This research from the University of Sheffield reveals the impact of changing (US) guidelines on prescribing antibiotic prophylaxis (AP) before invasive dental treatment to prevent life-threatening infective endocarditis . The findings presented in the Journal of the American College of Cardiology provide further evidence against the complete elimination, in some countries, of the use of PA before invasive dental procedures, even for patients considered to be at high risk. This was particularly the case with the latest recommendation (2008) from the UK National Institute for Health and Care Excellence (NICE) that PA should cease altogether in the UK.
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Infectious endocarditis (IE) is a serious infection of the heart valves resulting in high morbidity and mortality – 30% of people die within a year of diagnosis. Previous studies have shown that around 40% of cases are likely due to bacteria from the mouth. A large number of people with heart conditions are at increased risk of IE and some patients, for example those with artificial heart valves or a history of IE or certain congenital heart conditions, are at high risk of developing IE .
This study is the largest and most comprehensive to take stock of the 2007 American Heart Association (AHA) guidelines which suggested that PA should continue to be prescribed to patients at high risk of developing infective endocarditis but not to moderate-risk patients. In fact, the analysis confirms the validity of these 2007 directives. The analysis shows, following these directives:
- a sharp drop (64%) in the number of PA prescriptions for people at moderate risk of IE;
- but also a worrying drop in the number of PAs prescribed to high-risk patients (20%), despite AHA recommendations for this group of patients;
- a significant increase in the incidence of IE (177%) in those at high risk, but only a marginally significant increase in patients at moderate risk.
Findings that strongly support the AHA recommendation: Lead author Professor Martin Thornhill of the University of Sheffield School of Clinical Dentistry explains that while the data does not prove a causal relationship between reduction in PA and increase in EI, they strongly support the AHA's recommendation to prescribe PA to patients at high risk, but not to those at moderate risk of endocarditis. On the other hand, the study goes against current British recommendations.
While poorly known evidence for the effectiveness of antibiotic prophylaxis, concerns about the risk of adverse effects and the development of antibiotic resistance have led experts to gradually reduce the number of situations in which AP is recommended, the patient has the right to know the arguments for and against prophylaxis and to make an informed decision with their dentist.
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