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Antibiotic Prophylaxis

07 November 2016

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Recent research suggested that rates of infective endocarditis (IE) have risen in recent years and in view of the new research, the National Institute for Health and Care Excellence (NICE) reviewed the existing guidance produced in 2008. After weighing the available evidence in 2015 NICE concluded that the existing guidance was in fact still appropriate and should remain the relevant standard in the management of patients at risk of endocarditis.

In line with the process for all NICE guidance documents NICE will of course continue to monitor any future relevant evidence, that might suggest a further review of the guidance would be justified but at the present time the guidance remains unchanged. The insertion of the  additional word “routinely” in August 2015 improves interpretation of the NICE guidance which otherwise remains unchanged.

Unless, and until, the recommendations in the NICE guidance change, the current guidance published on the NICE website remains the recognised standard to which practitioners should refer.

Background to the existing NICE guidance

For many years it was accepted clinical practice, when carrying out dental procedures on patients who were considered to be at risk of developing IE, to administer preventive (prophylactic) antibiotics beforehand. The evidence base for doing this, however, was not clear.

The guidance produced by NICE in 2008 was based upon the best available published evidence at that time and a consensus of multidisciplinary, expert opinion. The evidence demonstrated that there is no consistent association between a patient having an “interventional procedure” (dental or non-dental) and the development of IE. On this basis, the clinical effectiveness of antibiotic prophylaxis is not proven. The evidence also suggests that antibiotic prophylaxis against IE for dental procedures is not cost-effective.

Is the guidance obligatory?

Some dentists have a contractual obligation to observe the guidance of NICE when writing prescriptions (eg, NHS England). However, clinicians without any such contractual obligation to follow the guidance would still need a very strong justification for choosing not to do so.

Patient awareness

There are patients with cardiac conditions who have come to expect that antibiotic cover will be provided when they receive dental treatment. With the existing NICE guidance, however, there is no justification for this and clinicians need to ensure that clear communication with the patient about current guidance is provided along with reassurance and support.

Although there is no justification for the routine use of antibiotics for prophylaxis of infective endocarditis in connection with dental procedures, it should be recognised that the early diagnosis and effective management of infection is of particular importance for patients who are at increased risk of IE. Any infection in this group of patients should be dealt with quickly and appropriately.

What can the dental team do?

Dentists (and other healthcare professionals) can help by offering people at risk of IE clear and consistent information about prevention, including:

  • advice about the importance of maintaining good oral health recognition of symptoms that may indicate IE and when to seek expert advice
  • an explanation of why antibiotic prophylaxis is no longer recommended for routine dental care.

Dental Protection is not, and does not purport to be an arbiter of clinical opinion but can certainly signpost members to recognised bodies of opinion. In recognising the importance of the NICE guidance, Dental Protection also recognises that its implementation may pose concerns for some practitioners and patients.

Consent issues

In the recent “Montgomery” case1, it was ruled that consent is considered to be valid if the patient has been presented with all of the information necessary for that patient to make a fully informed choice about his/her care, based upon the patient’s view of the material risks.

What is a material risk?

“The test of materiality is whether, in the circumstances of the particular case, a reasonable person in the patient’s position would be likely to attach significance to the risk, or the clinician is or should reasonably be aware that the particular patient would be likely to attach significance to it.”

The current NICE guidance clearly states that there is no indication for antibiotics to be prescribed routinely for patients who undergo dental treatment. The reason for this is that there is no clear evidence that routine prophylaxis is in any way effective.

Against this background, there have been queries from members wondering how to respond to dental patients who are known to be at increased risk of developing IE, but who do not have an existing infection,  and yet still feel that they should be given antibiotics to “protect” them when consenting to treatment. This may be more likely if the patients have been told in the past – perhaps, over many years – that receiving dental treatment without antibiotic prophylaxis could be very dangerous.

Patients with an elevated risk of IE are likely to be in the care of a cardiologist and they may attach greater significance to their cardiologist’s opinion over any other.

If there is a disparity in opinions, it would be sensible that you seek the patient’s permission to discuss the matter with their cardiologist to ensure that any advice they have had was given in the light of the latest guidance from NICE and to which you are adhering. An agreed way forward can then be presented to the patient before any treatment is started.

The patient’s best interests

Prescribing antibiotics without clear reason exposes the patient to the avoidable risks of unnecessary medication.  It also may create a risk of lessening the efficacy of the antibiotic when it is actually required.

A clinician who prescribes antibiotics which are not indicated or justified, particularly when this departs from expert, evidence-based, guidance, may find him/herself in some difficulty if this were to be challenged.

A practitioner who chooses to treat a patient in a manner which is at variance with current evidence-based recommendations for best practice (“guidance”) would be well-advised to carefully consider his/her reasons for so doing and be prepared to justify the reason for departing from the guidance. Detailed records of the consent process must be made and kept.

View our Antibiotic Prophylaxis FAQs

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