Guidelines differ in their recommendations for antibiotic prophylaxis; check your local protocols. Decisions about antibiotic prophylaxis should only be made after careful evaluation of the individual patient’s circumstances, following discussion with the patient, taking into account the patient’s values and preferences, and using your clinical judgement.
The European Society of Cardiology (ESC) recommends that antibiotic prophylaxis should only be considered if the patient is at highest risk of IE and undergoing a dental procedure that requires manipulation of the gingival or periapical region of the teeth or perforation of the oral mucosa. The ESC considers a patient to be at highest risk of IE if they have:[7]
A prosthetic valve, including a transcatheter valve or a valve in which any prosthetic material was used for valve repair
A history of a previous episode of IE
Untreated cyanotic congenital heart disease, or congenital heart disease that has been repaired with a prosthetic material (including valved conduits or systemic-to-pulmonary shunts)
A ventricular assist device.
In the UK, the National Institute for Health and Care Excellence (NICE) recommends that an at-risk patient undergoing interventional procedures should not be given antibiotic prophylaxis against IE routinely. However, NICE emphasises that antibiotic therapy is still necessary to treat active or potential infections.[17] NICE considers a patient to be at-risk if they have:[17]
Acquired valvular heart disease with stenosis or regurgitation
Hypertrophic cardiomyopathy
Previous IE
Structural congenital heart disease, including surgically corrected or palliated structural conditions, but excluding isolated atrial septal defect, fully repaired ventricular septal defect, fully repaired patent ductus arteriosus, and closure devices that are judged to be endothelialised
Valve replacement.
NICE recommends giving clear information about prevention to any patient at risk of IE, which should include:[17]
The benefits and risks of antibiotic prophylaxis, and an explanation of why antibiotic prophylaxis is no longer routinely recommended
The importance of maintaining good oral health
Symptoms that may indicate IE and when to seek expert advice
The risks of undergoing invasive procedures, including non-medical procedures such as body piercing or tattooing.
The recommendations from the ESC and NICE may not be universally accepted in other countries.
The most common cause of infective endocarditis following dental, oral, respiratory tract, or oesophageal procedures is Streptococcus viridans (alpha-haemolytic streptococci). Therefore, antibiotics (if they are to be given for prophylaxis) are directed toward this organism, and administered as a single dose 30 to 60 minutes before the procedure.
Base your choice of antibiotic on your local hospital protocols.
The ESC recommends clindamycin if the patient is allergic to penicillin or ampicillin. However, the American Heart Association no longer recommends clindamycin, based on a study that suggests a single dose of clindamycin may cause complications, including death, from Clostridioides difficile infection.[18][19]
The evidence for antibiotic prophylaxis preventing infection following dental procedures and instrumentation of the respiratory, genitourinary, or gastrointestinal tract is weak. Conflicting data suggest that a reduction in bacteraemia may not result in a lower incidence of infective endocarditis in low-risk individuals.[20] The risk of bacteraemia resulting from interventions such as dental procedures and instrumentation of the respiratory, genitourinary, or gastrointestinal tract is significantly smaller than from usual life-time activities such as toothbrushing or chewing.[21] Data have indicated that, even if treatment with prophylactic antibiotics were 100% effective, only a small number of cases would be prevented.