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On 15 November 1998, David Durack published a famous editorial entitled ‘Antibiotics for prevention of endocarditis during dentistry: time to scale back?’.1 It was the starting point to the progressive restriction of antibiotic prophylaxis (AP) of infective endocarditis (IE) to the most at-risk patients, that is, patients with previous IE, prosthetic materials or some forms of congenital heart diseases, and in the most at-risk situations, that is, bleeding dental procedures. Both American2 and European3 guidelines agreed on this very important change in our clinical practice. Unfortunately, neither recent nor previous guidelines were based on strong evidence.
Since that time, several alarming messages arose mainly from the UK, about the potential link between the partial or total cessation of AP and the risk of increasing incidence of IE.4 In this issue of the journal, Thornhill et al5 again sound the alarm about this risk and ask themselves the question of the need to reassess the current guidelines and to ‘scale up’ AP in some patients at risk of IE.
The excellent paper from Thornhill et al5 gives us the opportunity to retrace the story of AP in IE and try to think about the future.
Why was AP restricted in the 2000s and what were the consequences of these changes?
The justification for restricting AP in the 2000s was clearly detailed in previous guidelines2 3 or scientific statements6 and is as follows:
IE is more likely to result from frequent exposure to random bacteraemia associated with daily activities than from bacteraemia caused by a dental, gastrointestinal (GI) tract or genitourinary (GU) procedure.
Prophylaxis may prevent an exceedingly small number of cases of IE in individuals who undergo a dental, GI tract or GU procedure.
The risk of antibiotic adverse effects, either individual (anaphylaxis) or collective (resistance …
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Contributors GH wrote the paper. BI corrected the paper and approved it.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.