Overview of Guidelines on Antibiotic Prophylaxis for Infective Endocarditis
NICE Clinical Guideline 64
NICE Clinical Guideline 64 (CG64) evaluates the role of antibiotic prophylaxis (ABP) in reducing infective endocarditis (IE) in high-risk individuals undergoing interventional procedures. The 2015 update concluded that:
- Evidence on ABP efficacy is of very low quality, with studies showing high bias and inconclusive results.
- There has been a global increase in IE cases, but this trend lacks a clear link to ABP practices.
NICE critiqued a 2014 study suggesting that the withdrawal of routine ABP increased IE cases, citing issues with the statistical analysis. The organisation maintained that the rising IE trend is multifactorial and not solely attributable to changes in ABP guidance.
ESC and AHA Recommendations
The European Society of Cardiology (ESC) and the American Heart Association (AHA) have also provided guidelines:
- ESC (2015): ABP is reserved for high-risk patients undergoing at-risk dental procedures.
- AHA (2007): While ABP effectiveness remains unproven, it may be reasonable for high-risk individuals due to the severity of potential IE outcomes.
Both guidelines emphasise the limited evidence for ABP and its associated risks but justify selective use for patients with severe risk profiles.
Common Observations Across Guidelines:
- Evidence supporting ABP effectiveness is weak or inconclusive.
- ABP should focus on high-risk individuals to prevent severe complications.
- Risk-benefit assessments are very important for patient-centred decisions.
Differences in Emphasis:
- NICE prioritises reducing ABP use unless evidence improves, highlighting concerns over antibiotic resistance and adverse reactions.
- ESC and AHA acknowledge the uncertainty of ABP effectiveness but still recommend its consideration in specific high-risk cases based on expert opinion.