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Original research article
Antibiotic prophylaxis for infective endocarditis: a systematic review and meta-analysis
  1. Thomas J Cahill1,
  2. James L Harrison2,
  3. Paul Jewell1,
  4. Igho Onakpoya3,
  5. John B Chambers2,
  6. Mark Dayer4,
  7. Peter Lockhart5,
  8. Nia Roberts6,
  9. David Shanson7,
  10. Martin Thornhill8,
  11. Carl J Heneghan9,
  12. Bernard D Prendergast2
  1. 1 Oxford Heart Centre, John Radcliffe Hospital, Oxford, UK
  2. 2 Department of Cardiology, St Thomas Hospital, London, UK
  3. 3 Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
  4. 4 Department of Cardiology, Taunton and Somerset NHS Foundation Trust, Taunton, UK
  5. 5 Department of Oral Medicine, Carolinas Medical Center, Charlotte, North Carolina, USA
  6. 6 Outreach Librarian Knowledge Centre, Bodleian Health Care Libraries, Oxford, UK
  7. 7 Department of Microbiology, Great Ormond Street Children's Hospital, London, UK
  8. 8 Unit of Oral & Maxillofacial Surgery & Medicine, University of Sheffield School of Clinical Dentistry, Sheffield, UK
  9. 9 Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
  1. Correspondence to Dr. Bernard D Prendergast, Department of Cardiology, St Thomas’ Hospital, Westminster Bridge Rd, London SE1 7EH, UK; bernard.prendergast{at}


Objective The use of antibiotic prophylaxis (AP) for prevention of infective endocarditis (IE) is controversial. In recent years, guidelines to cardiologists and dentists have advised restriction of AP to high-risk groups (in Europe and the USA) or against its use at all (in the UK). The objective of this systematic review was to appraise the evidence for use of AP for prevention of bacteraemia or IE in patients undergoing dental procedures.

Methods We conducted electronic searches in Medline, Embase, Cochrane Library and ISI Web of Science. We assessed the methodological characteristics of included studies using the Strengthening the Reporting of Observational Studies in Epidemiology criteria for observational studies and the Cochrane Risk of Bias Tool for trials. Two reviewers independently determined the eligibility of studies, assessed the methodology of included studies and extracted the data.

Results We identified 178 eligible studies, of which 36 were included in the review. This included 10 time-trend studies, 5 observational studies and 21 trials. All trials identified used bacteraemia as an endpoint rather than IE. One time-trend study suggests that total AP restriction may be associated with a rising incidence of IE, while data on the consequences of relative AP restriction are conflicting. Meta-analysis of trials indicates that AP is effective in reducing the incidence of bacteraemia (risk ratio 0.53, 95% CI 0.49 to 0.57, p<0.01), but case–control studies suggest this may not translate to a statistically significant protective effect against IE in patients at low risk of disease.

Conclusions The evidence base for the use of AP is limited, heterogeneous and the methodological quality of many studies is poor. Postprocedural bacteraemia is not a good surrogate endpoint for IE. Given the logistical challenges of a randomised trial, high-quality case–control studies would help to evaluate the role of dental procedures in causing IE and the efficacy of AP in its prevention.

  • Endocarditis
  • Antibiotic prophylaxis
  • Systematic review

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  • Contributors Data extraction and analysis was performed by TJC, JLH, PJ and IO. Electronic searches were performed by NR. Input on methodology, study identification, appraisal and analysis was provided by JC, MJD, PL, DS, MHT, CH and BDP. The manuscript was drafted by TJC, JLH and BDP and was approved by all authors.

  • Competing interests MJD was a non-voting member of the NICE panel who reviewed guidance concerning the use of antibiotic prophylaxis to prevent infective endocarditis in 2015.

  • Provenance and peer review Commissioned; externally peer reviewed.

  • Correction notice Since this paper was first published online the discussion section has been amended.