UK urged to revise dental antibiotic policy for heart risks

Franziska Beier, Dental Tribune International

Tue. 9 April 2024

save

SHEFFIELD, UK: Infective endocarditis (IE) is a potentially life-threatening heart infection that is caused by dental bacteria in around a third of cases. A recent review led by researchers from the University of Sheffield confirmed that dental patients at high risk of IE should be given antibiotics before undergoing invasive dental treatment. As antibiotic prophylaxis is currently not recommended in the UK—in contrast to other countries around the world—the researchers are urging UK healthcare authorities to update the guidelines.

“Infective endocarditis is a rare but devastating heart infection in which around 30% of people die within the first year of developing it,” commented lead author Prof. Martin Thornhill, from the University of Sheffield’s School of Clinical Dentistry, in a press release. “There are currently 400,000 people at high risk of developing IE in the UK, and this number is increasing each year due to the growing number of patients having cardiac interventions,” he added.

People at increased risk of IE are patients who have undergone cardiac interventions such as prosthetic heart valves, valve repairs and congenital heart disease repairs. In approximately 30% to 40% of cases, IE is attributed to bacteria originating from the oral cavity, owing to poor oral hygiene or as a result of invasive dental procedures.

Other guideline committees

In 2023, the European Society of Cardiology (ESC) updated its IE guidelines, strongly recommending antibiotic prophylaxis before invasive dental procedures for high-risk patients. The American Heart Association is aligned with this view and reaffirmed the need for antibiotic prophylaxis to prevent IE in those at high risk in its 2021 guidelines.

In contrast, the UK’s National Institute for Health and Care Excellence (NICE) recommended against this practice in 2008, owing to insufficient evidence of efficacy and concerns about adverse reactions, and has not reviewed its recommendation since 2015. Although other guideline committees around the world had similar concerns, recommending antibiotic prophylaxis was continued, since the risks of developing IE were considered to far outweigh any risks of giving antibiotic prophylaxis to patients susceptible to IE.

New evidence

Previous research from 2015 conducted by the University of Sheffield showed high compliance with the NICE guidance in the UK and identified an 88% decline in antibiotic prophylaxis prescribing since 2008. In addition, it found a significant increase in IE incidence after this change. Another university study from 2022 found that dental patients at high risk of IE should receive antibiotics before undergoing invasive treatment such as extractions or oral surgery.

The recent review by the university observed that the risk of IE in high-risk patients after invasive dental procedures is one in 1,000, dropping to one in 3,333 with antibiotic prophylaxis. For extractions, the risk decreased from one in 100 to one in 1,000 with antibiotic prophylaxis, and after oral surgery, the risk reduced from one in 40 to one in 500 when antibiotics were administered. In contrast, the risk of a significant adverse drug reaction after amoxicillin antibiotic prophylaxis was found to be one in 250,000 prescriptions.

The study authors stated that, when taken together, the reviewed studies support an association between invasive dental procedures and subsequent IE, particularly in high-risk patients.

Call to action

Based on their results, the researchers have urged NICE to review dental antibiotic prophylaxis guidelines in the UK. “All major guidelines committees around the world, such as the American Heart Association and the European Society for Cardiology, recommend that those at high risk of infective endocarditis should receive antibiotic prophylaxis before undergoing invasive dental procedures. We are urging NICE to review its guidance so that high-risk patients in the UK receive the same protection against IE that is afforded to patients in the rest of the world,” emphasised Prof. Thornhill.

Ideally, NICE would adopt similar recommendations to those of the 2023 ESC guidance, resulting in a uniform approach across Europe, said the study authors.

Cost-effectiveness

Prof. Thornhill also highlighted the economic impact that updated guidelines would have: “Our previous study showed that prescribing antibiotic prophylaxis would be cost-effective if it prevented just 1.4 high-risk patients per year from developing infective endocarditis. So, by preventing between 40 and 260 cases per year antibiotic prophylaxis would be highly cost-effective and would likely save the [National Health Service] in excess of £5.5 million [€6.4 million]^* annually as well as generating substantial health gains for those at risk of endocarditis.”

The recommendation of administering antibiotics prophylactically for patients deemed at risk of contracting IE is an internationally debated topic. Sweden and the UK are currently the only countries in Europe that restrict the use of antibiotics. In contrast to the results of the University of Sheffield, a Swedish study from 2022 found no increase in IE cases after the use of antibiotics was reduced in 2012.

The review, titled “Endocarditis prevention: Time for a review of NICE guidance”, was published on 5 March 2024 in The Lancet.

Editorial note:

^* Calculated on the OANDA platform on 1 April 2024.