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Prophylaxis against infective endocarditis:

antimicrobial prophylaxis against infective

endocarditis in adults and children undergoing

interventional procedures

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What this presentation covers

Background

Recommendations

Costs and savings

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Background

Infective endocarditis is an infection of the endocardium.

It is a rare condition, but people with certain structural cardiac

conditions are at risk.

It remains a life-threatening disease with significant mortality (about

20%) and morbidity.

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Rationale for Antibiotic Prophylaxis

Standard practise for 50 years

10 per 100,000 per annum IE life threatening

IE follows bacteraemia

Dental procedures cause bacteraemias

Cases of IE following dental procedures

IE usually caused by oral organisms

These organisms sensitive to antibiotics

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Current Status

BSAC Guideline 1993

BCS Guideline 2004

ESC Guideline 2004

BSAC Guideline 2006

CDO England letter 2006

AHA Guideline 2007

NICE (Short Guideline) 2008

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Scope of NICE Guideline

To provide evidence-based recommendations

to guide healthcare professionals in theappropriate care of people considered to be

at increased risk of infective endocarditis who

may require antimicrobial prophylaxis before

an interventional procedure.

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Patients at Risk of IE

The following patients should be regarded as being at risk ofdeveloping infective endocarditis:

acquired valvular heart disease with stenosis or regurgitation

valve replacement

structural congenital heart disease, including surgically correctedor palliated structural conditions but excluding isolated atrial septaldefect, fully repaired ventricular septal defect or fully repaired

patent ductus arteriosus, and closure devices that are judged to beendothelialised

previous endocarditis

hypertrophic cardiomyopathy.

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Prophylaxis against IE

Antibiotic prophylaxis against IE is not recommended:

For people undergoing dental procedures

For people undergoing non-dental procedures

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Non Dental Procedures

upper and lower gastrointestinal tract

genitourinary tract; this includes urological, gynaecological

and obstetric procedures, and childbirth upper and lower respiratory tract; this includes ear, nose

and throat procedures and bronchoscopy.

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Rationale

Antibiotic prophylaxis against IE is not recommended for patients at

risk of IE undergoing dental procedures.

No consistent association between having an interventional

procedure and the development of IE

Regular toothbrushing almost certainly presents a greater risk of

IE than a single dental procedure

The clinical effectiveness of antibiotic prophylaxis is not proved

Antibiotic prophylaxis against IE for dental procedures is not cost

effective and may lead to a net loss of life

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Other recommendations

Chlorhexidine mouthwash should not be offered as prophylaxis

against IE to people at risk of IE undergoing dental procedures

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Patient Advice

Healthcare professionals should offer people clear and consistent

advice about prevention including:

Benefits and risks of antibiotic prophylaxis

The importance of maintaining good oral health

Symptoms that may indicate IE and when to seek expert advice

Risks of undergoing invasive procedures such as body piercing or

tattooing

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Managing infection

Offer an antibiotic that covers organisms that cause infective

endocarditis if a person at risk of infective endocarditis is

receiving antimicrobial therapy because they are undergoing a

gastrointestinal or genitourinary procedure at a site where there

is a suspected infection.

Investigate and treat promptly any episodes of infection in

people at risk of infective endocarditis to reduce the risk of

endocarditis developing.

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Savings

per 100,000 population

Recommendations with savings

Savings

( per year)

Prophylaxis for patients at risk undergoing a

dental procedure 1541

Prophylaxis for patients at risk undergoing a

non-dental procedure 267

Total net saving of implementing the

guideline 1808

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BCS President's statement on NICE Guideline to prophylaxis against infective endocarditis

29 April 2008British Cardiovascular SocietyAntibiotic Prophylaxis against Infective Endocarditis

Position StatementThe National Institute for Health and Clinical Excellence (NICE) published new guidance on the use of antibiotic prophylaxis against infective endocarditis last

month . This recommends an end to the long-established practice of prescribing antibiotics for at risk patients undergoing routine dental, upper and lower GItract, genito-urinary tract and respiratory tract procedures.

The Society recognises that many of its members may question this approach; indeed 70% of those who participated in a debate at last years conference wereopposed to the adoption of similar recommendations proposed by the American Heart Association.

The BCS contributed to the development of the NICE guidelines in its capacity as a registered stakeholder and has hosted discussions on the guidance atmeetings of its Executive, Board and Council. In all these deliberations there has been broad agreement on a number of points:-

a.The available evidence is not conclusive or definitive.b.The evidence that we do have suggests that, on first principles, antibiotic prophylaxis is likely to be ineffective.

c.It would be very unfortunate if credible authorities produce contradictory guidelines. (The new NICE guidance is broadly in agreement with current AmericanGuidelines, forthcoming ESC guidelines, and the existing British Society for Antimicrobial Therapy guidelines).

d.It is essential to monitor the impact of any change in practice by monitoring the incidence of infective endocarditis closely.In the light of all this the Officers of the BCS have concluded that we should endorse the new NICE guidance whilst recognising that it may create difficulties for

some cardiologists and patients. We anticipate that most practising cardiologists wil l no longer recommend antibiotic prophylaxis to new patients but will notnecessarily advise existing patients, some of whom have had the need for antibiotic cover drummed into them over many years, to abandon the practice

instantly. Nevertheless, practitioners may wish to explain the change in thinking to existing patients before agreeing how to proceed. We certainly hope thatnone of our members will feel under undue pressure to change their practice and that patients who wish to continue with antibiotic prophylaxis will be allowed to

do so. Indeed, in the absence of definitive evidence, the Society views this issue as a matter of conscience and will support any member who chooses torecommend antibiotic prophylaxis in selected circumstances.

Dr Nicholas Boon

PresidentOn behalf of the BCS Executive and Guidelines and Practice Committee

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