Management of patients at increased risk of infective endocarditis
Management of patients at increased risk of infective endocarditis
For patients at high risk of infective endocarditis, offer antibiotic prophylaxis prior to extractions and oral surgery procedures (see 'At-risk' dental procedures for examples of these procedures).
For patients at high risk of infective endocarditis, consider antibiotic prophylaxis for dental procedures that involve manipulation of the gingival or periapical region of the teeth (see 'At-risk' dental procedures for examples of these procedures).
- The consideration of antibiotic prophylaxis for these dental procedures must involve reaching a shared decision with the patient. This will require a discussion about the uncertain risk of infective endocarditis associated with the dental procedure and the potential benefits and harms of antibiotic prophylaxis, and consideration of the patient’s individual oral health status. The shared decision must fully reflect the patient’s values and preferences. A list of important points to discuss with the patient is available (see Patient discussion aid).
For patients at moderate risk of infective endocarditis, antibiotic prophylaxis is not recommended prior to ‘at-risk’ dental procedures.
Identification of high risk and moderate risk patients may require consultation with the patient’s cardiac team(s). It is recommended that the dental team determines the patient’s risk of infective endocarditis when they register with the practice, or when they are first diagnosed with a cardiac condition, to ensure that the relevant information is available should they require ‘at-risk’ dental treatment or have a dental emergency. Re-assessment will only be required if there is a change in the patient’s medical history.
Note that some patients who undergo a cardiac procedure are only considered to be at high risk of infective endocarditis in the first six months following the procedure (see High risk patients).
For all patients at increased risk of infective endocarditis who require an ‘at-risk’ dental procedure (see 'At-risk' dental procedures):
Determine whether the patient’s specific cardiac condition places them at high risk or moderate risk of infective endocarditis (see Patients at risk of infective endocarditis).
- This may require consultation with the patient’s cardiac team(s). A template letter to facilitate this can be found in Supporting tools.
If a patient is unsure about the nature of their cardiac condition, contact their cardiac team(s) or general medical practitioner for further information.
For patients who have a high risk cardiac condition (see High risk patients) and require an ‘at-risk’ dental procedure (see 'At-risk' dental procedures):
Provide advice about prevention of infective endocarditis (see Prevention of infective endocarditis, Patient discussion aid and Patient information).
Explain why antibiotic prophylaxis before ‘at-risk’ dental procedures is recommended or should be considered for them (see Patient discussion aid).
Ensure that the patient and/or their carer or guardian is aware of the potential benefits and harms of antibiotic prophylaxis (see Prescribing antibiotic prophylaxis) to inform a shared decision about whether antibiotic prophylaxis is appropriate for their individual situation.
- A list of points to cover in your discussion with the patient (see Patient discussion aid) and a patient information leaflet (see Patient information) are available.
If the patient chooses to have antibiotic prophylaxis prior to the procedure, ensure that this, and the discussions around the decision, are recorded in the patient’s clinical notes and prescribe an appropriate drug (see Prescribing advice).
If the patient chooses not to have antibiotic prophylaxis prior to the procedure, ensure that this decision and the discussions around it, are clearly recorded in the patient’s clinical notes.
- If the procedure is an ‘at-risk’ dental procedure where prophylaxis is recommended (e.g. extraction, oral surgery), ensure that the patient is aware that their decision may expose them to a higher risk of infective endocarditis.
Ensure that any episodes of dental infection in patients at high risk of infective endocarditis are investigated and treated promptly to reduce the risk of endocarditis developing.
For patients who have a moderate risk cardiac condition (see Moderate risk patients) and require an ‘at-risk’ dental procedure (see 'At-risk' dental procedures):
Provide advice about prevention of infective endocarditis (see Prevention of infective endocarditis, Patient discussion aid and Patient information).
Explain that antibiotic prophylaxis before ‘at-risk’ dental procedures is not recommended for them as there is no evidence that it will reduce their risk of infective endocarditis and there is a risk of an adverse reaction to the antibiotic prophylaxis.19
- A list of points to cover in your discussion with the patient (see Patient discussion aid) and a patient information leaflet (see Patient information) are available.
If, following this discussion, the patient chooses antibiotic prophylaxis, make a shared decision on whether prophylaxis is appropriate for their individual situation.
- Consider seeking further advice from their cardiac team if required.
Patients at moderate risk of infective endocarditis do not require antibiotic prophylaxis unless this is already specified by the patient's cardiac team (e.g. due to comorbidities). In this situation, follow the advice for high risk patients above.
Ensure that any episodes of dental infection in patients at moderate risk of infective endocarditis are investigated and treated promptly to reduce the risk of endocarditis developing.
The management of high risk and moderate risk patients is illustrated in this Management flowchart.