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Analysis of Data from the U.K. Estimates that Use of Antibiotic Prophylaxis Prior to Invasive Dental Procedures in Patients at Risk of Infective Endocarditis More Effective/Less Costly than No Prophylaxis

November 16, 2016 In 2008, the National Institute for Health and Care Excellence (NICE) in the U.K. recommended against antibiotic prophylaxis in patients undergoing invasive dental procedures and who were at any risk of infective endocarditis (IE), including those at potentially high risk, citing a lack of evidence of efficacy and cost-effectiveness.1, 2 This recommendation was different from other international specialty society guidelines issued on the topic at the time (e.g., the American Heart Association), which recommend IE prophylaxis in certain high-risk patients undergoing invasive dental procedures.3, 4  The NICE recommendation was reviewed and upheld in July 2016.  Data published since the 2008 change in recommendation have described both a sharp decrease in antibiotic prophylaxis prescribing for IE, as well as an increase in cases of IE in the U.K.5

A recent analysis1 attempted to estimate the cost-effectiveness of antibiotic prophylaxis (i.e., single-dose amoxicillin or clindamycin for those allergic to penicillin) in patients at risk of IE by using as the basis for cost-benefit analysis recent estimates of the effect of prophylaxis on IE in the U.K. population,5 rates of adverse drug reactions to antibiotic prophylaxis, and estimates for the probability of developing IE after dental procedures derived from French data.  The decision analytic model evaluated a strategy using antibiotic prophylaxis for all at-risk individuals (i.e., those at moderate or high risk of IE) compared with a strategy of no antibiotic prophylaxis (per the NICE guidelines).1 Investigators also compared a “no antibiotic prophylaxis” strategy with a strategy restricting its use to just those at high risk of IE (as per the European6 and North American3, 4 guidelines).

The analysis determined that antibiotic prophylaxis was less costly and more effective than no antibiotic prophylaxis for all patients at risk of IE and was more cost-effective in patients at high risk of IE. Only a small reduction in annual IE rates (i.e., approximately 1.44 cases in high-risk and 33 cases in all at-risk patients) would be required for antibiotic prophylaxis to be considered cost-effective.  The authors concluded, “Our data suggest that European and American guidelines recommending [antibiotic prophylaxis] use in high-risk individuals are likely to be cost-effective.”

It should be noted that this paper provides information in the context of a U.K. population, where the decision to discontinue the practice of antibiotic prophylaxis in any patient at risk of IE was made in 2008.  Other limitations of the study are the lack of randomized, controlled trial data to inform the modeling estimates, resulting in use of observational studies to identify the input parameters for health economic analysis. In particular, the assumptions regarding the effectiveness of antibiotic prophylaxis are based on an observational study of the increase in IE cases and fall in antibiotic prophylaxis prescribing that occurred after the introduction of the 2008 NICE guideline; although the study demonstrated a temporal association between the fall in antibiotic prophylaxis prescribing and increasing IE incidence, it did not establish causation. Although the drug prophylaxis regimens evaluated (penicillin, clindamycin) provide coverage for IE potentially caused by oral streptococcus, a 2015 letter to the editor7 of The Lancet reported increases in IE cases caused by staphylococcus, likely from implanted cardiovascular devices.

The ADA has a recently updated Oral Health Topic on “Antibiotic Prophylaxis Prior to Dental Procedures” that outlines the evidence for the “currently relatively few patient subpopulations for whom antibiotic prophylaxis may be indicated prior to certain dental procedures,” as compared with previous recommendations.

References

  1. Franklin M, Wailoo A, Dayer MJ, et al. The cost-effectiveness of antibiotic prophylaxis for patients at risk of infective endocarditis. Circulation 2016.
  2. Richey R, Wray D, Stokes T. Prophylaxis against infective endocarditis: summary of NICE guidance. Bmj 2008;336(7647):770-1.
  3. Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 2007;116(15):1736-54.
  4. Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. J Am Dent Assoc 2008;139 Suppl:3S-24S.
  5. Dayer MJ, Jones S, Prendergast B, et al. Incidence of infective endocarditis in England, 2000-13: a secular trend, interrupted time-series analysis. Lancet 2015;385(9974):1219-28.
  6. Habib G, Lancellotti P, Antunes MJ, et al. 2015 ESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J 2015;36(44):3075-128.
  7. Gouriet F, Habib G, Raoult D. Infective endocarditis and antibiotic prophylaxis. The Lancet;386(9993):528.

Prepared by: Center for Scientific Information, ADA Science Institute

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