Recent changes to NICE CG64: Prophylaxis against infective endocarditis: antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures

Infective Endocarditis Inflammation of the endocardium Due to S Viridans (Oral) ; Streptococci (Skin) Acess via venous drainage in the head & neck Endocardium has atypical blood supply Fatal (60% within year 1) Drastically impacts quality of life

Symptoms / Early detection Temperature >38oc Night sweats SOB on exertion Fatigue Muscle/joint pain Weight Loss Petechiae, Splinter haemorrhages, Osler’s nodes Can be acute or subacute

Timeline of Guidelines > 1923: IE linked to invasive dental procedures < 2008: Abx prophylaxis commonplace 3g Amoxicillin orally 600mg Clindamycin > 2008: NICE Guidelines introduced Abx cover no longer recommended for any patients At odds with ECS & AHA guidance for high risk patients

Timeline (Cont’d) 2015: Lancet Article Upward trend in IE cases since guidelines introduced Triggered review of NICE guidelines: No changes made! ESC maintained need for Abx July 2016: One word changed in Nice CG 64 They added the word: “routinely”

CG64 July2016 Antibiotic prophylaxis against infective endocarditis is not recommended “In individual cases, antibiotics may be appropriate” CEO Of NICE routinely

An issue of consent? An issue of risk? Changes to informed consent The clinician's advice must be both fact sensitive and sensitive also to the characteristics of the patient. An issue of risk?

How to Apply NICE CG64 NICE do not provide an antibiotic regime NICE still do not advocate prophylaxis for any specific groups Leaves door open for informed patient choice Removes the handcuffs from practitioners Consider ESC 2015 guidelines High risk patients receiving dentally invasive procedures require antibiotic prophylaxis

Identify ‘high risk’ patients Prev hx of IE Prosthetic or repaired heart valves Acquired valvular heart disease with stenosis / regurgitation Structurally congenital heart disease Exclusions apply Hypertrophic cardiomyopathy Patent ductus arteriosus,

Identify invasive dental procedures Any procedure involving the gingival crevice Extractions, scaling, RCT, oral mucosa perforation Exclusions: LA administration in non infected tissues Suture removal Trauma to lips/oral mucosa Supragingival fillings not involving the gingival crevice

Consult the patient’s cardiologist if necessary Finally… Allow the patient to make an informed choice based on their own priorities/situation. Signposting ECS guidelines and NICE CG64 guidelines Signposting signs and symptoms of IE Signposting need for good OH and regular dental visits Signpost non dental risk factors (IV drug use, tatoos) Consult the patient’s cardiologist if necessary

Antibiotic Options? NKDA: Penicillin allergy: Amoxicillin 2g orally 30-60mins prior to procedure 3g sachets closest formulation available in the UK Penicillin allergy: Clindamycin 600mg 30 -60 mins prior to procedure Caution in elderly due to pseudomembranous colitis risk

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