In March 2008 the National Institute for Health and Clinical Excellence (NICE) produced new guidance recommending the cessation of antibiotic prophylaxis for all patients at risk of infective endocarditis undergoing dental and a wide range of other invasive procedures. At the time this was controversial and although there were similar changes to recommendations in American and Europe they stopped short of recommending the complete cessation of antibiotic prophylaxis.

In the UK dentists were responsible for most of the prescribing (91.6%) and following the introduction there has been a 78.6% decrease in prescribing. In 2011 Thornhill et al published at before and after study using routinely collected data and found that the study;

excluded any large increase in the incidence of cases of or deaths from infective endocarditis in the two years after the guideline.

Consequently they considered that the findings support the cessation of prescribing of antibiotic prophylaxis recommended by the guideline, although they did recommended ongoing monitoring.

In American dental practice antibiotic prophylaxis is used for a wide range of patient populations thought to be a risk of infection from dental procedures, although the evidence-base to support their use is weak or lacking. There are three concerns with the widespread use of antibiotics for routine prophylaxis; life-threatening anaphylaxis; increasing prevalence of drug-resistant bacterial strains and costs.

Lockhart et al in an interesting new paper have estimated the potential costs of this wide spread use if antibiotics in the USA and put the costs at $19,880,279 to $143,685,823 although they consider that these could be an underestimate.  Given the experience here in the UK and both the potential adverse effects of widespread antibiotic prescribing and the costs Lockhart’s call for a more evidence-based guidance in the US is clearly warranted.

Links

NICE CG64. Prophylaxis against infective endocarditis: Antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures

Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et al. Prevention of infective endocarditis. Guidelines from the American Heart Association. A guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 2007;116:1736-54.

Habib G, Hoen B, Tornos P, Thuny F, Prendergast B, Vilacosta I, et al. Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009): the Task Force on the Prevention, Diagnosis, and Treatment of Infective Endocarditis of the European Society of Cardiology (ESC). Eur Heart J 2009;30:2369-413.

Thornhill MH, Dayer MJ, Forde JM, Corey GR, Chu VH, Couper DJ, Lockhart PB. Impact of the NICE guideline recommending cessation of antibiotic prophylaxis for prevention of infective endocarditis: before and after study. BMJ. 2011 May 3;342:d2392. doi: 10.1136/bmj.d2392. PubMed PMID: 21540258; PubMed Central PMCID: PMC3086390.

Lockhart PB, Blizzard J, Maslow AL, Brennan MT, Sasser H, Carew J. Drug cost implications for antibiotic prophylaxis for dental procedures. Oral Surg Oral Med Oral Pathol Oral Radiol. 2012 Dec 19. doi:pii: S2212-4403(12)01639-2. 10.1016/j.oooo.2012.10.008. [Epub ahead of print] PubMed PMID: 23265984.