Clark, R., Kaka, S. Antibiotic prophylaxis for patients undergoing dental care: a multi-centre evaluation in community and hospital dental services. Br Dent J 238, 37–43 (2025). https://doi.org/10.1038/s41415-024-8181-2
Background
Infective endocarditis (IE) is a rare life-threatening condition with a high mortality rate at one year. Oral bacteria is predominantly implicated in IE especially streptococci, staphylococci and enterococci. A systematic review found 11% of patients with IE had dental treatment in the three months before diagnosis. Antibiotic prophylaxis (AP) may be indicated for high risk patients before invasive dental treatment (IDT) (Box 1).
The NICE guidelines have changed through the years, with the most recently update being in 2016. Many cardiac conditions increase the risk of IE, increasing the risk of adverse reactions from IE. In high risk patients, AP should be considered with input from the cardiology team as well.
Oral AP options for adults:
- Amoxicillin
- Clindamycin for patients allergic to penicillin
- Azithromycin for patients allergic to penicillin and unable to swallow capsules
Oral antibiotics are preferred but IV cover may be needed for certain patients.
IV AP for adults undergoing IDT:
- Amoxicillin
- Clindamycin for patient allergic to penicillin
NICE guidelines, SCDEP implementation, American Heart Association guidelines and European Society of Cardiology guidelines must all be considered.
Aims:
Assess current compliance with SDCEP’s Implementation of NICE guidelines on AP for IE in UK special care dental services.
Methods:
Retrospective data collected from multiple services, aiming for 50 episodes of AP from each service. Excluding patients under 16 and any treatment before 2019 as SCDEP guidance was published in 2018.
Results:
There was 248 episodes of care out of the aimed 300. Two services could not provide 50 episodes of care. AP was given in 193 episodes of care to patients within SDCEP’s special consideration subgroup (Table 4.1). A valid reason was recorded for the 5- patients that received AP without being in the special consideration subgroup. No reason was recorded for three patients and the data was missing for 2 patients. In all cases of AP without special consideration, a cardiologist was consulted before IDT. A consultation with a cardiac team was undertaken before planning AP for IDT in 193 episodes of care. SDCEP guidance was followed in 92% of cases (Figure 4).
Discussion
Figure 5 summaries the comparison between the SDCEP standard and the results of the evaluation. In standard 1, cardiologists are more likely to suggest AP for patients who are at risk of IE without being in the sub-group. However, this means there is a conflict in the way the guidance is used in primary dental care services.
Amoxicillin AP has less fatal reactions than Clindamycin AP. Suggesting the safety of amoxicillin and it’s likely the reason why it is the first line AP. Different guidance suggests different second line AP such as macrolides, cephalexin or doxycycline.
There are also concerns about antimicrobial resistance. Studies have suggested that there is an increase in the proportion of resistant streptococci following amoxicillin prophylaxis. Therefore, some guidance suggests a minimum interval of 4 weeks between AP doses of amoxicillin. If this is not possible the guidance suggests use of different antibiotics instead.
There are also different guidance depending on which guidelines are followed such as the dose of amoxicillin recommended and the second line antibiotic recommended
Systematic reviews show AP reduces bacteraemia but it is difficult to determine if AP is truly effective at preventing IE.
Conclusion
If a patient has an increased risk of IE, practitioners should be aware of arguments for and against AP to objectively inform patients and guide them through their decision making. More studies need to be done to prove that AP prevents IE.
Research Summary Written By: Omobolaji Adenuga, University of Manchester – BDS3