Primary prevention

The evidence for antibiotic prophylaxis preventing infection following dental procedures and instrumentation of the respiratory, genitourinary, or gastrointestinal tract is weak.[45][46]​​​​​ An increase in incidence of IE in recent years has not been found to be temporally related to changes in recommendations regarding use of prophylactic antibiotics.[46][47][48][49]​​​​ Conflicting data suggest that a reduction in bacteraemia may not result in a lower incidence of IE in low-risk individuals.[50]​ The risk of bacteraemia resulting from interventions such as dental procedures and instrumentation of the respiratory, genitourinary, or gastrointestinal tract is significantly smaller than from usual life-time activities such as toothbrushing or chewing.[46]​[51]​​​​ Data have indicated that, even if treatment with prophylactic antibiotics were 100% effective, only a small number of cases would be prevented.​

Guidelines differ in their recommendations for antibiotic prophylaxis; check your local protocols. Decisions about antibiotic prophylaxis should only be made after careful evaluation of the individual patient’s circumstances, following discussion with the patient, taking into account the patient’s values and preferences, and using your clinical judgement.[45][52][53]​​

The European Society of Cardiology (ESC) recommends that antibiotic prophylaxis should only be considered if the patient is at highest risk of IE and undergoing a dental procedure that requires manipulation of the gingival or periapical region of the teeth or perforation of the oral mucosa. The ESC considers a patient to be at highest risk of IE if they have:[6] 

  • A prosthetic valve, including a transcatheter valve or a valve in which any prosthetic material was used for valve repair

  • A history of a previous episode of IE

  • Untreated cyanotic congenital heart disease, or congenital heart disease that has been repaired with a prosthetic material (including valved conduits or systemic-to-pulmonary shunts)

  • A ventricular assist device.

In the UK, the National Institute for Health and Care Excellence (NICE) recommends that an at-risk patient undergoing interventional procedures should not be given antibiotic prophylaxis against IE routinely. However, NICE emphasises that antibiotic therapy is still necessary to treat active or potential infections.[36] NICE considers a patient to be at-risk if they have:[36]

  • Acquired valvular heart disease with stenosis or regurgitation

  • Hypertrophic cardiomyopathy

  • Previous IE

  • Structural congenital heart disease, including surgically corrected or palliated structural conditions, but excluding isolated atrial septal defect, fully repaired ventricular septal defect, fully repaired patent ductus arteriosus, and closure devices that are judged to be endothelialised

  • Valve replacement.

NICE recommends giving clear information about prevention to any patient at risk of IE, which should include:[36][45]

  • The benefits and risks of antibiotic prophylaxis, and an explanation of why antibiotic prophylaxis is no longer routinely recommended

  • The importance of maintaining good oral health

  • Symptoms that may indicate IE and when to seek expert advice

  • The risks of undergoing invasive procedures, including non-medical procedures such as body piercing or tattooing.

The recommendations from the ESC and NICE may not be universally accepted in other countries.

The most common cause of infective endocarditis following dental, oral, respiratory tract, or oesophageal procedures is Streptococcus viridans (alpha-haemolytic streptococci). Therefore, antibiotics (if they are to be given for prophylaxis) are directed toward this organism, and administered as a single dose 30 to 60 minutes before the procedure.

  • Base your choice of antibiotic on your local hospital protocols.

  • The ESC recommends clindamycin if the patient is allergic to penicillin or ampicillin. However, the American Heart Association no longer recommends clindamycin, based on a study that suggests a single dose of clindamycin may cause complications, including death, from Clostridioides difficile infection.[54]​​

Secondary prevention

Patients with a previous history of IE are at high risk of a further episode of endocarditis.

The European Society of Cardiology (ESC) recommends consideration of systemic antibiotic prophylaxis for high-risk patients undergoing invasive diagnostic or therapeutic procedures of the respiratory, gastrointestinal, genitourinary tract, skin, or musculoskeletal systems.[6]

The ESC also recommends that high-risk patients (e.g., patients with a prosthetic valve, a history of IE, untreated congenital heart disease or congenital heart disease repaired with prosthetic material, or a ventricular assist device) should be given antibiotic prophylaxis for oro-dental procedures.[6]

In the UK, the National Institute for Health and Care Excellence (NICE) recommends that an at-risk patient undergoing interventional procedures should no longer be given antibiotic prophylaxis against IE. However, NICE emphasises that antibiotic therapy is still necessary to treat active or potential infections.[36]

The recommendations from the ESC and NICE may not be universally accepted in other countries.

IE may signify occult malignancy. The relationship between Streptococcus gallolyticus infection and colon cancer is well documented. Exclusion of occult colon cancer is recommended in patients with IE secondary to infection with these organisms. Annual colonoscopy is strongly suggested for those individuals where no tumour is detected.[150]

There has been an increase in the number of individuals affected by congenital heart disease and the incidence of IE in this group is reported as being 15 to 140 times higher than that of the general population,​ although the prognosis remains better than in other forms of IE.[151][152] Primary prevention in those with congenital heart disease is paramount, and patient education regarding oral, dental, and skin hygiene, and the avoidance of tattoos and piercings remains crucial.[151]​[152]​

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