthyromycin.  We are happy to pass the question onto a specialist medicines information unit if further guidance is needed.

 

The British Society for Antimicrobial Chemotherapy guideline, published in 2006, states:

 

“If the patient (>/=10 years of age) has a documented penicillin allergy, a single dose of oral 600 mg clindamycin (<5 years of age: 150 mg; >/=5 to <10 years of age: 300 mg) should be given 1 h before the procedure. For iv administration we recommend a single dose of 300 mg clindamycin (given over at least 10 min) (<5 years of age: 75 mg; >/= 5 to <10 years of age: 150 mg).

 

For those patients who are allergic to penicillin and cannot swallow capsules, oral azithromycin suspension (>/=10 years: 500 mg; <5 years of age: 200 mg; >/=5 to <10 years of age: 300 mg) given 1 h before the procedure can be used as an alternative.

 

In addition, where practicable, a pre-operative mouthwash of chlorhexidine gluconate (0.2%) should be administered and held in the mouth for 1 min.

 

For patients requiring sequential dental procedures, these should ideally be performed at intervals of at least 14 days to allow healing of oral mucosal surfaces. If further dental procedures cannot be delayed, we suggest alternating amoxicillin and clindamycin. In this scenario if the patient has a penicillin allergy, we suggest that expert advice be sought.” [See page 2 of the guideline]. [1]

 

In addition, the 1997 American Heart Foundation guideline on prevention of bacterial endocarditis, recommends:

 

“Regimens for Dental, Oral, Respiratory Tract, or Esophageal Procedures
Individuals who are allergic to penicillins (such as amoxicillin, ampicillin, or penicillin) should be treated with the provided alternative oral regimens. Clindamycin hydrochloride is one recommended alternative. Individuals who can tolerate first-generation cephalosporins (cephalexin or cefadroxil) may receive these agents, provided they have not had an immediate, local, or systemic IgE-mediated anaphylactic allergic reaction to penicillin.

 

Azithromycin or clarithromycin are also acceptable alternative agents for the penicillin-allergic individual, although they are more expensive than the other regimens. When parenteral administration is needed in an individual who is allergic to penicillin, clindamycin phosphate is recommended; cefazolin may be used if the individual does not have an immediate type local or systemic anaphylactic hypersensitivity to penicillin.

 

The previous recommendations from this committee listed erythromycin as an alternate agent for the penicillin-allergic patient. Erythromycin is no longer included because of gastrointestinal upset and complicated pharmacokinetics of the various formulations.Practitioners who have successfully used erythromycin for prophylaxis in individual patients may choose to continue with this antibiotic. The regimen is included in our previous recommendations.” [2]

 

References
1. British Society for Antimicrobial Chemotherapy. Guidelines for the prevention of endocarditis: a working party report of the British Society for Antimicrobial Chemotherapy (2006).
(http://jac.oxfordjournals.org/cgi/reprint/dkl121v1)
2. Dajani AS, Taubert KA, Wilson W et al. Prevention of bacterial endocarditis. Recommendations by the American Heart Association. Circulation. 1997 Jul 1;96(1):358-66. (http://circ.ahajournals.org/cgi/content/full/96/1/358).

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