Impact of the NICE guideline recommending cessation of antibiotic prophylaxis for prevention of infective endocarditis: before and after study

Abstract

Objective: To quantify the change in prescribing of antibiotic prophylaxis before invasive dental procedures for patients at risk of infective endocarditis, and any concurrent change in the incidence of infective endocarditis, following introduction of a clinical guideline from the National Institute for Health and Clinical Excellence (NICE) in March 2008 recommending the cessation of antibiotic prophylaxis in the United Kingdom.

Design: Before and after study.

Setting: England. Population All patients admitted to hospital in England with a primary or secondary discharge diagnosis of acute or subacute infective endocarditis.

Main outcome measures: Monthly number of prescriptions for antibiotic prophylaxis consisting of a single 3 g oral dose of amoxicillin or a single 600 mg oral dose of clindamycin, and monthly number of cases of infective endocarditis, infective endocarditis related deaths in hospital, or cases of infective endocarditis with a possible oral origin for streptococci.

Results: After the introduction of the NICE guideline there was a highly significant 78.6% reduction (P < 0.001) in prescribing of antibiotic prophylaxis, from a mean 10,277 (SD 1068) prescriptions per month to 2292 (SD 176). Evidence that the general upward trend in cases of infective endocarditis before the guideline was significantly altered after the guideline was lacking (P = 0.61). Using a non-inferiority test, an increase in the number of cases of 9.3% or more could be excluded after the introduction of the guideline. Similarly an increase in infective endocarditis related deaths in hospital of 12.3% or more could also be excluded.

Conclusion: Despite a 78.6% reduction in prescribing of antibiotic prophylaxis after the introduction of the NICE guideline, this study excluded any large increase in the incidence of cases of or deaths from infective endocarditis in the two years after the guideline. Although this lends support to the guideline, ongoing data monitoring is needed to confirm this, and further clinical trials should determine if antibiotic prophylaxis still has a role in protecting some patients at particularly high risk.

Fig 1 Total number of prescriptions for antibiotic prophylaxis (amoxicillin 3 g or clindamycin 600 mg) dispensed each month by type of prescriber. Red lines represent moving average figure for prescriptions every three months

Fig 2 Monthly number of cases of infective endocarditis. Also plotted are separate lines for linear trend within 2 standard deviations (broken lines) for periods before and after introduction of NICE guideline. Red lines represent moving average figure for number of cases every three months

Fig 3 Proportion of infective endocarditis cases recorded each month with a code for streptococci or staphylococci as cause. Red lines represent moving average figure for cases every three months