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Lancet article suggests increase in infective endocarditis tied to reduction in antibiotics use

December 03, 2014

By Jean Williams

A time-series study on antibiotic prophylaxis published online Nov. 18 in the Lancet noted a gradual increase in the incidence of infective endocarditis in England that appears to correspond with a reduction in antibiotic prophylaxis for IE prevention.
The National Institute for Health and Clinical Excellence began recommending cessation of antibiotic prophylaxis for IE prevention in England in March 2008.   
According to "Incidence of Infective Endocarditis in England, 2000–13: a Secular Trend, Interrupted Time-Series Analysis," the Lancet article: "Although our data do not establish a causal association, prescriptions of antibiotic prophylaxis have fallen substantially and the incidence of infective endocarditis has increased in England since introduction of the 2008 NICE guidelines."
"It is a well-designed study that raises the question about the relevance of premedicating with antibiotics but before firm conclusions can be made, more well-designed clinical studies need to be conducted to confirm these initial findings," said Dr. Daniel Meyer, ADA chief science officer.
Dr. Thomas Sollecito, a member of the ADA Council on Scientific Affairs, provided additional perspective on the study.
"The findings from this study show a possible correlation but that doesn't equate to causation," Dr. Sollecito said.
Dr. Elliot Abt, vice chair of the CSA, also weighed in on the Lancet article. "Although several investigators have called for a randomized controlled trial, the best design in a situation where adverse events and rare outcomes are being evaluated would be a case-control study," he said.
"Because there is no control group, it becomes difficult, if not impossible, to say that changes in IE incidence are actually due to the implementation of the 2008 guidance. This is especially true since the incidence of IE was increasing prior to 2008."  
Regarding IE, antibiotic prophylaxis and management of patients, Dr. Sollecito added: "It is recommended that dentists continue to adhere to the 2007 guidelines from the American Heart Association, the most recent available. These guidelines provide appropriate information about when antibiotics are indicated as well as type and dosage."
Dr. Edmond Truelove, former chair of the Council on Scientific Affairs, too, cautioned dentists to adhere to the AHA recommendations on antibiotic prophylaxis and endocarditis. "The guidelines [in the U.S.] are different and recommend prophylaxis for high risk groups," he said. "Therefore applying the Lancet findings to the U.S. population may not be prudent."
The AHA guidelines are also available through JADA and the ADA Evidence-Based Dentistry Center.
For more information regarding the England study, visit the Lancet online. Search for infective endocarditis and look for the article's title: "Incidence of Infective Endocarditis in England, 2000–13: A Secular Trend, Interrupted Time-Series Analysis."