Infective endocarditis, a severe infection of the heart lining, maybe following invasive dental procedures in at-risk individuals. This condition is particularly risky for individuals with certain heart conditions, making the prevention critical. The use of antibiotics before such dental interventions is still widely debated.
Key findings
- Antibiotic prophylaxis significantly reduces infective endocarditis risk in high-risk patients post-dental procedures, aligning with American Heart Association and European Society of Cardiology guidelines
- No significant benefit for moderate or low/unknown risk groups.
Aim
To systematically review and evaluate the effectiveness of antibiotic prophylaxis in preventing infective endocarditis among at-risk patients following dental procedures, according to the guidelines of the American Heart Association and the European Society of Cardiology.
Methods
- The study protocol was registered with PROSPERO for transparency, and adhered to MOOSE and PRISMA standards.
- A literature search was carried out across several key databases, including PubMed and Cochrane-CENTRAL, up until May 2023, targeting keywords related to endocarditis and dental prophylaxis.
- Eligibility criteria aimed at including studies with direct assessments or time-trend analyses related to antibiotic prophylaxis, while specifically excluding those lacking peer review, relevance, or sufficient quality.
- The dental procedures included: dental extractions, periodontal surgeries, endodontic treatments (such as root canal therapy), and oral surgeries (e.g., tooth implants, and bone grafting).
- The quality of the included studies was evaluated using validated tools from the Cochrane Collaboration and the National Heart, Lung, and Blood Institute (NHLBI).
- A random-effects meta-analysis of observational studies was conducted to quantify the protective benefit of antibiotic prophylaxis.
Results
Description of Included Studies
- 30 studies met the inclusion criteria, featuring a variety of study designs: observational cohorts, case-control studies, self-controlled series, and time-trend analyses.
- The review included data from 8 countries including the US, Europe, Taiwan, and Canada, covering a wide timeframe and ranging from under 100 to over a thousand participants.
Main Findings
Risk Group Variability:
from the Meta-analysis, high-risk patients receiving antibiotic prophylaxis showed a 59% reduced risk of infective endocarditis compared to those not receiving prophylaxis, with a confidence interval of (43-71).
Impact of Guideline Changes:
- Mixed Outcomes: Time-trend analyses showed variable impacts of guideline changes on prophylaxis use, with 9 studies reporting no significant change, 7 noting an increase, and 3 observing a decrease in infective endocarditis incidence.
Study Quality and Heterogeneity:
- High Quality with Variability: The included studies were of good quality but demonstrated considerable heterogeneity in design, participant demographics, interventions, and measured outcomes.
Study citation:
Comments:
The study addressed a key clinical question regarding the effectiveness of antibiotic prophylaxis in preventing infective endocarditis post-dental procedures. It incorporated data from various study designs and multiple countries, thereby enhancing the generalisability of findings. Rigorous methodology was evident through the use of structured tools for study selection, quality assessment, and statistical analysis, ensuring methodological robustness. However, several limitations warrant consideration. Variability in infective endocarditis diagnosis criteria and antibiotic prophylaxis adherence across studies may introduce bias and affect result validity. Unaccounted confounders, such as changes in healthcare practices or patient characteristics over time, could influence the observed associations, and the reliance on observational data rather than randomised controlled trials limits the ability to establish causality.
Photo credit
Photo by Volodymyr Hryshchenko on Unsplash
