12 19 Focus 5

Antibiotic premedication revisited

Dec. 16, 2014
Prescriptions of antibiotic prophylaxis medications have decreased significantly, and the frequency of infective endocarditis has increased in England since introduction of the 2008 NICE guidelines.

In the Introduction of the last issue (December 5, 2014) I mentioned a Lancet study on antibiotic prophylaxis and infective endocarditis (IE). The study was published online November 18, 2014, and stated a gradual increase in the incidence of IE in England.(1) This increased incidence seems to parallel a reduction in antibiotic prophylaxis for IE prevention. This article will discuss these guidelines as well as newguidelines for prosthetic joints.

The National Institute for Health and Clinical Excellence (NICE) began recommending cessation of antibiotic prophylaxis for IE prevention in England in March 2008. According to the Lancet article, the data do not establish a causal association. However, prescriptions of antibiotic prophylaxis medications have decreased significantly, and the frequency of infective endocarditis has increased in England since introduction of the 2008 NICE guidelines. It is a respectable study that questions the importance of premedication with antibiotics. However, further studies are needed to confirm these preliminary findings. While we usually rely on randomized controlled trials (RCTs) for products and interventions, the best design in a situation where adverse events and rare outcomes are being evaluated is a case-control study. Since there is no control group, it is difficult to state that changes in IE incidence are actually due to the implementation of the 2008 guidance.
The American Dental Association (ADA) suggests that dental professionals continue to follow the 2007 guidelines from the American Heart Association.(2) These guidelines provide appropriate information on the indications for antibiotic use, type, and dosage. They state that only an extremely small number of cases of IE might be prevented by antibiotic prophylaxis for dental procedures, even if such prophylactic therapy were 100% effective.(3) IE prophylaxis for dental procedures is judicious only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis. For patients with these underlying cardiac conditions, prophylaxis is reasonable for all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth, or perforation of the oral mucosa.(4) Prophylaxis is not recommended based exclusively on an increased lifetime risk of acquisition of infective endocarditis.(5)

The January issue of The Journal of the American Dental Association will feature updated ADA guidelines about the indication for antibiotic prophylaxis before dental treatment in patients with prosthetic joints.(6) A 2014 panel of experts, tasked by the ADA Council on Scientific Affairs, developed the ADA guidelines, "The Use of Prophylactic Antibiotics Prior to Dental Procedures in Patients with Prosthetic Joints: Evidence-Based Clinical Practice Guideline for Dental Practitioners."

This panel updated the systematic review that was the base of "Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures Evidence-Based Guideline and Evidence Report," which a 2012 panel of American Academy of Orthopaedic Surgeons and ADA authors co-developed.(7) Dentists should be aware that there does not appear to be conflict between the updated ADA prosthetic joint infection guideline and a recent Lancet publication on infective endocarditis.

Be sure to read the January issue of The Journal of the American Dental Association!

Maria Perno Goldie, RDH, MS, is the editorial director of RDH eVillage FOCUS.


1. "Incidence of Infective Endocarditis in England, 2000–13: a Secular Trend, Interrupted Time–Series Analysis."
2. Prevention of Infective Endocarditis: Guidelines From the American Heart Association. Circulation. 2007;116:1736-1754. http://circ.ahajournals.org/content/116/15/1736.full.pdf.
3. Strom BL, Abrutyn E, Berlin JA, Kinman JL, Feldman RS, Stolley PD, Levison ME, Korzeniowski OM, Kaye D. Dental and cardiac risk factors for infective endocarditis: a population-based, case-control study. Ann Intern Med. 1998;129: 761–769.
4. Durack DT. Antibiotics for prevention of endocarditis during dentistry: time to scale back? Ann Intern Med. 1998;129: 829 – 831.
5. Lockhart PB, Brennan MT, Fox PC, Norton HJ, Jernigan DB, Strausbaugh LJ. Decision-making on the use of antimicrobial prophylaxis for dental procedures: a survey of infectious disease consultants and review. Clin Infect Dis. 2002; 34: 1621–1626.
6. ADA News. New guidelines addressing antibiotics and prosthetic joints in January JADA. December 03, 2014. http://www.ada.org/en/publications/ada-news/2014-archive/december/new-guidelines-addressing-antibiotics-and-prosthetic-joints-in-january-jada.
7. AAOS and ADA. Prevention of Orthopaedic Implant Infection In Patients Undergoing Dental Procedures Evidence-Based Guideline And Evidence Report. http://www.ada.org/~/media/ADA/Member%20Center/FIles/PUDP_guideline.ashx.