For many years, antibiotic prophylaxis was routinely administered before dental and other procedures to patients with cardiac conditions that carry a high lifetime risk of infective endocarditis. However due to the infrequent occurrence of endocarditis, prophylaxis prevents very few cases. Infective endocarditis is more likely to result from bacteraemia associated with daily activities (e.g. tooth brushing) than from specific dental procedures, so the maintenance of good oral health and hygiene everyday is more important than prophylactic antibiotics.
Most recommendations for antibiotic prophylaxis are based on expert opinion and consensus due to the lack of randomised controlled trials. There has been a steady reduction in the number of indications for prophylaxis in international consensus guidelines since 2002. The National Institute for Health and Care Excellence in the United Kingdom removed nearly all indications for antibiotic prophylaxis to prevent infective endocarditis in 2008. These guidelines are currently under review due to an unexplained possible increase in the incidence of endocarditis in the UK.
The Australian Therapeutic Guidelines: Antibiotic continues to recommend antibiotic prophylaxis in a restricted group of patients until further evidence is available. Indications where antibiotic prophylaxis should be used for a range of procedures in patients who meet these criteria (please consult the guidelines for more specific details):
- prosthetic cardiac valve or prosthetic material used for cardiac valve repair
- previous infective endocarditis
- some congenital heart disease
- rheumatic heart disease in high-risk patients
There is a patient fact sheet available from the Australian National Prescribing Service.
One of the IDSA Choosing Wisely issues was to: