The 2007 advent of guidelines recommending against antibiotic prophylaxis (AP) before dental procedures in most patients might have had more of an impact than intended, a new analysis suggests.

It led to a sharp decline in AP for patients at all levels of risk for endocarditis, including those at highest risk, the one group for which the guidelines still recommended prophylaxis. And among that highest-risk group, reduced AP was followed by a significant 177% jump in endocarditis cases in the ensuing 8 years.

Antibiotic prophylaxis

The fall in AP prescribing in high-risk patients "is rather concerning and suggests some difficulty on the part of dentists in distinguishing between those at high risk, who are recommended to receive antibiotic prophylaxis, and those at moderate risk, who are not," said Martin H. Thornhill, MBBS, School of Clinical Dentistry, University of Sheffield, United Kingdom.

"However, dentists are not cardiologists, and so better communication between a patient's cardiologist, who is best placed to identify if they are at high risk or not, and the patient's dentist is likely to be the most effective way of ensuring all those who are recommended for prophylaxis receive it."

Thornhill is scheduled to present the analysis based on 2003 to 2015 Medicare, Medicaid, and commercial insurance data on November 11 here at the American Heart Association (AHA) Scientific Sessions 2018. It was published online November 5 in the Journal of the American College of Cardiology.

The influential 2007 AHA-sponsored guidelines recommended AP be restricted to those at high risk for infective endocarditis (IE) who were undergoing invasive dental procedures, as reported. Such procedures consisted of those that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa.

High-risk patients included those with previous IE, prosthetic valves, unrepaired cyanotic congenital heart defects, or congenital defects completely repaired with prosthetic material or a device by means of surgery or a transcatheter.

Similar guidelines were published by the European Society of Cardiology (ESC) in 2009, and the UK National Institute for Health and Care Excellence (NICE) announced stricter AP-curbing recommendations in 2008. Interestingly, increases in endocarditis cases were seen in the UK after the NICE guidelines came out.

The current analysis "strongly supports the current AHA antibiotic prophylaxis recommendations," Thornhill said. "Doctors and dentists should continue to put these into effect in their clinical practice, perhaps with some reassurance now about the benefit of giving antibiotic prophylaxis to those at high risk."