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Infective endocarditis: Coroner’s report questions NICE guidance on prevention

BMJ 2024; 385 doi: (Published 13 May 2024) Cite this as: BMJ 2024;385:q1081

Rapid Response:

Re: Infective endocarditis: Coroner’s report questions NICE guidance on prevention

Dear Editor

The coroner was right to raise these concerns regarding the infective endocarditis (IE) related death of Mr Briggs following dental extractions. Particularly as these coincide with the publication of two papers one in the Lancet Regional Health Europe [1] and the other in the British Dental Journal [2] raising the same concerns and calling for NICE to review its guidance on IE prevention (last reviewed in 2015) because of more recent evidence demonstrating the efficacy, safety and cost-effectiveness of giving high-risk patients (such as Mr Briggs) antibiotic prophylaxis (AP) before undergoing invasive dental procedures. The new evidence reviewed in these two papers is strongly supportive of the European Society of Cardiology (ESC) Guidelines for the management of endocarditis [3] and all other international guidelines that recommend AP before invasive dental procedures for those at high-risk. However, the new evidence raises serious questions about the ambiguity and safety of current NICE guidance (CG64) that says “Antibiotic prophylaxis against infective endocarditis is not recommended routinely for people undergoing dental procedures”.[4]

NICE has established a prioritisation committee to determine if it should expend scarce public resources to produce or review guidelines, particularly in situations where good quality national or international guidelines already exist. Given this, NICE should urgently review CG64 and determine if it wouldn’t be better for it to adopt or endorse the high-quality and regularly reviewed ESC guidelines that are already adopted by doctors and dentists across Europe and by most cardiologists in the UK. Adoption of the ESC guidelines would also ensure that the 400,000 patients at high-IE-risk in the UK would benefit from the same protection against IE afforded high-risk patients across Europe and the rest of the world.

1. Thornhill M, Prendergast B, Dayer M, et al. Endocarditis prevention: time for a review of NICE guidance. Lancet Reg Health Eur 2024;39:100876.
2. Thornhill M, Prendergast B, Dayer M, et al. New evidence calls into question NICE's endocarditis prevention guidance. British dental journal 2024;236(9):702-08.
3. Delgado V, Ajmone Marsan N, de Waha S, et al. 2023 ESC Guidelines for the management of endocarditis. Eur Heart J 2023;44(39):3948-4042.
4. National Institute for Health and Care Excellence (NICE). Prophylaxis against infective endocarditis. [NICE Clinical Guideline No 64]. Mar 2008, (last reviewed March 2015, reworded Jul 2016).

Competing interests: No competing interests

14 May 2024
Martin H. Thornhill
Professor of Translational Research in Dentistry
University of Sheffield