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Infective Endocarditis Antibiotic Prophylaxis After Dental Procedures
Quick Takes
- After extensive literature review, data from case-control/crossover, cohort, and self-controlled case series studies showed that the use of antibiotic prophylaxis was associated with a reduced risk of infective endocarditis (IE) following an invasive dental procedure among individuals at high risk, whereas no association was proven for those at low/unknown risk.
- Meta-analysis based on four substudies in two prior publications revealed a 59% reduction in relative risk of IE associated with antibiotic prophylaxis after invasive dental procedures among individuals at high risk.
Study Questions:
Based on existing evidence, is there an association between antibiotic prophylaxis and infective endocarditis (IE) following invasive dental procedures?
Methods:
PubMed, Cochrane-CENTRAL, Scopus, Web of Science, Proquest, Embase, Dentistry and Oral Sciences Source, and ClinicalTrials.gov were systematically searched from inception to May 2023 for studies on the association between antibiotic prophylaxis and IE following invasive dental procedures or time-trend analyses of IE incidence before and after current antibiotic prophylaxis guidelines. After evaluation of study quality and data extraction, a pooled relative risk (RR) of developing IE following invasive dental procedures was computed by random-effects meta-analysis for individuals who were receiving antibiotic prophylaxis compared to those who were not.
Results:
Of 11,217 records identified, 30 were included (1,152,345 IE cases). Of those, eight (including 12 substudies) were either case-control/crossover or cohort studies or self-controlled case series, and 22 were time-trend studies; all were of good quality. Eight of the 12 substudies with case-control/crossover, cohort, or self-controlled case series designs performed a formal statistical analysis; five supported a protective role of antibiotic prophylaxis, especially among individuals at high risk, whereas three did not. Meta-analysis (based on four substudies in two publications) revealed that antibiotic prophylaxis was associated with a significantly lower risk of IE after invasive dental procedures in individuals at high risk (pooled RR, 0.41; 95% confidence interval [CI], 0.29-0.57; p for heterogeneity = 0.51; I2 0%). Nineteen of the 22 time-trend studies performed a formal pre-post statistical analysis; nine found no significant changes in IE incidence, seven demonstrated a significant increase for the overall population or subpopulations (individuals at high and moderate risk, streptococcus-IE, and viridans group streptococci-IE), whereas three found a significant decrease for the overall population and among oral streptococcus-IE.
Conclusions:
Although results from time-trend studies were inconsistent, data from case-control/crossover, cohort, and self-controlled case series studies showed that the use of antibiotic prophylaxis is associated with reduced risk of IE following invasive dental procedures in individuals at high risk, while no association was proven for those at low/unknown risk; thereby supporting current American Heart Association and European Society of Cardiology recommendations. The authors conclude that currently there are insufficient data to support the benefit of antibiotic prophylaxis in individuals at moderate risk.
Perspective:
There is and likely always will be an absence of prospective, randomized clinical trials addressing the utility of antibiotic prophylaxis in mitigating IE risk following invasive dental procedures. Based on the review of previously published studies, this review and meta-analysis supports the use of IE prophylaxis among patients at high risk of IE, providing support to current national and international guideline statements. A major limitation of the meta-analysis is its reliance on data from only four substudies that appeared in two prior publications, all relying on administrative databases. This study provides evidence to support the continued use of antibiotic prophylaxis among patients at high risk for IE undergoing an invasive dental procedure. Among patients at moderate risk of IE undergoing an invasive dental procedure, the absence of proof in this study still might not be taken as proof of absence of benefit.
Clinical Topics: Valvular Heart Disease
Keywords: Antibiotic Prophylaxis, Endocarditis, Bacterial
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