Intended for healthcare professionals

Letters Infective endocarditis

NICE v world on endocarditis prophylaxis

BMJ 2011; 342 doi: (Published 14 June 2011) Cite this as: BMJ 2011;342:d3531
  1. John B Chambers, professor of clinical cardiology1,
  2. David Shanson, consultant in infectious diseases2,
  3. Graham Venn, consultant cardiac surgeon1,
  4. John Pepper, professor of cardiac surgery3
  1. 1Cardiothoracic Centre, St Thomas’ Hospital, London SE1 7EH, UK
  2. 2Department of Medical Microbiology, Great Ormond Street Hospital, London, UK
  3. 3Brompton Hospital, London, UK
  1. jboydchambers{at}

Articles defending the National Institute for Health and Clinical Excellence’s (NICE) advocacy of no antibiotic prophylaxis tend to suggest that the contrary position is universal antibiotic prophylaxis.1 But the essential difference between American, European, and Australian guidelines and those from NICE is in advising antibiotics for high risk cardiac patients (those with prosthetic heart valves or previous endocarditis) having high risk dental procedures (mainly extractions).2

In this high risk group, endocarditis is more common and more dangerous than in native valve lesions,3 4 with an acute mortality of 25% and a survival rate of only 55% at five years.2 Furthermore there is evidence, albeit no proof, that antibiotics are effective.2 In one study,5 six cases of endocarditis occurred in 304 patients with prosthetic valves who were not protected by antibiotics, but none in 229 protected patients.

The number of high risk patients having high risk procedures in the recent study is unknown, but probably small.1 The incidence of endocarditis is low, so the study was not designed to detect an effect in the group under debate. Furthermore, unpublished local audits suggest that patients at high risk tend to continue taking antibiotics.

The authors are wrong to conclude that their findings support the near total cessation of antibiotic prescribing recommended by NICE. We urgently need a national registry of new cases of endocarditis and a randomised controlled trial of antibiotic prophylaxis in high risk patients before we change from almost universally accepted international guidelines in favour of NICE.


Cite this as: BMJ 2011;342:d3531


  • Competing interests: None declared.


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