Impact of the NICE guideline recommending cessation of antibiotic prophylaxis for prevention of infective endocarditis: before and after studyBMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d2392 (Published 03 May 2011) Cite this as: BMJ 2011;342:d2392
All rapid responses
Endocarditis prevention guides have advanced in recent years;
however, there are few evidence-based recommendation schedules in the
The first controversies regarding preventive schemes derived from the
Task Force on Infective Endocarditis of the ESC (Guidelines on Prevention, Diagnosis and Treatment of IE. Eur Heart J (2004); Horstkotte
D). Later updates reconsider these descriptives in the 'Prevention of
infective endocarditis. Guidelines from the American Heart Association (Wilson W. Circulation 2007;115:1656-8), and infective endocarditis in valvular heart disease was considered by Nishimura RA et al. (ACC/AHA 2008 guideline update. Circulation 2008;118:887-96).
Competing interests: No competing interests
Articles (1) defending the NICE committee's advocacy of no antibiotic
prophylaxis tend to suggest that the contrary position is universal
antibiotic prophylaxis. In fact the essential difference between
American, European or Australian guidelines (2-4) and NICE (5) is in
continuing to advise antibiotics for high-risk cardiac patients
(prosthetic heart valves or prior endocarditis) having high-risk dental
procedures (predominantly extractions).
In this high-risk group, endocarditis is more common (6) and more
dangerous (7) than in native valve lesions with an acute mortality 25% and
a survival rate of only 55% at 5 years (8). Furthermore there is evidence
(9), albeit no proof, that antibiotics are effective. In one small study
(10), 6 cases of endocarditis occurred in 304 patients with prosthetic
valves unprotected by antibiotics, but no cases in 229 protected patients.
The number at high-risk having high-risk procedures in the recent
study (1) is not known, but the authors acknowledge that it is likely to
be small. The incidence of endocarditis even in high-risk patients is low
so the study is not designed to detect an effect in the very group that is
under debate. Furthermore patients continuing to take antibiotics are
likely to be those at high risk, which is supported by unpublished local
audits. The authors also acknowledge they had no data on viridans
streptococci which are by far the most relevant for a possible dental
cause of endocarditis.
The authors are wrong to conclude that their findings support the
near-total cessation of antibiotic prescribing as recommended by NICE. We
urgently need a national registry of new cases of endocarditis to examine
the temporal relationships between disease-onset and dental procedures.
We also need a randomised controlled trial of antibiotic prophylaxis in
high-risk patients before considering changing from almost universally-
accepted International guidelines in favour of NICE.
1.Thornhill MH, Dayer MJ, Forde JM et al. Impact of the NICE guideline
recommending cessation of antibiotic prophyaxis for prevention of
infective endoacrditis: before and after study. BMJ 2011; 342:d2392.
2.Nishimura RA, Carabello BA, Faxon DP et al. ACC/AHA guideline update on
valvular heart disease: focused update on infective endocarditis.
Circulation 2008; 118: 887-96.
3.Habib G, Hoen B, Tornos P et al.
Guidelines on the prevention, diagnosis, and treatment of infective
endocarditis (new version 2009. The Task Force on the Prevention ,
Diagnosis and Treatment of Infective Endocarditis of the European Society
of Cardiology. European Heart J 2009; 30: 2369-413.
Endocarditis Prophylaxis Expert Group. Prevention of Endocarditis 2008
update from Therapeutic Guidelines: Antibiotic Version 13, and Therapeutic
Guidelines: Oral and Dental Version 1, Melbourne: Therapeutic Guidelines
5.National Institute for Health and Clinical Excellence.
Prophylaxis against infective endocarditis. Antimicrobial prophylaxis
against infective endocarditis in adults and children undergoing
interventional procedures. UR http: // www.nice.org.uk/CG064. March 2008.
6.Oliver R, Roberts GJ, Hooper L, Worthington HV. Antibiotics for the
prophylaxis of bacterial endocarditis in dentistry (Review). The Cochrane
Library 2008 issue 4.
7.Wang A, Athan E, Pappas PA et al. Contemporary
clinical profile and outcome of prosthetic valve endocarditis. JAMA 2007;
8.Edwards MB, Ratnatunga CP, Dore CJ, Taylor KM. Thirty-
day mortality and long-term survival following surgery for prosthetic
endocarditis: a study from the UK heart valve registry. Eur J
Cardiothoracic Surg 1998; 14: 156-64.
9.Chambers J, Shanson D, Hall R,
Venn G, Pepper J, McGurk M. Antibiotic prophylaxis of endocarditis: the
rest of the world and NICE. JRSM 2011; 104: 138-40.
Rosin H, Friedrichs W, Loogen F. Contribution for choosing the optimal
prophylaxis of bacterial endocarditis. Europ Heart J 1987; 8 (Suppl J):
Competing interests: No competing interests