A 2013 Cochrane Review1 found there is little scientific evidence to support the effectiveness of antibiotic prophylaxis for patients at risk of developing bacterial endocarditis who are about to undergo invasive dental treatment. The review authors found few primary studies that evaluated the effectiveness of antibiotic prophylaxis and they were generally of low quality. Only one case-control study met the inclusion criteria for the review.
In terms of implications for practice, the study authors conclude that “...practitioners need to discuss the potential benefits and harms of preventive antibiotic treatment with their patients before a decision is made about prescribing it.”
CDA’s position statement on prevention of infective endocarditis2 supports the American Heart Association’s (AHA) 2007 guidelines3, which suggest that short-term preventive antibiotic therapy before certain dental and medical procedures are reasonable for patients at greatest risk of developing infective endocarditis.
“The AHA guidelines recognize that the effectiveness of antibiotic prophylaxis for high risk patients is unknown, which is consistent with this most recent Cochrane Review,” says Dr. Susan Sutherland, chair of CDA’s Clinical and Scientific Affairs Committee. “The uncertainty surrounding the effectiveness of antibiotic prophylaxis for these high risk patients makes it all the more important for dentists to discuss the benefits and risks of antibiotic prophylaxis with these patients before a decision is made to prescribe antibiotics.”
Use of prophylactic antibiotic therapy to prevent mortality, serious illness or incidence of bacterial endocarditis is controversial because the adverse effects of antibiotics may outweigh the potential benefits. Many countries recommend giving antibiotics prophylactically to patients at high risk for developing bacterial endocarditis, such as patients with previous endocarditis and prosthetic heart valves. For example, European, American, and Australian guidelines recommend giving antibiotics only to those patients deemed to be at high risk. However, in England and Wales, guidelines published by the National Institute for Health and Care Excellence (NICE) indicate that patients at risk of developing infective endocarditis do not require antibiotics for any interventional procedure—dental or surgical.
To read the CDA position statement on prevention of infective endocarditis, go to cda-adc.ca/_files/position_statements/infectiousEndocarditis.pdf. For information on the impact of the NICE guidelines in the 2 years after they were introduced, see: http://www.jcda.ca/article/jcda_express_issue_6_2011.
- Glenny AM, Oliver R, Roberts GJ, Hooper L, Worthington HV. Antibiotics for the prophylaxis of bacterial endocarditis in dentistry. Cochrane Database Syst. Rev. 2013;10: CD003813.
- Canadian Dental Association. CDA position on prevention of infective endocarditis [accessed 2014 Feb 13]. Available: http://www.cda-adc.ca/_files/position_statements/infectiousEndocarditis.pdf
- American Heart Association. 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(15):1736-54. Epub 2007 Apr 19.