Clinical scenarios
Clinical scenarios
The clinical scenarios below are intended to support decision-making on antibiotic prophylaxis against infective endocarditis. They demonstrate how the recommendations on antibiotic prophylaxis might be applied in practice for patients at increased risk of infective endocarditis.
These scenarios are illustrative and do not cover all possible patient presentations or clinical situations. Therefore, refer to the full implementation advice and use clinical judgement to ensure decisions on antibiotic prophylaxis are appropriate for the individual circumstances of each increased risk patient.
Charlie is 63 years old and has a prosthetic mitral valve. She attends for an examination and is concerned about the health of her gums. Charlie has suboptimal oral hygiene and has obvious gingival inflammation when examined visually. A BPE examination is required to assess her periodontal condition.
Discuss with Charlie:
- that due to her cardiac condition, she is at high risk of infective endocarditis
- that antibiotic prophylaxis before dental treatment is recommended or should be considered for her
- that due to her suboptimal oral hygiene, further assessment of her gums will likely cause bleeding
- that antibiotic prophylaxis should be considered for this BPE assessment
- the potential benefits and harms of antibiotic prophylaxis
to inform a shared decision about antibiotic prophylaxis.
Give Charlie information about prevention of infective endocarditis, including:
- the importance of maintaining good oral health
- symptoms that may indicate infective endocarditis and when to seek advice
- the risks of undergoing invasive procedures including non-medical procedures such as body piercing or tattooing
If Charlie indicates that she understands the potential benefits and harms of antibiotic prophylaxis and chooses to have a BPE without antibiotic prophylaxis:
Carry out the BPE without antibiotic prophylaxis.
Document all discussions in the case records.
Given that Charlie’s oral health status is poor and that she has a high risk cardiac condition, it is more likely that, following the discussion, Charlie may choose antibiotic prophylaxis. In this situation, respect Charlie’s choice:
Do not undertake a BPE at this examination appointment but continue with other aspects of the examination and special tests that do not require manipulation of the gingival tissues.
Prescribe antibiotic prophylaxis for Charlie’s return appointment.
At the return appointment, combine the BPE with any other indicated “at-risk” procedures, for example supragingival PMPR (and if required, subgingival instrumentation), to minimise episodes of antibiotic prophylaxis.
Document all discussions in the case records.
In a slightly different scenario, Charlie has excellent oral hygiene and has no evidence of gingival inflammation when examined visually. In this scenario, periodic BPE examination will be helpful to check that any periodontal issues are not missed. The same discussions about antibiotic prophylaxis (as described above) should be had with Charlie. Charlie’s choice of whether or not to have antibiotic prophylaxis may or may not differ. However, even if you believe that there is minimal risk of infective endocarditis from carrying out the BPE in this scenario, if Charlie chooses antibiotic prophylaxis for the BPE, then respect her decision and provide antibiotic prophylaxis for the procedure. Document all discussions in the case records.
Alex is 45 years old and requires an extraction of tooth 35. They have a cardiovascular implanted electronic device (CIED).
Discuss with Alex:
- that due to their cardiac condition, they are at moderate risk of infective endocarditis
- that antibiotic prophylaxis before dental treatment is not recommended for them
- the potential benefits and harms of antibiotic prophylaxis
to inform a shared decision about antibiotic prophylaxis.
Give Alex information about prevention of infective endocarditis, including:
- the importance of maintaining good oral health
- symptoms that may indicate infective endocarditis and when to seek advice
- the risks of undergoing invasive procedures including non-medical procedures such as body piercing or tattooing
If Alex indicates that they understand the risks and benefits and chooses to have a tooth extraction without antibiotic prophylaxis:
Proceed with the tooth extraction without antibiotic prophylaxis.
Document all discussions in the case records.
If Alex states that they are uncomfortable having a tooth extracted without antibiotic prophylaxis:
Reiterate to Alex that antibiotic prophylaxis is not recommended in their case as there is no evidence that prophylaxis will significantly reduce their risk of IE and this may be outweighed by the risk of an adverse reaction to prophylaxis.
If Alex indicates that, despite knowing and understanding that antibiotic prophylaxis is not recommended for them, they still wish to have antibiotic prophylaxis:
Respect Alex’s choice and proceed with the tooth extraction with antibiotic prophylaxis.
Document all discussions in the case records.
Amira is 32 years old and presents as an emergency patient with acute toothache and a longitudinal root fracture of tooth 16. She is new to your practice and the area, and reports she had a cardiac condition as a child but is unsure what it is. She remembers that she had discussions some years before with her previous cardiac team about antibiotic prophylaxis but cannot remember what they said. She has no letters or documents available from a previous cardiac team. She is allergic to penicillin.
Extraction of tooth 16 is required. Visual examination reveals that Amira also has poor oral health and gingival inflammation. She is not currently taking any medication and has no other medical issues of concern that preclude extraction in a practice setting.
You are unable to get in touch with Amira's general medical practitioner and despite best efforts, other than deeming that it is safe to extract the tooth, you are unable to find out if she requires antibiotic prophylaxis on the day that the urgent treatment is required.
Discuss with Amira:
- that given her reported medical history, she may be at increased risk of infective endocarditis
- that to ensure that the tooth extraction is as safe as possible for her, she will be managed as if she is a patient who is at high risk of infective endocarditis for treatment of this dental emergency
- that dental extractions are associated with an increased risk of infective endocarditis in high risk patients
- that antibiotic prophylaxis is recommended for this procedure
- the potential benefits and harms of antibiotic prophylaxis
to inform a shared decision about antibiotic prophylaxis.
Give Amira information about prevention of infective endocarditis, including:
- the importance of maintaining good oral health
- symptoms that may indicate infective endocarditis and when to seek advice
- the risks of undergoing invasive procedures including non-medical procedures such as body piercing or tattooing
If Amira chooses antibiotic prophylaxis:
Prescribe a suitable dose of clarithromycin or azithromycin (giving her advice about potential adverse events) to be collected as soon as possible from a pharmacy.
Arrange for the soonest available emergency slot for extraction of the tooth, ensuring that there is time for Amira to take the antibiotic prophylaxis 30-60 minutes before the procedure.
Document all discussions in the case records.
If Amira chooses not to have antibiotic prophylaxis:
Inform Amira that her decision may expose her to a higher risk of infective endocarditis.
Extract the tooth without antibiotic prophylaxis.
Document all discussions in the case records.
In both situations described above:
Inform Amira that she is likely to require more dental treatment which is non-urgent and can be delayed.
Contact Amira’s general medical practitioner to determine whether she is in a moderate or high risk group.
If this information cannot be obtained from the GP, refer Amira to the local cardiac team for assessment and advice.
Document all discussions in the case records.
Tomasz is 19 years old and requires an occlusal restoration in tooth 24. He has untreated cyanotic congenital heart disease (CHD).
Discuss with Tomasz:
- that due to his cardiac condition, he is at high risk of infective endocarditis
- that antibiotic prophylaxis is not required as the planned dental procedure is not associated with an increased risk of infective endocarditis
Give Tomasz information about prevention of infective endocarditis, including:
- the importance of maintaining good oral health
- symptoms that may indicate infective endocarditis and when to seek advice
- the risks of undergoing invasive procedures including non-medical procedures such as body piercing or tattooing
Discuss the usual potential risks and benefits of an occlusal restoration with Tomasz and proceed with this procedure without antibiotic prophylaxis.
Document all discussions in the case records.
Inform Tomasz that in future he may require dental procedures that put him “at-risk” of infective endocarditis and at that point further discussions with him will be necessary to determine if antibiotic prophylaxis should be offered or considered for these specific dental procedures.