A call for national monitoring of antibiotic prophylaxis

The UK National Institute for Health and Clinical Excellence (NICE) recently published guidelines on antibiotic prophylaxis for preventing infective endocarditis in high risk patients with structural heart disease.1 2 The guidelines no longer recommend their use during dental and other invasive procedures of the respiratory tract, genitourinary tract, and upper and lower gastrointestinal tract—a considerable change from current practice. The guidelines apply to all high risk patients. The guidelines point to the lack of high quality evidence on whether antibiotics are effective in this situation or whether such procedures are linked to infective endocarditis. This was also highlighted in other recent guidelines,3 but they stopped short of recommending a change to current practice. This raises questions and anxiety in patients and those who treat them.

The report cites reactions to antibiotics (including anaphylaxis) as an argument against their use on a population scale, but in practice cardiologists can ask individual patients about previous antibiotic use and reactions.

Unlike most areas where NICE issues guidance, there are no randomised control trials on antibiotic prophylaxis for infective endocarditis. Small observational and case-control studies provide inconclusive evidence in favour of antibiotic prophylaxis. Infective endocarditis is not a notifiable disease in the UK and we know of no system that could accurately detect a rise in incidence on a national level corrected for the use of antibiotic prophylaxis in individual cases.

Infective endocarditis is a life threatening condition with overall mortality of around 20%.1 We call for a system that can robustly assess the outcome of this important change in practice to be in place alongside its implementation.