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

2. 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

3. 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

4. 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

5. 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”

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

7. 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?

8. 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

9. 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,

10. 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

11. 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

12. 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 mins prior to procedure
Caution in elderly due to pseudomembranous colitis risk

13. ECS apps and downloads available Thanks for your time