Prescribing advice
Prescribing advice for antibiotic prophylaxis against infective endocarditis
Antimicrobial stewardship is essential in UK dental practice to optimise patient outcomes, to prevent the overuse and misuse of antimicrobials and to combat the growing global threat of antimicrobial resistance. Inappropriate or excessive prescribing can contribute to the development of drug-resistant bacteria. In 2024, dentists accounted for approximately 7.7% of all NHS primary care antibiotic prescriptions in Scotland, 3.2% in England, and 5.9% in Wales.37-39 Data for Northern Ireland is only available for 2022, with antibiotic prescribing in dental care accounting for 5.2% of total antibiotic prescribing in primary care in that period.40
While it is unclear whether providing a single prophylactic dose of antibiotics will impact significantly on community antimicrobial resistance, there is some low certainty evidence suggesting there is an increased risk of the individual patient transiently acquiring antibiotic resistant strains.41
Adverse events
Potential harms associated with the use of antibiotics include common side effects (such as nausea, diarrhoea or skin reactions), hypersensitivity (including anaphylaxis) and gut dysbiosis (which can increase the risk of Clostridioides difficile infection). Consideration of these potential harms forms a key part of the decision to prescribe and the potential for adverse effects, even from a single prophylactic dose, should be discussed with the patient.
Treatment with beta-lactam antibiotics, such as amoxicillin, can result in hypersensitivity reactions but reports of anaphylactic reactions to amoxicillin prophylaxis are extremely rare.42,43 Amoxicillin prophylaxis should not be prescribed for patients with a history of true penicillin allergy. Note that many reported penicillin allergies are misclassified and true allergy should be distinguished from common side effects like nausea or diarrhoea.
The use of broad spectrum antibiotics, such as amoxicillin can cause gut dysbiosis and is associated with Clostridioides difficile-associated disease. Whilst even a single dose can potentially increase the risk of Clostridioides difficile infection (CDI), reports of adverse reactions to amoxicillin prophylaxis appear to be rare.*43 Antibiotic-associated colitis can be fatal and therefore care should be taken when prescribing these antibiotics to vulnerable groups (e.g. older age, frailty, immunosuppressed), those who have received prolonged or repeated courses of antibiotics and those with a history of gastrointestinal disease, including those using proton pump inhibitor drugs for dyspepsia and gastro-oesophageal reflux diseases. The British National Formulary (BNF) provides more information on prescribing for specific patient groups.
*It should be noted that this finding is based on analysis of reports of adverse reactions to a single 3 g dose of amoxicillin based on data from the Medicines and Healthcare products Regulatory Agency (MHRA) Yellow Card Scheme. There are concerns about the appropriateness of this analysis and the MHRA states that this data should not be used to estimate the frequency of side effects.
Adverse or unwanted reactions might occur after use of any drug. The Medicines and Healthcare products Regulatory Agency (MHRA) monitors suspected adverse drug reactions through the Yellow Card Scheme. Healthcare professionals are advised to record and report any adverse drug reactions using the scheme. Patients and carers can also report suspected adverse reactions to the MHRA using the scheme.
Prescribing antibiotic prophylaxis
Good antimicrobial stewardship principles, such as prescribing only when clinically indicated, using narrow-spectrum agents where possible and accurate assessment of allergy history, apply when prescribing antibiotic prophylaxis. In addition, the potential benefits and harms, including the potential for adverse effects even from a single antibiotic dose, should be discussed with the patient and the indication, choice, and rationale should be documented in the clinical record.
Refer to the SDCEP Drug Prescribing for Dentistry guidance for more information on antimicrobial stewardship.
Note that if antibiotic prophylaxis is required for planned ‘at-risk’ procedures, it usually will be the responsibility of the dentist to prescribe this.
When prescribing antibiotic prophylaxis for planned ‘at-risk’ procedures:
Provide the patient with a prescription for antibiotic prophylaxis at the appointment prior to the planned procedure unless you hold a supply of antibiotics in your practice.
- If a patient’s cardiac team suggests an alternative prophylaxis regimen, it is acceptable to follow their advice but ensure that the reasons for this are recorded in the patient’s clinical notes.
- For patients who require sequential ‘at-risk’ dental procedures (see 'At-risk' dental procedures) over a short time period, and it has been agreed that prophylaxis is appropriate, the same antibiotic can be prescribed for each treatment episode. In this situation, the AHA suggests a delay of 10 days between procedures that require antibiotic prophylaxis.23
- For a patient who has received a recent course of antibiotics for a medical or dental infection, it is not necessary to select a drug from a different antibiotic class for the prophylaxis prescription.
- If the antibiotic regimens included in this implementation advice are unsuitable, contact an expert, such as a consultant microbiologist or community pharmacist, for advice on an alternative drug regimen. The UK Dental Medicines Advisory Service can also offer advice be contacted for advice.
Give advice on possible side effects (e.g. nausea, diarrhoea) and other adverse events (e.g. hypersensitivity, anaphylaxis and antibiotic-related colitis).
- Patients prescribed an antibiotic should be advised to seek urgent medical attention if they develop antibiotic-associated colitis (severe diarrhoea, which can be fatal). The risk of colitis is increased in vulnerable groups (e.g. older age, frailty, immunosuppressed), those who have received prolonged or repeated course of antibiotics and those with a history of gastrointestinal disease.
Arrange for the antibiotic to be taken in the practice 30-60 minutes before the planned procedure is due to commence.
- If you do not hold a supply of antibiotics in your practice, advise the patient to bring the prescribed antibiotic with them to the dental practice on the day of the procedure and ensure that the patient remains in the practice in the interval between taking the antibiotic and the start of treatment.
- Alternatively, if the patient expresses a preference to take the antibiotic at home or at another location outside the practice, and has not previously had an adverse reaction to prophylaxis, it is acceptable to agree to this. Consider advising they contact the practice prior to taking the antibiotic to confirm that the procedure will be going ahead.