For a patient with a documented allergy to penicillin who requires antibiotic prophylaxis for dental procedures, which antibiotic is the most appropriate alternative?

Correct answer: D. Clindamycin

• A. Amoxicillin is a penicillin; it is absolutely contraindicated in patients with penicillin allergy.
• B. Metronidazole has activity against anaerobes but is not indicated for streptococcal endocarditis prophylaxis.
• C. Azithromycin (macrolide) was previously listed as an alternative in older guidelines but was removed in 2021 AHA updates due to variable efficacy and resistance concerns.
• D. Correct. Per the 2021 AHA guidelines, clindamycin is a recommended alternative for endocarditis prophylaxis in penicillin-allergic patients who cannot take amoxicillin. (Note: The 2021 update removed cephalosporins as alternatives due to cross-reactivity concerns for truly allergic patients.)