Antimicobial Prophylaxis for Endocarditis: Emotion or Science?

David R Ramsdale, Consultant Cardiologist,

Other Contributors:

February 07, 2007

Dear Editor,

The editorial by Ashrafian and Bogle[1] suggests that the authors have little clinical experience in the management of patients with infective endocarditis (IE). The body of cardiologists and cardiac surgeons in Europe, North America and the UK would disagree that the BSAC guidelines are important or “a step in the right direction” and almost certainly the guidelines will be disregarded by the rest of the world as an eccentricity not based on any evidence whatsoever. Without doubt, they are out of line with the views of physicians who have cared for patients with IE over the last 50 years and of those who continue to have this responsibility. The Joint Formulary Committee of the British National Formulary and our dental colleagues would do well to take note of the advice from specialist cardiologists from Europe and the USA regarding antibiotic prophylaxis (ABP) for those at risk of IE and remember the devastating consequences that often occur in those patients who are unfortunately affected. Sadly, within our own Centre we have recently seen two patients who developed IE after dental treatment who despite requesting ABP from their dentist, were told that based on the new BSAC guidelines ABP was not necessary and hence not administered.

Although a very large randomised controlled clinical trial of ABP prior to dental treatment in those patients considered to be at high/moderate risk of IE because of their cardiac structural abnormality might help quantify the benefit/risks of ABP, we think it would prove difficult to obtain ethical approval and even the patients’ consent for such a study. With regards to the cost-effectiveness and safety of oral amoxicillin, we believe it is very cost-effective at ₤1.50 per 3G sachet, set against the high cost of a prolonged in-patient stay for parenterally administered antibiotics, the high morbidity and mortality and the need for surgery in those individuals with the serious destructive cardiac and extracardiac complications of IE. Although anaphylaxis may occur as an allergic response to penicillin, this is extremely rare and not a reason for the omission of ABP.

Patients who place their trust in health professionals to do everything in their power to protect them deserve a sensible cautious approach from their physician to diminish the risk of developing a life- threatening illness with high morbidity and mortality. Dentists look to cardiologists and not microbiologists for advice about the need for ABP for patients with cardiac abnormalities that place them at increased risk of IE. Not to offer ABP to those patients who cardiologists consider to be at risk of IE is a disservice and in most countries in the Western World would be considered medico-legally negligent. Dentists will find it difficult to obtain the support of the patient’s cardiologist when disaster strikes their patient as a result of omitting ABP when this has been recommended.

Dr David R Ramsdale MD FRCP, Consultant Cardiologist and Dr Nick D Palmer MD MRCP, Consultant Cardiologist,
The Cardiothoracic Centre,
Thomas Drive,
Liverpool.

Reference

1. Ashrafian H and Bogle RG.
Antimicrobial prophylaxis for endocarditis:emotion or science?
Heart 2007;93:5-6.

Conflict of Interest

None declared