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NICE Issues New Guideline on Prophylactic Antibiotic Use Against Infective Endocarditis

LONDON -- March 17, 2008 -- The National Institute for Health and Clinical Excellence (NICE) has issued a clinical guideline on antibiotic prophylaxis against infective endocarditis (IE). In a significant change to current clinical practice, the guideline recommends that antibiotics used to prevent IE should not be given to adults and children with structural cardiac defects at risk of IE who are also undergoing dental and nondental interventional procedures.

The new guideline is based on the best available published evidence and a consensus of multidisciplinary, expert opinion within the Guideline Development Group. The guideline concludes that there is no consistent association between having an interventional procedure -- dental or nondental -- and the development of IE, and the clinical effectiveness of antibiotic prophylaxis is not proven. The evidence also suggests that antibiotic prophylaxis against IE for dental procedures is not cost effective, and it may lead to a greater number of deaths through fatal anaphylactic reactions compared with not using preventive antibiotics.

The guideline makes a number of key recommendations, including:

· Patients should not be offered antibiotics to prevent IE for any of the following procedures:
– A dental procedure
– An obstetric or gynaecological procedure, or childbirth
– A procedure on the bladder or urine system
– A procedure on the gullet, stomach, or intestines
– A procedure on the airways, including ear, nose, and throat, and bronchoscopy

· Healthcare professionals should consider people with the following cardiac conditions as being at risk of developing IE:
– Acquired valvular heart disease with stenosis or regurgitation
– Valve replacement
– Structural congenital heart disease, including surgically corrected or palliated structural conditions, but excluding isolated atrial septal defect, fully repaired ventricular septal defect, or fully repaired patent ductus arteriosus, and closure devices that are judged to be endothelialised
– Previous IE
– Hypertrophic cardiomyopathy

· Healthcare professionals should offer people at risk of IE clear and consistent information about prevention, including:
– The benefits and risks of antibiotic prophylaxis, and an explanation of why antibiotic prophylaxis is no longer routinely recommended
– The importance of maintaining good oral health
– The symptoms that may indicate IE and when to seek expert advice
– The risks of undergoing invasive procedures, including nonmedical procedures such as body piercing or tattooing

· People at risk of IE who are receiving antimicrobial therapy because they are undergoing a gastrointestinal or genitourinary procedure at a site where there is a suspected infection should be offered an antibiotic that covers organisms that cause IE.

· Investigate and promptly treat any episodes of infection in people at risk of IE to reduce the risk of endocarditis developing.

Dr. Gillian Leng, Deputy Chief Executive of NICE, said, "Although the anticipated cost savings are quite modest -- around £1 million across the [National Health Service] in England and Wales -- the implementation of this guideline will have other far-reaching benefits, notably an increased patient awareness of the risk of IE and a decrease in the number of adverse reactions to antibiotics, such as anaphylaxis. Finally, the implementation of this guidance should reduce the level of antibiotic resistance in the general population, the cost and wider benefits of which we haven't calculated but are likely to be substantial."

David Wray, MD, Professor of Oral Medicine, Chair, Guideline Development Group, NICE, said, "In recommending that antibiotic prophylaxis should not be offered to people at risk of [IE] undergoing both dental and some nondental interventional procedures, this new NICE guideline represents a fundamental change in clinical practice. … Professional groups must now ensure that their patients are fully informed about the changes and the reasons for this in order to encourage implementation."

The guideline is available on NICE's Web site at www.nice.org.uk/060.

SOURCE: National Institute for Health and Clinical Excellence

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