Overview of Guidelines on Antibiotic Prophylaxis for Infective Endocarditis
UK Guidance: NICE CG64 (and current status)
NICE Clinical Guideline 64 (CG64) considers the role of antibiotic prophylaxis (ABP) in preventing infective endocarditis (IE) in people undergoing interventional procedures, including dentistry. NICE’s full review (2015), with a clarification in 2016, concluded that:
- Evidence supporting ABP to prevent IE is of very low quality, with uncertainty and risk of bias in the available studies.
- Although IE rates have increased internationally, this trend cannot be clearly or directly attributed to changes in ABP practice.
As a result, NICE advises that antibiotic prophylaxis is not recommended routinely for dental procedures. The term “routinely” allows for individualised clinical judgement and shared decision-making, including consultation with the patient’s cardiology team where appropriate.
Update note (2024–2025): NICE published exceptional surveillance in October 2024 indicating that newer evidence may justify updating CG64, with a proposed focus on high-risk patients undergoing dental procedures. Always check the most current national and local guidance.
Implementation Advice: SDCEP (Scotland) and Local Policy
SDCEP implementation advice is widely used in practice to support decision-making for people at increased risk of IE. It provides practical frameworks (e.g. identifying higher-risk groups and defining “invasive” dental procedures). In UK practice, decisions should align with NICE, SDCEP implementation advice, and local cardiology/antimicrobial guidance.
International Guidelines
International guidance differs in emphasis from NICE:
- ESC (2023): The European Society of Cardiology generally supports ABP for a clearly defined group of patients at highest risk of IE undergoing invasive dental procedures.
- AHA (updated guidance): The American Heart Association supports prophylaxis for selected high-risk groups, but places strong emphasis on minimising antibiotic-related harm and uses updated recommendations on antibiotic choices.
International guidance is useful context, but UK dentists should apply NICE CG64 (with SDCEP/local policy) as the primary framework for practice.
Common Themes Across Guidance
- Evidence for ABP effectiveness remains limited and uncertain.
- Any potential benefit appears most plausible in patients at highest risk of severe outcomes from IE.
- Risk–benefit assessment and patient-centred decision-making are essential.
Major Differences in Emphasis:
- NICE (UK): does not recommend ABP routinely for dental procedures and prioritises antimicrobial stewardship and avoiding unnecessary antibiotic exposure.
- ESC/AHA: are more prescriptive for narrowly defined high-risk groups and support prophylaxis in those groups, reflecting a different balance between uncertainty of benefit and severity of harm from IE.