Australian Dental Journal 2008; 53: 196200

REVIEW

doi: 10.1111/j.1834-7819.2008.00049.x

A change of heart: the new infective endocarditis prophylaxis

guidelines
CG Daly,* BJ Currie, MS Jeyasingham, RFW Moulds, JA Smith,
NF Strathmore,** AC Street, AN Goss
*Faculty of Dentistry, The University of Sydney, New South Wales.
Menzies School of Health Research and Royal Darwin Hospital, Casuarina, Northern Territory.
Therapeutic Guidelines Limited, Melbourne, Victoria.
Fiji School of Medicine, Suva, Fiji.
Monash University and Monash Medical Centre, Clayton, Victoria.
**The University of Melbourne and The Royal Melbourne Hospital, Victoria.
Victorian Infectious Diseases Services, The Royal Melbourne Hospital, Victoria.
The University of Adelaide, South Australia.
Infective Endocarditis Prophylaxis Expert Group, Therapeutic Guidelines Limited.

ABSTRACT
New Australian guidelines for the prevention of infective endocarditis were published in July 2008. The guidelines were
revised by a multidisciplinary group to reflect recent changes in international recommendations regarding antibiotic
prophylaxis for infective endocarditis. The reasons for the changes are explored in this review and the implications for
dental practice are discussed.
Key words: Infective endocarditis, antibiotic prophylaxis, guidelines.
Abbreviations and acronyms: AHA = American Heart Association; IE = infective endocarditis; NICE = National Institute for Health and
Clinical Excellence; RHD = rheumatic heart disease.
(Accepted for publication 26 May 2008.)

The recent publication of new Australian guidelines1

for antibiotic prophylaxis for the prevention of infective
endocarditis (IE) represents a major revision of previously accepted protocols. The changes follow similar
revisions in the United States of America2 and the
United Kingdom.3 They have occurred largely as a
result of critical analysis of the evidence, which has
questioned the traditional linking of some types of
dental treatment to IE and the claimed value of
antibiotic prophylaxis in preventing IE.
Antibiotic prophylaxis for patients with congenital or
acquired cardiac conditions who were considered to be
at risk of IE, and who required dental treatment, was
introduced by the American Heart Association (AHA)
in 1955, not long after penicillin became widely
available.4 The rationale for recommending antibiotic
prophylaxis was that dental treatment was known to
cause a spread of oral bacteria into the circulation
(bacteraemia), and these bacteria (especially viridans
group streptococci) had the potential to colonize
damaged heart valves and result in what was then
known as bacterial endocarditis, either acute, sub-acute
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or chronic. It was considered that prophylactic antibiotics would destroy bacteria in the bloodstream so
that bacterial endocarditis would be prevented. For half
a century, between 1955 and 2006, the alterations to
antibiotic guidelines in various countries related mainly
to antibiotic choice and route of administration. The
use of intramuscular injections or intravenous infusions
of antibiotics such as penicillin, vancomycin, gentamicin and erythromycin was gradually replaced with an
oral route of administration, with a single dose of
amoxycillin or clindamycin given prior to treatment.
The recommendation for post-treatment antibiotic
administration was abolished by the AHA in 1997.5
The first guidelines to recommend a major departure
from the traditional belief that all patients at risk of IE
required antibiotic prophylaxis prior to dental or other
invasive procedures were produced by a working party
of the British Society for Antimicrobial Chemotherapy
in 2006.6 The British guidelines reduced the number of
cardiac conditions requiring antibiotic prophylaxis
to only those individuals with previous IE, those
who had undergone cardiac valve replacement surgery
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(i.e., mechanical or biological prosthetic valves), or
those who had surgically constructed systemic or
pulmonary shunts or conduits. Patients with mitral
valve prolapse or rheumatic heart disease were no
longer recommended to receive antibiotic cover.
In 2007, the AHA introduced new guidelines which
were significantly different from previous AHA recommendations.2 Like the British guidelines,6 the new
American guidelines significantly reduced the categories
of cardiac conditions which required antibiotic prophylaxis for dental or other mucosally invasive procedures. In the new guidelines prophylaxis is no longer
recommended on the basis of lifetime risk of IE, but
is now only required for cardiac conditions identified
as having the highest risk of an adverse outcome if
IE occurs. These conditions include prosthetic cardiac
valve insertion, previous IE, some specific congenital
heart diseases, and cardiac transplant recipients who
develop cardiac valvulopathy. The AHA guidelines
concluded that the death rate for native valve IE caused
by viridans group streptococci was 5 per cent or less,
whilst it was approximately 20 per cent for viridans
streptococcal prosthetic valve endocarditis.2
The AHA conceded that for over 50 years, since the
publication of the first AHA guidelines,4 patients and
health professionals alike believed that antibiotic prophylaxis given for bacteraemia-producing procedures
would prevent IE in those with underlying cardiac risk
conditions. Patients were educated to inform their
dentist of their underlying cardiac risk factor for IE and
dentists were trained and expected to provide bacteraemia-producing treatment under antibiotic cover.
As such, there was a professional and medico-legal
responsibility on behalf of dentists to protect their
patients from IE. In their discussion of the reasons for
revising the IE guidelines, the AHA acknowledged that
the new recommendations could violate long-standing
expectations and practice patterns but they also
suggested that the new recommendations could reduce
malpractice claims related to IE prophylaxis.2
The reason for the major departure from previous
guidelines was the impact of evidence-based medicine
on current health care practice. The AHA was unable to
identify published evidence to prove that antibiotic
prophylaxis prevents IE associated with bacteraemia
from invasive procedures. A similar finding has been
reported by a recent Cochrane review7 which could not
identify any randomized, placebo-controlled clinical
trials to demonstrate the efficacy of penicillin prophylaxis in the prevention of IE caused by dental treatment.
The lack of randomized, placebo-controlled trials has
occurred in part due to the ethical considerations of
performing such trials. Given existing IE guidelines, it
would have been considered unethical and dangerous
to randomly and blindly allocate patients at risk of IE
to antibiotic or placebo groups and then expose them to
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bacteraemia-causing dental procedures. As a result, the

previous guidelines, which were not based on clinical
trial evidence, were themselves acting as barriers to the
acquisition of evidence on which valid decisions could
be made about the value of antibiotic prophylaxis.
Although the 2007 American guidelines were seen as
a major challenge to existing protocols, the more recent
UK guidelines3 shifted the goalposts even further. The
National Institute for Health and Clinical Excellence
(NICE) was requested by the UK Department of Health
to produce guidelines which would provide guidance
on best clinical practice for prophylaxis against IE for
patients undergoing dental and other interventional
procedures. The NICE clinical guideline issued in
March 2008 does not recommend antibiotic prophylaxis against IE for any patient, regardless of their
cardiac risk status, when undergoing dental procedures
or interventional procedures of the gastrointestinal,
genitourinary or respiratory tracts. In addition, the
NICE guideline recommends that chlorhexidine mouthwash should not be offered as prophylaxis against IE
in patients undergoing dental procedures. There is no
doubt that the NICE guideline is a logical but courageous step. The UK National Health Service has
effective data collection and reporting mechanisms
which, over the next few years, will be able to demonstrate either an increase or no change in the incidence
rate of streptococcal IE as a result of the new guideline.
The reason for the differing recommendations of the
American2 and UK3 guidelines is that there is no clear
evidence on which to base the recommendations. What
evidence is available has been assessed closely by expert
groups in both countries who have graded the value of
the evidence and interpreted it accordingly. In casecontrolled studies, it has been found that there were no
links between IE and dental treatment.810 The fact that
assessment of the same evidence by two different
groups has led to differing recommendations highlights
the subjective nature of all such guidelines. Although
the AHA has criticized its own previous guidelines as
being based on minimal published data or on expert
opinion, the same criticism holds true for the current
American and UK guidelines. However, one of the
important ramifications of the new guidelines is that
ethical and medico-legal impediments appear to have
been removed so as to permit randomized, placebocontrolled trials to investigate the efficacy of antibiotic
prophylaxis against IE in patients with various cardiac
conditions.
The recently updated Australian guidelines for antibiotic prophylaxis for IE1 were developed by an expert
group comprising cardiologists, cardiac surgeons, infectious diseases physicians and dentists. Both the American2 and UK3 guidelines were closely evaluated and
interpreted in the Australian context. Although there
have been no case-controlled studies of IE in Australia,
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CG Daly et al.
Table 1. Cardiac conditions associated with the
highest risk of adverse outcomes from endocarditis
Antibiotic prophylaxis is recommended in patients with the
following cardiac conditions if undergoing a specified dental
procedure (see Tables 2 and 3):
prosthetic cardiac valve or prosthetic material used for cardiac
valve repair
previous infective endocarditis
congenital heart disease but only if it involves:
unrepaired cyanotic defects, including palliative shunts and
conduits
completely repaired defects with prosthetic material or devices,
whether placed by surgery or catheter intervention, during the
first 6 months after the procedure (after which the prosthetic
material is likely to have been endothelialized)
repaired defects with residual defects at or adjacent to the site of
a prosthetic patch or device (which inhibit endothelialization)
cardiac transplantation with the subsequent development of
cardiac valvulopathy
rheumatic heart disease in Indigenous Australians only

the Australian experience of IE has been well documented11 and dental issues associated with IE have been
investigated.12,13 The UK guidelines3 were carefully
considered but it was decided that the abolition of
antibiotic prophylaxis for all patients at risk of IE could
not be supported at this time. Instead, the American
guidelines2 were adopted with one important modification to the cardiac conditions requiring prophylaxis
(Table 1). Although the incidence of rheumatic heart
disease (RHD) is low in developed countries and it is
not considered a cardiac condition at high risk of an
adverse outcome from IE in the American guidelines,
there is still a high incidence of RHD among Indigenous
Australians and the adverse outcomes of IE in this
group are considered significant.14 Therefore, it was the
consensus of the expert group that antibiotic prophylaxis is necessary in this particular group. As with
the American2 and British guidelines,6 mitral valve
prolapse with or without significant regurgitation
and RHD in non-Indigenous Australians have been
removed from the list of cardiac conditions requiring
antibiotic prophylaxis.
An important difference between the Australian and
American guidelines is the description of dental procedures requiring antibiotic prophylaxis. In the American
guidelines, the dental procedures for which IE prophylaxis is recommended are: Dental procedures that
involve manipulation of gingival tissue or the periapical
region of teeth or perforation of the oral mucosa.2
Manipulation of gingival tissue is a confusing
description and therefore the new Australian guidelines
have sought to identify which dental procedures are
likely to have a high incidence of bacteraemia (may
occur in 70 per cent or more of cases). The dental highrisk treatments for which antibiotic prophylaxis should
be given, for those patients with specified cardiac
conditions (Table 1), are listed in Table 2. Consideration was given to deleting the moderate risk group of
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Table 2. Prophylaxis always required

extraction
periodontal procedures including surgery, subgingival scaling
and root planing
replanting avulsed teeth
other surgical procedures (e.g. implant placement, apicoectomy)

Table 3. Prophylaxis required in some circumstances

Consider prophylaxis for the following procedures if multiple
procedures are being conducted, the procedure is prolonged or
periodontal disease is present:
full periodontal probing for patients with periodontitis
intraligamentary and intraosseous local anaesthetic injection
supragingival calculus removal cleaning
rubber dam placement with clamps (where risk of damaging
gingiva)
restorative matrix band strip placement
endodontics beyond the apical foramen
placement of orthodontic bands
placement of interdental wedges
subgingival placement of retraction cords, antibiotic fibres or
antibiotic strips

dental procedures (may occur in 30 per cent or more

cases). However, in a lengthy appointment in which
multiple treatments are being performed, particularly in
a patient with periodontal disease, consideration must
be given to providing antibiotic prophylaxis (Table 3).
For example, it has been shown that the incidence of
bacteraemia due to full-mouth periodontal probing
is 40 per cent in patients with periodontitis but only
10 per cent in patients with gingivitis.15 If possible, it
is preferable to structure appointments for patients
requiring antibiotic prophylaxis so that multiple treatments are performed at the one sitting, thus avoiding
the need for repeated visits under antibiotic prophylaxis. Dental procedures for which antibiotic prophylaxis is not required are shown in Table 4.
One aspect which all guidelines agree upon is the
need for patients at risk of IE to ensure optimal oral
health and to attend regular preventive dental checks.16
This is a responsibility of the patient but patients should
have such advice given to them by both their treating
medical and dental practitioners. The aim of ensuring
optimal oral health is to reduce the occurrence of
bacteraemia caused by daily activities such as oral
Table 4. Prophylaxis not required

oral examination
infiltration and block local anaesthetic injection
restorative dentistry
supragingival rubber dam clamping and placement of rubber dam
intracanal endodontic procedures
removal of sutures
impressions and construction of dentures
orthodontic bracket placement and adjustment of fixed appliances
application of gels
intraoral radiographs
supragingival plaque removal
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hygiene procedures. Indeed, the occurrence of regular bacteraemia due to oral hygiene procedures as
compared with the isolated occurrence of bacteraemia
at a dental visit is part of the rationale for reducing
the reliance on antibiotic prophylaxis to prevent IE.
The American guidelines have commented that: It is
inconsistent to recommend prophylaxis for dental
procedures but not for these same patients during
routine daily activities.2 The UK guidelines state that:
Regular toothbrushing must represent a much greater
risk of IE than a single dental procedure because of the
repetitive exposure to bacteraemia with oral flora
during the process of daily dental care.3 Similarly,
the Australian guidelines conclude that: It is considered that the cumulative effect of repeated episodes of
bacteraemia caused by oral hygiene activities is very
likely to be a more important risk factor for IE than
isolated episodes of bacteraemia occurring during
dental visits.1 In one study, it was postulated that
the everyday bacteraemia occurring over one year
would be millions of times greater than the bacteraemia
created by extraction of teeth.17
There is no doubt that the changes in IE guidelines
will have an impact on patients as well as medical and
dental professionals. Patients who, for many years,
have always had antibiotic prophylaxis provided for
dental treatment will need to be advised and counselled
as to why this is no longer necessary. Some of these
patients will be relieved but some will be confused as to
why the use of antibiotics, which they were once
informed was essential, is no longer advised. Traditional practice in any aspect of culture, including
medicine and dentistry, always takes time to be
changed. There will no doubt be some medical and
dental practitioners who will be resistant to change and
will still want to give antibiotic prophylaxis to their
patients. This is particularly so if the practitioner
underestimates the possibility of an adverse reaction
to the antibiotic and the broader community issue of
bacterial resistance.
The issue of change is not unique to Australia.
A comment on the 2007 American guidelines published in Journal Watch General Medicine states that:
The primary care physicians responsibility is to
determine whether the patient is in one of the four
qualifying cardiac conditions. If the patient has one of
these conditions, it is the dentists responsibilitynot
the physiciansto determine whether the upcoming
dental procedure warrants prophylaxis.18 The probability that some Australian medical practitioners will
still wish, not unreasonably, to have an input into the
decision about which dental treatments require antibiotic cover will probably continue. If a resolution
cannot be met for individual patients, then dental
practitioners should either follow the Australian
guidelines1 or, if they wish not to prescribe but the
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medical practitioner is insistent that this occurs for an

individual patient, then the dentist could prescribe but
document in the patients record that this was done on
the insistence of the patients medical practitioner.
This profound change in practice for IE prophylaxis
will take time to bed down but we will hopefully end up
with a more streamlined process which is primarily to
the benefit of our patients. Antibiotics must clearly be
used in an evidence-based fashion and not as a just in
case precaution to avoid medico-legal repercussions.19
It may also help further prepare medical and dental
practitioners for what might well be a foretaste of the
post-antibiotic era.
REFERENCES
1. Infective Endocarditis Prophylaxis Expert Group. Prevention of
endocarditis. 2008 update from Therapeutic Guidelines: Antibiotic version 13, and Therapeutic Guidelines: Oral and Dental
version 1. Melbourne: Therapeutic Guidelines Limited, 2008.
2. Wilson W, Taubert K, Gewitz M, et al. Prevention of infective
endocarditis: guidelines from the American Heart Association: a
guideline from the American Heart Association Rheumatic Fever,
Endocarditis, and Kawasaki Disease in the Young, and the
Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes
Research Interdisciplinary Working Group. Circulation
2007;116:17361754.
3. National Institute for Health and Clinical Excellence. Prophylaxis
against infective endocarditis. Antimicrobial prophylaxis against
infective endocarditis in adults and children undergoing interventional procedures. URL: http://www.nice.org.uk/CG064.
Accessed 19 March 2008.
4. American Heart Association Committee on Prevention of Rheumatic Fever and Bacterial Endocarditis. (Jones TD, Baumgartner
L, Bellows MT, et al.) Prevention of rheumatic fever and bacterial
endocarditis through control of streptococcal infections. Circulation 1955;11:317320.
5. Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial
endocarditis. Recommendations by the American Heart Association. Circulation 1997;96:358366.
6. Gould FK, Elliot TSJ, Foweraker J, et al. Working Party of the
British Society for Antimicrobial Chemotherapy. Guidelines for
the prevention of endocarditis: report of the Working Party of the
British Society for Antimicrobial Chemotherapy. J Antimicrob
Chemother 2006;57:10351042.
7. Oliver R, Roberts GJ, Hooper L. Penicillins for the prophylaxis of
bacterial endocarditis in dentistry. Cochrane Database Syst Rev
2004. Issue 2: CD003813.
8. Van de Meer JT, Thompson J, Valkenburg HA, Michel MF.
Epidemiology of bacterial endocarditis in The Netherlands. II.
Antecedent procedures and use of prophylaxis. Arch Intern Med
1992;152:18691873.
9. Strom BL, Abrutyn E, Berlin JA, et al. Dental and cardiac risk
factors for infective endocarditis. A population-based, casecontrol study. Ann Intern Med 1998;129:761769.
10. Duval X, Alla F, Hoen B, et al. Estimated risk of endocarditis in
adults with predisposing cardiac conditions undergoing dental
procedures with or without antibiotic prophylaxis. Clin Infect Dis
2006;42:e102107.
11. Dwyer DE, Chen SC, Wright E, Crimmins D, Collignon P,
Sorrell T. Hospital practices influence the pattern of infective
endocarditis. Med J Aust 1994;160:709718.
12. Ching M, Straznicky I, Goss AN. Cardiac murmurs: echocardiography in the assessment of patients requiring antibiotic
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CG Daly et al.
prophylaxis for dental treatment. Aust Dent J 2005;50(Suppl 2):
S69S73.
13. Singh J, Straznicky I, Avent M, Goss AN. Antibiotic prophylaxis
for endocarditis: time to reconsider. Aust Dent J 2005;50(Suppl
2):S60S68.
14. Moulds RF, Jeyasingham MS. Antibiotic prophylaxis against
endocarditis: time for a rethink. MJA 2008 (in press).
15. Daly CG, Mitchell DH, Highfield JE, Grossberg DE, Stewart D.
Bacteremia due to periodontal probing: a clinical and microbiologic investigation. J Periodontol 2001;72:210214.
16. Duval X, Leport C. Prophylaxis of infective endocarditis:
current tendencies, continuing controversies. Lancet Infect Dis
2008;8:225232.
17. Roberts GJ. Dentists are innocent! Everyday bacteraemia is the
real culprit: a review and assessment of the evidence that dental
surgical procedures are the principal cause of infective endocarditis in children. Paediatr Cardiol 1999;20:317325.

18. Brett AS. The new endocarditis guideline: which dental procedures merit prophylaxis? Journal Watch General Medicine. 28
February 2008.
19. Daly CG. Antibiotic prophylaxis for infective endocarditis.
Protecting the patient or the dentist? Periodontology 1995;16:
3240.

Address for correspondence:

Alastair N Goss
Professor and Director
Oral and Maxillofacial Surgery Unit
The University of Adelaide
Adelaide, South Australia 5005
Email: oral.surgery@adelaide.edu.au
Web: http://www.health.adelaide.edu.au/dentistry/omfs/

*The new Australian guidelines are available free-of-charge on the Therapeutic Guidelines Limited website,
http://www.tg.com.au, and also in their electronic publications (eTG complete and miniTG). The booklet versions of
Therapeutic Guidelines: Antibiotic and Therapeutic Guidelines: Oral and Dental will be updated as the new editions
are published.

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