NICE reaffirms no antibiotic prophylaxis for infective endocarditis

NICE has reaffirmed that antibiotics should not routinely be prescribed to prevent infective endocarditis.

This advice comes in an updated guideline on the use of antibiotic prophylaxis against infective endocarditis in cardiac patients undergoing dental and certain other interventional procedures.

Clinicians had questioned the advice first set out in a 2008 guideline after research published in The Lancet last year suggested that rates of infective endocarditis had increased in England after NICE advised against giving antibiotics to prevent the infection.

Antibiotic prescribing fell significantly from an average of 10,900 prescriptions per month from January 2004 to March 2008, to only 2,236 prescriptions per month from April 2008 to March 2013. But at the same time, rates of infective endocarditis rose by an extra 35 cases a month. However, NICE says there was no evidence to suggest a direct link between the two and the study researchers from the University of Sheffield acknowledged that there may be other reasons for the increase in infections.

NICE decided to assess the research and carried out an immediate review of its 2008 guideline but it found "insufficient evidence" to warrant a change to the existing recommendations.

The decision has caused some controversy, coming just two weeks after the European Society of Cardiology (ESC) guideline committee announced that after evaluation of the same evidence as reviewed by NICE, it had drawn the conclusion that "the balance of evidence/opinion was in favour of the usefulness/efficacy of antibiotic prophylaxis for those at high-risk of IE" and "it therefore continues to recommend that dentists should give antibiotic prophylaxis to patients at high-risk of IE because it considers the risks of IE outweigh any risks from giving antibiotic prophylaxis".

Martin Thornhill, Professor of Translational Research in Dentistry and lead researcher on the Sheffield study, said: "The decision by NICE to dismiss evidence that their decision in 2008 to recommend cessation of antibiotic prophylaxis could be wrong, as well as evidence that antibiotic prophylaxis is safer than previously thought, will cause understandable disbelief and confusion on the part of many cardiologists, dentists and patients in the UK.

"This is particularly the case, when only two weeks ago, following a review of the same information, the European guidelines committee advised dentists that they should give antibiotic prophylaxis to patients at high-risk of infective endocarditis because in their view the risk of not giving antibiotic prophylaxis to these patients far outweighed any risk of giving it."

NICE is recommending further research with a randomised controlled trial with long-term follow-up comparing antibiotic prophylaxis with no antibiotic prophylaxis in adults and children with underlying structural cardiac defects undergoing interventional procedures.

NICE Link: Prophylaxis against infective endocarditis