NICE guideline

National Institute for Health and Care Excellence (NICE)

In 2008, NICE issued Clinical Guideline 64 (CG64) Prophylaxis against infective endocarditis.²¹ The guideline recommended that people at risk of infective endocarditis (IE) having dental procedures should not be offered antibiotic prophylaxis against infective endocarditis (Recommendation 1.1.3). The basis for NICE’s recommendation was the lack of evidence to link dental procedures with development of IE and to support the effectiveness of antibiotic prophylaxis in preventing IE. Additionally, NICE noted that daily activities may pose a greater cumulative risk and that the number of deaths from anaphylaxis related to antibiotic prophylaxis may be higher than the number of prevented deaths, making it not cost effective. 

In 2015, NICE carried out a review of the evidence. It found very low quality evidence that was inconclusive about the efficacy of antibiotic prophylaxis before an interventional procedure to reduce the incidence of IE. Recommendation 1.1.3 remained unchanged. However, in 2016 NICE amended recommendation 1.1.3 to emphasise the importance of shared decision-making:

‘Antibiotic prophylaxis against infective endocarditis is not recommended routinely for people undergoing dental procedures’.

In 2018, the Scottish Dental Clinical Effectiveness Programme (SDCEP) published implementation advice to help dental teams apply the amended recommendation 1.1.3.

In 2024, NICE undertook a surveillance review²² of the evidence in response to a coroner’s request following the death of a patient in England who developed IE after a dental extraction procedure. The patient had not been prescribed antibiotic prophylaxis. The review found new evidence but concluded that this was inadequate to support the use of antibiotic prophylaxis before dental procedures in patients at risk of infective endocarditis. However, NICE did acknowledge that there is a sub-group of individuals at high risk of infective endocarditis (IE) who may benefit from antibiotic prophylaxis:

“While high quality research evidence remains scarce, there is some evidence with uncertainty that a small proportion of IE in patients at high risk may be attributable to invasive dental procedures.”

As a result, NICE clarified recommendation 1.1.3 to include a link to the SDCEP implementation advice. The clarified recommendation states:

Antibiotic prophylaxis against infective endocarditis is not recommended routinely for people undergoing dental procedures

• For advice on antibiotic prophylaxis for people at high risk of infective endocarditis undergoing dental procedures and for relevant patient information, see the implementation advice provided by the Scottish Dental Clinical Effectiveness Programme (this programme is part of NHS Education for Scotland). This advice was developed in conjunction with, and is endorsed by, NICE. It has been endorsed for use across the UK by the Chief Dental Officers of the UK.