Antibiotics for the prevention of bacterial endocarditis (severe infection or inflammation of the lining of the heart chambers) in dentistry - Cochrane

Review question

This Cochrane Review aimed to find out whether people with increased risk of bacterial endocarditis (a severe infection or inflammation of the lining of the heart chambers that can be fatal) should be given antibiotics routinely before invasive dental procedures to reduce the incidence of endocarditis, the number of deaths, and the amount of serious illness this group of people experiences.

Background

Bacterial endocarditis is an infection that tends to occur in previously damaged or malformed areas of the heart. It is usually treated with antibiotics. Though rare, bacterial endocarditis is potentially life-threatening. Up to 30% of people who get it may die, even with antibiotic treatment.

Invasive dental procedures could cause bacterial endocarditis in people who are at risk of developing it. The number of cases of bacterial endocarditis (if any) directly caused in this way is unknown. Many dental procedures cause bacteraemia, which is the presence of bacteria in the blood. Although bacteraemia is usually dealt with quickly by the body's immune system, some experts think that it may lead to bacterial endocarditis in some at-risk people. 

Guidelines in many countries have recommended that people at high risk of bacterial endocarditis be given antibiotics before undergoing invasive dental procedures. But other authorities have questioned the routine use of antibiotics, arguing that overprescription has resulted in the emergence of resistance to common antibiotics in many organisms, and also that the occasional adverse effects of antibiotics (severe allergic reactions) may outweigh the potential benefits. 

In 2007, guidance from the American Heart Association changed to recommend that antibiotics be given only to people at high risk of developing bacterial endocarditis before dental interventions. Guidance from the National Institute for Health and Care Excellence (NICE) in England and Wales went further, advising against the routine prescription of preventive antibiotics for invasive dental or surgical procedures.

Study characteristics

There are no new studies to include in this updated review. Our original review included one study, based in the Netherlands, that compared the treatment of people at high risk of endocarditis who did or did not develop bacterial endocarditis. The authors collected information on 48 people who had contracted bacterial endocarditis over a specific two-year period and had undergone a medical or dental procedure with an indication for prophylaxis within the past 180 days. These people were matched to a similar group of people who had not contracted bacterial endocarditis. All study participants had undergone an invasive medical or dental procedure. The two groups were compared to establish whether those who had received preventive antibiotics were less likely to have developed endocarditis.

Key results

It is unclear whether taking antibiotics as a preventive measure before undergoing invasive dental procedures is effective or ineffective against bacterial endocarditis in people at increased risk.

We found no studies that assessed numbers of deaths, serious adverse events requiring hospital admission, other adverse effects, or cost implications of treatment.

It is unclear whether the potential harms and costs of antibiotic administration outweigh any beneficial effects. Ethically, practitioners should discuss the potential benefits and harms of preventive antibiotic treatment with their patients before a decision is made about whether to prescribe it.

Limitations of the evidence

The evidence is based on one study that has some limitations in its design. For example, the participants who received antibiotics may have been in worse general health than those who did not. We are not confident about the evidence we found. We can only conclude that we do not know the effects of antibiotic prophylaxis for the prevention of bacterial endocarditis.

Date of the evidence

This review updates one carried out originally in 2004 and last revised in 2013. It is now up to date to 10 May 2021.

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