Re: Need quick response on recommended antiobiotics

[Cleveland Clinic, MD]

Posted By CCF CARDIO MD - CRC on January 26, 1999 at 12:47:27:

In Reply to: Re: Need quick response on recommended antiobiotics posted by rodger on January 25, 1999 at 23:44:37:






Dear Doctor,
I just have a very quick question that I need an answer ASAP. I am going to the
Dentist on Wednesday and have conflicting opinions regarding premedication
for dental work with mitral valve.  Could you please let me know if
Biaxin is an o.k. choice of drug for Mitral Valve premedication.  Will it do
the job it is suppose to.  The dentist says it is not one of the AMA's
drug of choice for this.
Thanks in advance,
Lori  
I'm a heart patient, not a doctor, but you may not get an answer by Wednesday.
(these questions are assigned to working doctors who have to answer as their
schedules permit) It's my understanding that you don't have to premedicate for
all valve problems.
Did the doctor say that your problem requires you to premedicate for dental
procedures? Why not call the doctor's office? They are familliar with your
condition and can advise you as to what to do for a dental appointment. If
the doctor is busy, the nurse can get the answers for you and call you back. The
dentist or the doctor can call in an Rx if you need one. I take amoxicillin, which
I think is the most common Rx for premedication. The last time I checked
the American Heart Assn. guidelines recomend Amoxicillin, or, for the penicillin alergic (allergic):
Clindamycin, Cephalexin, Cedfadroxil, Azithromycin, or Clarithromykcin.
--------------------------------------------------------------------------------------------------------------------
Dear Rodger,
You are correct that Amoxicillin is the most common drug used for non-penicillin allergic patients.  Also not as many people need to take antibiotics as was previously recommended.  I have attached a full test version of the recommendations:
http://gateway.ovid.com/server3/ovidweb.cgi?T=gtflink&gNum=T4&AN=0005407-970611-034&D=medl&S=IDNJHKMPFACALK
JAMA: Journal of the American Medical Association
  Copyright 1997 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to
            Government Use. American Medical Association, 515 N State Street, Chicago, IL 60610.
                        Volume 277(22)             June 11, 1997             pp 1794-1801
    Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association
                                        [Clinical Cardiology]
Dajani, Adnan S., MD; Taubert, Kathryn A., PhD; Wilson, Walter, MD; Bolger, Ann F., MD; Bayer, Arnold, MD; Ferrieri,
  Patricia, MD; Gewitz, Michael H., MD; Shulman, Stanford T., MD; Nouri, Soraya, MD; Newburger, Jane W., MD; Hutto,
  Cecilia, MD; Pallasch, Thomas J., DDS, MS; Gage, Tommy W., DDS, PhD; Levison, Matthew E., MD; Peter, Georges,
                                    MD; Zuccaro, Gregory, Jr, MD
From the American Heart Association, Dallas, Tex (Drs Dajani, Taubert, Wilson, Bolger, Bayer, Ferrieri, Gewitz, Shulman, Nouri, Newburger, and
Hutto); American Dental Association, Chicago, Ill (Drs Pallasch and Gage); the Infectious Diseases Society of America, Alexandria, Va (Dr
Levison); American Academy of Pediatrics, Elk Grove Village, Ill (Dr Peter); and American Society for Gastrointestinal Endoscopy, Manchester,
Mass (Dr Zuccaro).

[Background]
     CARDIAC CONDITIONS
          High Risk
          Moderate Risk
          Negligible Risk
     BACTEREMIA-PRODUCING PROCEDURES
     DENTAL AND ORAL PROCEDURES
     RESPIRATORY, GASTROINTESTINAL, AND GENITOURINARY TRACT PROCEDURES
     PROPHYLACTIC REGIMENS
          Regimens for Dental, Oral, Respiratory Tract, or Esophageal Procedures
          Regimens for Genitourinary and Nonesophageal Gastrointestinal Procedures
     SPECIFIC SITUATIONS AND CIRCUMSTANCES
          Patients Already Receiving Antibiotics
          Procedures Involving Infected Tissues
          Patients Who Receive Anticoagulants
          Patients Who Undergo Cardiac Surgery
          Status Following Cardiovascular Procedures
     OTHER CONSIDERATIONS
     REFERENCES
Graphics
     Table 1
     Figure 1
     Table 2
     Table 3
     Table 4
     Table 5

Objective.- To update recommendations issued by the American Heart Association last published in 1990 for the prevention of bacterial
endocarditis in individuals at risk for this disease.
Participants.- An ad hoc writing group appointed by the American Heart Association for their expertise in endocarditis and treatment with
liaison members representing the American Dental Association, the Infectious Diseases Society of America, the American Academy of
Pediatrics, and the American Society for Gastrointestinal Endoscopy.
Evidence.- The recommendations in this article reflect analyses of relevant literature regarding procedure-related endocarditis, in vitro
susceptibility data of pathogens causing endocarditis, results of prophylactic studies in animal models of endocarditis, and retrospective
analyses of human endocarditis cases in terms of antibiotic prophylaxis usage patterns and apparent prophylaxis failures. MEDLINE database
searches from 1936 through 1996 were done using the root words endocarditis, bacteremia, and antibiotic prophylaxis. Recommendations in this
document fall into evidence level III of the US Preventive Services Task Force categories of evidence.
Consensus Process.- The recommendations were formulated by the writing group after specific therapeutic regimens were discussed. The
consensus statement was subsequently reviewed by outside experts not affiliated with the writing group and by the Science Advisory and
Coordinating Committee of the American Heart Association. These guidelines are meant to aid practitioners but are not intended as the
standard of care or as a substitute for clinical judgment.
Conclusions.- Major changes in the updated recommendations include the following: (1) emphasis that most cases of endocarditis are not
attributable to an invasive procedure; (2) cardiac conditions are stratified into high-, moderate-, and negligible-risk categories based on
potential outcome if endocarditis develops; (3) procedures that may cause bacteremia and for which prophylaxis is recommended are more
clearly specified; (4) an algorithm was developed to more clearly define when prophylaxis is recommended for patients with mitral valve
prolapse; (5) for oral or dental procedures the initial amoxicillin dose is reduced to 2 g, a follow-up antibiotic dose is no longer recommended,
erythromycin is no longer recommended for penicillin-allergic individuals, but clindamycin and other alternatives are offered; and (6) for
gastrointestinal or genitourinary procedures, the prophylactic regimens have been simplified. These changes were instituted to more clearly
define when prophylaxis is or is not recommended, improve practitioner and patient compliance, reduce cost and potential gastrointestinal
adverse effects, and approach more uniform worldwide recommendations.
JAMA. 1997;277:1794-1801

Clinical Cardiology section editors: Bruce Brundage, MD, University of California, Los Angeles, School of Medicine; Margaret
A. Winker, MD, Senior Editor, JAMA.
ENDOCARDITIS is a life-threatening disease, although it is relatively uncommon. Substantial morbidity and mortality result
from this infection, despite improvements in outcome due to advances in antimicrobial therapy and enhanced ability to diagnose
and treat complications. Primary prevention of endocarditis whenever possible is therefore very important.
Endocarditis usually develops in individuals with underlying structural cardiac defects who develop bacteremia with organisms
likely to cause endocarditis. Bacteremia may occur spontaneously or may complicate a focal infection (eg, urinary tract
infection, pneumonia, or cellulitis). Some surgical and dental procedures and instrumentations involving mucosal surfaces or
contaminated tissue cause transient bacteremia that rarely persists for more than 15 minutes. Blood-borne bacteria may lodge
on damaged or abnormal heart valves or on the endocardium or the endothelium near anatomic defects, resulting in bacterial
endocarditis or endarteritis. Although bacteremia is common following many invasive procedures, only certain bacteria
commonly cause endocarditis. It is not always possible to predict which patients will develop this infection or which particular
procedure will be responsible.
There are currently no randomized and carefully controlled human trials in patients with underlying structural heart disease to
definitively establish that antibiotic prophylaxis provides protection against development of endocarditis during
bacteremia-inducing procedures. Further, most cases of endocarditisare not attributable to an invasive procedure. The
following recommendations reflect analyses of relevant literature regarding procedure-related endocarditis, including in vitro
susceptibility data of pathogens causing endocarditis, results of prophylactic studies in experimental animal models of
endocarditis, and retrospective analyses of human endocarditis cases in terms of antibiotic prophylaxis usage patterns and
apparent prophylaxis failures.
The incidence of endocarditis following most procedures in patients with underlying cardiac disease is low. A reasonable
approach for endocarditis prophylaxis should consider the following: the degree to which the patient's underlying condition
creates a risk of endocarditis; the apparent risk of bacteremia with the procedure (as defined in these recommendations); the
potential adverse reactions of the prophylactic antimicrobial agent to be used; and the cost-benefit aspects of the recommended
prophylactic regimen. Failure to consider all of these factors may lead to overuse of antimicrobial agents, excessive cost, and
risk of adverse drug reactions.
This statement provides guidelines for prevention of bacterial endocarditis. It is not intended as the standard of care or as a
substitute for clinical judgment. The current recommendations are an update of those made by the committee in 1990 (1) and
incorporate new data and include opinions voiced by national and international experts at endocarditis meetings around the
world.
CARDIAC CONDITIONS
Certain cardiac conditions are associated with endocarditis more often than others. (2) Furthermore, when endocarditis
develops in individuals with underlying cardiac conditions, the severity of the disease and the ensuing morbidity can be variable.
Prophylaxis is recommended in individuals who have a higher risk for developing endocarditis than the general population and is
particularly important for individuals in whom endocardial infection is associated with high morbidity and mortality.
(* Table 1*) (2-22) stratifies cardiac conditions into high- and moderate-risk categories primarily on the basis of potential
outcome if endocarditis occurs.

                            *Table 1.-Cardiac Conditions Associated With Endocarditis sup 2-22 *

High Risk
Individuals at highest risk are those who have prosthetic heart valves, a previous history of endocarditis (even in the absence of
other heart disease), complex cyanotic congenital heart disease, or surgically constructed systemic pulmonary shunts or
conduits. (2,3) These individuals are at a much higher risk for developing severe endocardial infection that is often associated
with high morbidity and mortality.
Moderate Risk
Individuals with certain other underlying cardiac defects are at moderate risk for severe infection. (2-4) Congenital cardiac
conditions listed in the moderate-risk category include the following uncorrected conditions: patent ductus arteriosus, ventricular
septal defect, primum atrial septal defect, coarctation of the aorta, and bicuspid aortic valve. Acquired valvar dysfunction (eg,
due to rheumatic heart disease or collagen vascular disease) and hypertrophic cardiomyopathy are also moderate-risk
conditions.
Mitral valve prolapse (MVP) is common, and the need for prophylaxis for this condition is controversial. Only a small
percentage of patients with documented MVP develop complications at any age. (5-7) Mitral valve prolapse represents a
spectrum of valvular changes and clinical behavior. (5-7) In view of the controversy surrounding the need for prophylaxis of the
individual patient with MVP, a detailed description of the spectrum of MVP is warranted.
Normal mitral valve leaflets close at or below the plane of the mitral annulus. This closure position is controlled by the lengths of
the leaflets, their attached chordae and papillary muscles, and the systolic size of the ventricle. The closure position will shift
beyond the annular plane toward the left atrium, or prolapse, if the lengths of the valve apparatus, which are constant, become
too large for the size of the end-systolic ventricle, which is variable and dynamic. Dehydration and tachycardia are common
causes of intermittent MVP. Abnormal motion of normal mitral valves is found on echocardiographic examination in a small
percentage of the adult and adolescent ambulatory population. The high prevalence of such motion abnormalities in young
adults underscores that MVP is often an abnormality of volume status, adrenergic state, or growth phase and not of valve
structure or function. When normal valves prolapse without leaking, as in patients with 1 or more systolic clicks but no murmurs
and no Doppler-demonstrated mitral regurgitation, the risk of endocarditis is not increased above that of the normal population.
(2,6,7) Antibiotic prophylaxis against bacterial endocarditis is therefore not necessary. This is because it is not the abnormal
valve motion but the jet of mitral insufficiency that creates the shear forces and flow abnormalities that increase the likelihood of
bacterial adherence on the valve during bacteremia.
Normal mitral valves with normal motion often have minimal leaks detectable by Doppler examination. This does not appear to
increase the risk of endocarditis. In contrast, the regurgitation that occurs with structurally normal but prolapsing valves
originates from larger regurgitant orifices and creates broader areas of turbulent flow. Patients with prolapsing and leaking mitral
valves, evidenced by audible clicks and murmurs of mitral regurgitation or by Doppler-demonstrated mitral insufficiency, should
receive prophylactic antibiotics. (7-11) This is supported by formal cost-benefit analysis. (12)
Mitral valve prolapse also occurs in the setting of myxomatous degeneration of the mitral valve. This is a progressive disorder
that has a spectrum of manifestations. (13,14) The mitral leaflets of these patients appear thickened on the echocardiogram, due
to accumulations of proteoglycan deposits. (15) The amount of thickening is variable and may increase with age. (16) There is a
range of valve motion in these patients as well: they may prolapse continuously or only with changes in heart rate or volume.
Further, when prolapse occurs, it may or may not create valvular insufficiency. In patients of any age, myxomatous mitral valve
degeneration with regurgitation is an indication for antibiotic prophylaxis. (11,17,18)
Anterior mitral valve thickening is commonly found in both competent and insufficient myxomatous mitral valves, but its
presence increases the likelihood of significant mitral regurgitation. (16) Those with significant regurgitation were older and more
likely to be men. (16) Other studies have shown that male sex and age older than 45 years represent increased risk for
developing endocarditis. (8,10,11,19) Patients with thickened valves that do not leak on resting examination often develop
regurgitation with exercise. These patients with exercise-induced mitral insufficiency have been shown to constitute a higher-risk
subset for common complications (syncope, congestive heart failure, progressive regurgitation requiring valve replacement);
endocarditis and cerebral embolic events, occurring far less frequently, were not demonstrated to be increased in this small
series. (20) Men older than 45 years with MVP, without a consistent systolic murmur, may warrant prophylaxis even in the
absence of resting regurgitation. (12,19)
Some experts feel that an audible nonejection click even without a murmur may identify patients with a potential for intermittent
regurgitation and therefore a risk of developing endocarditis. While there are insufficient data on this issue, an isolated click may
be an indication for more thorough evaluation of valve morphology and function, including Doppler-echocardiographic imaging
or auscultation during maneuvers that elicit or augment mitral regurgitation.
While children and adolescents with MVP may have the same symptoms as adults, such as palpitations or syncope, the
development of symptoms in childhood is relatively unusual. The vast majority of children with chest pain or fatigue do not have
any form of heart disease, including MVP. Careful evaluation is nevertheless required in children who have isolated clinical
findings, such as nonejection systolic click, since this may be the only indicator of important mitral valve abnormality requiring
prophylaxis. (21) In the most recent series of reports, MVP has emerged as an important underlying diagnosis associated with
endocarditis in the pediatric age group. (3,21)
A clinical approach to determination of the need for prophylaxis in individuals with suspected MVP is given in (* Figure 1*).
(23)

                            *Figure 1. Clinical approach to determination of the need for prophylaxis in patients with
                            suspected mitral valve prolapse. For more details on the role of echocardiography in the
                            diagnosis of mitral valve prolapse, see the text and the 1997 American College of
                            Cardiology/American Heart Association guidelines for the clinical application of
                            echocardiography. (23) *

Negligible Risk
Although endocarditis may develop in any individual, including persons with no underlying cardiac defect, the negligible-risk
category lists cardiac conditions in which the development of endocarditis is not higher than in the general population. Whereas
in pediatric patients innocent heart murmurs may be clearly defined on auscultation, in the adult population other studies such as
echocardiography may be necessary to confirm that a murmur is innocent. Individuals with innocent heart murmurs have
structurally normal hearts and do not require prophylaxis.
BACTEREMIA-PRODUCING PROCEDURES
Bacteremias commonly occur during activities of daily living such as routine tooth brushing or chewing. With respect to
endocarditis prophylaxis, significant bacteremias are only those caused by organisms commonly associated with endocarditis
and attributable to identifiable procedures. The procedures for which prophylaxis is recommended are those known to induce
such bacteremias and are discussed below. Invasive procedures performed through surgically scrubbed skin are not likely to
produce such bacteremias. Many centers do employ periprocedure prophylaxis for transcatheter insertion of prosthetic devices
(septal occluders and vascular coils), however, although there are no data to support the use of antibiotics in the procedures.
Routine cardiac catheterization and angioplasty do not require such precautions.
DENTAL AND ORAL PROCEDURES
Poor dental hygiene and periodontal or periapical infections may produce bacteremia even in the absence of dental procedures.
The incidence and magnitude of bacteremias of oral origin are directly proportional to the degree of oral inflammation and
infection. (24,25) Individuals who are at risk for developing bacterial endocarditis should establish and maintain the best
possible oral health to reduce potential sources of bacterial seeding. Optimal oral health is maintained through regular
professional care (24,26,27) and the use of appropriate dental products such as manual and powered toothbrushes, dental
floss, and other plaque-removal devices. Oral irrigator or air abrasive polishing devices used inappropriately or in patients with
poor oral hygiene have been implicated in producing bacteremia, but the relationship to bacterial endocarditis is unknown.
(24,28-31) Home-use devices pose far less risk of bacteremia in a healthy mouth than does ongoing oral inflammation.
(24,28-31)
Antiseptic mouth rinses applied immediately prior to dental procedures may reduce the incidence or magnitude of bacteremia.
(24) Agents include chlorhexidine hydrochloride and povidone-iodine. Fifteen milliliters of chlorhexidine can be given to all
at-risk patients via gentle oral rinsing for about 30 seconds prior to dental treatment; gingival irrigation is not recommended.
Sustained or repeated frequent interval use is not indicated as this may result in the selection of resistant microorganisms. (24)
Antibiotic prophylaxis for at-risk patients is recommended for dental and oral procedures likely to cause bacteremia ((* Table
2*) (22,24-26,28-31)). In general, prophylaxis is recommended for procedures associated with significant bleeding from hard
or soft tissues, periodontal surgery, scaling, and professional teeth cleaning. Similarly, antimicrobial prophylaxis is recommended
for tonsillectomy or adenoidectomy. It is recognized that unanticipated bleeding may occur on some occasions. In such an
event, data from experimental animal models suggest that antimicrobial prophylaxis administered within 2 hours following the
procedure will provide effective prophylaxis. (32) Antibiotics administered more than 4 hours after the procedure probably
have no prophylactic benefit. Procedures for which antimicrobial prophylaxis is not recommended are also listed (* Table 2*).

                            *Table 2.-Dental Procedures and Endocarditis Prophylaxis sup 22,24-26,28-31 *

Edentulous patients may develop bacteremia from ulcers caused by ill-fitting dentures. Denture wearers should be encouraged
to have periodic examination or to return to the practitioner if discomfort develops. When new dentures are inserted, it is
advisable to have the patient return to the practitioner to correct any problems that could cause mucosal ulceration.
If a series of dental procedures is required, it may be prudent to observe an interval of time between procedures to both reduce
the potential for the emergence of resistant organisms and allow repopulation of the mouth with antibiotic susceptible flora.
Various studies have suggested an interval of 9 (33) to 14 (34) days. If possible, a combination of procedures should be
planned within the same period of prophylaxis.
RESPIRATORY, GASTROINTESTINAL, AND GENITOURINARY
TRACT PROCEDURES
Surgical procedures involving the respiratory mucosa may lead to bacteremia; therefore, antimicrobial prophylaxis is
recommended ((* Table 3*) (35-58)). The use of a rigid bronchoscope may cause mucosal damage, whereas such damage is
unlikely with a flexible bronchoscope. Endotracheal intubation per se is not an indication for antibiotic prophylaxis.

                            *Table 3.-Other Procedures and Endocarditis Prophylaxis sup 35-58 *

The risk of endocarditis as a direct result of an endoscopic procedure is small. Transient bacteremia may occur during or
immediately after endoscopy; however, there are few reports of infective endocarditis attributable to endoscopy. (35-43) For
most gastrointestinal endoscopic procedures, the rate of bacteremia is 2% to 5%, and the organisms typically identified are
unlikely to cause endocarditis. (44,45) The rate of bacteremia does not increase with mucosal biopsy, polypectomy, or
sphincterotomy. (46-48) There are no data to indicate that deep biopsy, as may be performed in the rectum or stomach, leads
to a higher rate of bacteremia.
Some gastrointestinal procedures are associated with a higher rate of transient bacteremia; for these procedures, antimicrobial
prophylaxis is recommended, particularly for patients in the high-risk category (* Table 3*). Esophageal stricture dilation has
been associated with bacteremia rates as high as 45%. (44) However, this number is an average result of several clinical studies
in which the rate of bacteremia ranged from 0% to 100%. (49-52) In only 1 study was the oropharynx the documented source
of infection. (52) These studies were performed with differing methods and involved relatively small numbers of patients. Until
more data documenting the true rate of bacteremia associated with stricture dilation become available, it is prudent to consider
this procedure as one potentially associated with an increased risk of transient bacteremia.
The bacteremia rate associated with sclerotherapy of esophageal varices is approximately 31%. (44) Bacteremia appears to be
most associated with increased sclerosant volumes, as can occur with emergency sclerosis for active bleeding, and with
relatively longer injection needles. The bacteremia rate is lessened with the use of shorter injection needles and sterile water.
(53,54) Endoscopic ligation of varices, or banding, is not associated with increased rates of transient bacteremia. (55)
An obstructed biliary tree, due to benign or malignant disease, may be colonized with a variety of organisms. A prime risk
factor for dissemination of infection from an obstructed biliary tree is instrumentation of the obstructed region without provision
of adequate drainage. The bacteremia rates for endoscopic retrograde cholangiography in the absence of ductal obstruction are
approximately equal to most other endoscopic procedures. Prophylaxis should be considered primarily in cases in which biliary
obstruction is known or suspected.
In biliary tract surgery, or in any operative procedure that involves the intestinal mucosa, there is a potential for bacteremia with
organisms known to cause endocarditis. It is therefore prudent to provide prophylaxis for patients at high risk to develop
endocarditis.
Surgery, instrumentation, or diagnostic procedures that involve the genitourinary tract may cause bacteremia. Although the risk
that any particular patient will develop endocarditis is low, the genitourinary tract is second only to the oral cavity as a portal of
entry for organisms that cause endocarditis. The rate of bacteremia following urinary tract procedures is high in the presence of
urinary tract infection (UTI). Sterilization of the urinary tract with antimicrobial therapy in patients with bacteriuria should be
attempted prior to elective procedures, including lithotripsy. Results of a preprocedure urine culture will allow the practitioner to
choose antibiotics appropriate to the recovered organisms. Procedures for which antimicrobial prophylaxis is or is not
recommended are listed in (* Table 3*).
Many procedures involving the urethra and prostatic bed are associated with high rates of bacteremia. The incidence of
bacteremia was studied in 300 patients undergoing 1 of 4 different urologic procedures: transurethral resection (TUR) of the
prostate, cystoscopy, urethral dilation, and urethral catheterization. (56) Bacteremia was most frequent after TUR of the
prostate, occurring in 31% of the patients. In the other procedures, bacteremia occurred in 24% following urethral dilatation, in
17% following cystoscopy, and in 8% following urethral catheterization. Bacteremia was significantly associated with both
prostatitis on histological examination of resected prostate and prior UTI following TUR and with prior UTI following urethral
dilatation and cystoscopy. Preexisting UTI was the major source of organisms causing the bacteremia following TUR but was
the source in only about one third of patients following the other procedures. Enterococci and Klebsiella were the most frequent
organisms. Although bacteremia due to gram-negative bacilli is unlikely to cause endocarditis unless a prosthetic valve is
present, it may nevertheless cause life-threatening sepsis. Therefore, an antimicrobial regimen effective against the infective
urinary pathogen, eg, enteric gram-negative bacilli, in addition to the enterococcus, should be administered before the invasive
genitourinary procedures.
Bacteremia follows uncomplicated vaginal delivery in only 1% to 5% of procedures, usually with various types of streptococci
(22); well-documented cases of endocarditis after normal vaginal delivery are uncommon. (57) Therefore, antibiotic
prophylaxis for normal vaginal delivery is not recommended. If an unanticipated bacteremia is suspected during vaginal delivery,
intravenous antibiotics can be administered at that time. No bacteremia has been detected in studies following cervical biopsy
or manipulation of an intrauterine device (IUD) in the absence of obvious infections. (22) Bacteremia following removal of an
infected IUD is unresolved (58) but would seem possible and should warrant prophylaxis, as would other genitourinary
procedures in the presence of infection.
PROPHYLACTIC REGIMENS
Prophylaxis is most effective when given perioperatively in doses that are sufficient to assure adequate antibiotic concentrations
in the serum during and after the procedure. To reduce the likelihood of microbial resistance, it is important that prophylactic
antibiotics be used only during the perioperative period. They should be initiated shortly before a procedure and should not be
continued for an extended period (no more than 6 to 8 hours). In the case of delayed healing,