Most endocarditis prophylaxis no longer necessary: NICE guideline

General

Clinical Question:
Is prophylaxis necessary for patients with structural cardiac defects undergoing dental or other procedures?

Bottom Line:
The United Kingdom's National Institute for Health and Clinical Excellence (NICE) recommends antibiotic prophylaxis not be given to adults or children with structural cardiac defects undergoing dental and nondental procedures. Chlorhexidine mouthwash is also not recommended. The nondental procedures that do not require prophylaxis include upper and lower gastrointestinal tract procedures; upper and lower respiratory tract procedures; urologic, gynecologic, and obstetric procedures, including childbirth. These recommendations are more conservative than the latest American College of Cardiology/American Heart Association guidelines, described below. (LOE = 2b)

Reference:
Stokes T, Richey R, Wray D; Guideline Development Group. Prophylaxis against infective endocarditis: summary of NICE guidance. Heart 2008;84(7):930-931.  [PMID:18552226]

Study Design:
Practice guideline

Setting:
Various (guideline)

Synopsis:
Recommendations for the prevention of infective endocarditis have been built on a lot of postulated mechanisms and wishful thinking with little evidence to back them up. Although endocarditis is rare, its morbidity and mortality rates are high and the thought was to be safe rather than sorry. The risk of endocarditis, less than 10 per 100,000 per year, may even be less than the deaths associated with anaphylaxis to the antibiotics used to prevent it. Citing low cost-effectiveness and the lack of proof of effectiveness of antibiotic prophylaxis, the NICE committee no longer recommends antibiotic prophylaxis for patients with structural cardiac defects undergoing dental procedures. Upper and lower gastrointestinal tract, genitourinary tract, and respiratory tract procedures do not require prophylaxis. Childbirth also does not require prophylaxis. In contrast, the American College of Cardiology/American Heart Association, in a recent update, states endocarditis prophylaxis is "reasonable" -- a downgrade from "recommended" -- for patients at highest risk for adverse outcomes. These patients will have a prosthetic cardiac valve, previous infective endocarditis, or congenital heart disease either unrepaired or repaired with prosthetic material. Routine dental care does not require prophylaxis, according to this group, unless the procedure involves manipulation of the gingiva or perforation of the oral mucosa. They no longer recommend prophylaxis for nondental procedures (Circulation 2008;118:887-896).

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