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Practice Guidelines

Prophylaxis against infective endocarditis: summary of NICE guidance

BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39510.423148.AD (Published 03 April 2008) Cite this as: BMJ 2008;336:770
  1. Roberta Richey, technical analyst1,
  2. David Wray, professor of oral medicine2,
  3. Tim Stokes, associate director1
  4. on behalf of the Guideline Development Group
  1. 1National Institute for Health and Clinical Excellence, Manchester M1 4BD
  2. 2Glasgow Dental School, Glasgow G2 3JZ
  1. Correspondence to: D Wray d.wray{at}dental.gla.ac.uk

Why read this summary?

Infective endocarditis is a rare condition with a high mortality and morbidity. Accepted clinical practice has been to use antibiotic prophylaxis in those at risk of infective endocarditis who are having dental and certain non-dental interventional procedures, in the belief that this may prevent the development of infective endocarditis. The effectiveness of such antibiotic prophylaxis in humans is, however, not proved1 and recent international guidelines recommend a much more limited role for antibiotic prophylaxis against infective endocarditis. This article summarises the most recent guidance from the National Institute for Health and Clinical Excellence (NICE) on antibiotic prophylaxis against infective endocarditis.2

Recommendations

NICE recommendations are based on systematic reviews of best available evidence. When minimal evidence is available recommendations are based on the guideline development group’s opinion of what constitutes good practice. With a serious rare condition, such as infective endocarditis, research using experimental study designs is difficult and the evidence base consists of observational (predominantly case-control) studies. Evidence levels for the recommendations are given in italic in square brackets.

Identifying cardiac risk factors

Regard patients with the following cardiac conditions as being at risk of developing infective endocarditis [based on moderate quality evidence from medium sized observational studies]:

  • Acquired valvular heart disease with stenosis or regurgitation

  • Valve replacement

  • Structural congenital heart disease (including surgically corrected or palliated structural conditions but excluding isolated atrial septal defect, fully repaired ventricular septal defect or fully repaired patent ductus arteriosus, and closure devices deemed to be endothelialised)

  • Previous infective endocarditis

  • Hypertrophic cardiomyopathy.

Patient advice

Offer patients at risk of infective endocarditis clear and consistent information about the prevention of infective endocarditis, including the following topics [based on the experience of the guideline development group]:

  • Outline the benefits and risks of antibiotic prophylaxis, and include an explanation that antibiotic prophylaxis is no longer routinely recommended (as its clinical effectiveness is not proved, it is not cost effective, and, compared with no prophylaxis at all, it may lead to more deaths from anaphylaxis)

  • Emphasise the importance of maintaining good oral health

  • Outline the symptoms that may indicate a diagnosis of infective endocarditis and when to seek expert advice

  • Explain the potential risks of having non-medical invasive procedures (such as body piercing or tattooing).

Prophylaxis for patients at risk of infective endocarditis

  • Antibiotic prophylaxis against infective endocarditis is not recommended in the following circumstances:

    • -For patients undergoing dental procedures [based on moderate quality evidence from medium sized observational studies and small randomised controlled trials]

    • -For people undergoing non-dental procedures at the following sites [based on moderate quality evidence from medium sized observational studies, expert opinion, and the experience of the guideline development group]: upper and lower gastrointestinal tract; genitourinary tract (this includes urological, gynaecological, and obstetric procedures, and childbirth); upper and lower respiratory tract (this includes ear, nose, and throat procedures, and bronchoscopy).

  • Chlorhexidine mouthwash should not be offered as prophylaxis against infective endocarditis to people at risk of infective endocarditis who are having dental procedures [based on moderate quality evidence from small randomised controlled trials].

  • Promptly investigate and appropriately treat any episodes of infection to reduce the risk of the patient subsequently developing endocarditis [based on the experience of the guideline development group].

  • If a person at risk of infective endocarditis is receiving antimicrobial therapy because they are having a gastrointestinal or genitourinary procedure at a site where there is suspected infection, the person should receive an antibiotic that covers organisms that cause infective endocarditis [based on the experience of the guideline development group].

Overcoming barriers

This guideline represents an important change to accepted clinical practice in limiting the role of antibiotic prophylaxis for those at risk of infective endocarditis. The evidence shows that everyday activities such as regular tooth brushing almost certainly present a greater risk of infective endocarditis than a single dental procedure because they can cause repetitive bacteraemias with oral flora. Furthermore no consistent association has been shown between having an interventional procedure and the development of infective endocarditis. Effective implementation of this guideline will require the education and training of healthcare staff to ensure that consistent information is given by different professional groups. Patient information and education will be important. NICE has developed tools to help organisations implement the guideline.2

Further information on the guidance

Background

Infective endocarditis is a rare condition (<10 in 100 000) with considerable mortality and morbidity.1 The evidence base on the use of antibiotic prophylaxis against infective endocarditis is limited. This short clinical guideline aims to provide clear guidance on the use of antibiotic prophylaxis against infective endocarditis by giving evidence based recommendations.

Methods

This guideline was developed as a short clinical guideline. Short clinical guidelines tackle only part of a care pathway and are intended to allow the rapid (9-11 month timescale) development of guidelines for areas of care for which the NHS requires guidance. Short clinical guidelines are developed by the NICE technical team using the same methods as existing standard NICE guidelines developed by the National Collaborating Centres (www.nice.org.uk).

The NICE Short Clinical Guidelines Technical Team convened a group of healthcare professionals and patient representatives to oversee the work and to help develop the recommendations.

The group conducted a systematic review of the literature, assessed the quality of the literature, and qualitatively synthesised the included evidence as it related to both clinical and cost effectiveness. A de novo health economic model was also developed to determine the cost effectiveness of antibiotic prophylaxis in patients having dental procedures.

The guideline went through an external consultation with stakeholders. The development group then assessed stakeholders’ comments and appropriately modified the guideline.

NICE has produced three different versions of the guideline: a full version, a quick reference guide, and a version for patients and the public. All versions are available from the NICE website.2

Key areas of uncertainty needing further research
  • What is the risk of developing infective endocarditis in those with acquired valvular disease and structural congenital heart disease?

  • What is the frequency and level of bacteraemia caused by non-oral daily activities (for example, urination, defecation)?

Guideline development group

The guideline development group comprised Nicholas Brooks, Nick Cooley, Deborah Franklin, Martin Fulford, John Gibb, Anne Keatley-Clarke, Danny Keenan, Richard Oliver, Kathy Orr, Suzannah Power, Jonathan Sandoe, and David Wray (chair).

The NICE Short Guidelines Technical Team comprised Lynda Ayiku, Emma Banks, Michael Heath, Roberta Richey, Francis Ruiz, and Tim Stokes.

Footnotes

  • This is one of a series of BMJ summaries of new guidelines, which are based on the best available evidence; they will highlight important recommendations for clinical practice, especially where uncertainty or controversy exists.

  • Contributors: RR drafted the summary, and TS and DW reviewed the contents.

  • Funding: The Centre for Clinical Practice (Short Clinical Guidelines Technical Team), part of the National Institute for Health and Clinical Excellence, wrote this summary.

  • Competing interests: DW is a director with the Medical and Dental Defence Union of Scotland.

  • Provenance and peer review: Commissioned; not peer reviewed.

References

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