Management flowchart - accessible version

Management of patients at high and moderate risk of infective endocarditis

A text version of the management of patients at high and moderate risk of infective endocarditis is outlined below.

To use this version, follow the instructions at each decision point to determine the appropriate management strategy.

1. Does the patient’s cardiac condition place them at high risk or moderate risk of infective endocarditis? See Patients at increased risk of infective endocarditis for more information.

If moderate risk: go to 2. Management of moderate risk patients.

If high risk: go to 3. Is the planned dental procedure an extraction or oral surgery? 

If you are uncertain about the patient's risk status, contact the patient’s cardiac team or GP to determine if the patient is in the high risk or moderate risk group. If urgent dental treatment is required, go to 10. Emergency treatment

2. Management of moderate risk patients

• Discuss the potential benefits and harms of antibiotic prophylaxis, and explain that prophylaxis is not recommended as there is no evidence that this will be beneficial for them. 
• If a moderate risk patient requests antibiotic prophylaxis, make a shared decision on whether prophylaxis is appropriate for their individual situation.
• Moderate risk patients do not require prophylaxis unless already specified by the patient's cardiac team. In this situation, follow the high risk patient pathway.

See Management of patients at increased risk of infective endocarditis for more information.

3. Is the planned dental procedure an extraction or oral surgery? See ‘At-risk’ dental procedures for more information.

If yes: go to 5. Offer antibiotic prophylaxis.

If no: go to 4. Does the planned dental procedure involve manipulation of the gingival or periapical region of the teeth? 

4. Does the planned dental procedure involve manipulation of the gingival or periapical region of the teeth? See ‘At-risk’ dental procedures for more information.

If yes: go to 6. Consider antibiotic prophylaxis.

If no: explain that antibiotic prophylaxis is not recommended.

5. Offer antibiotic prophylaxis.

Discuss with the patient:

• the increased risk of infective endocarditis associated with the dental procedure 
  (see ‘At-risk’ dental procedures and Patient discussion aid for more information) 
• why antibiotic prophylaxis is offered
  (see ‘At-risk’ dental procedures and Patient discussion aid for more information) 
• the potential harms of antibiotic prophylaxis 
  (see Prescribing advice for more information)
• the patient’s values and preferences and any information provided by the cardiac team

to inform a shared decision about antibiotic prophylaxis.

See Management of patients at increased risk of infective endocarditis for more information.

Go to 7. Patient choice

6. Consider antibiotic prophylaxis.

Consider the patient’s oral health status and discuss:

• the uncertain risk of infective endocarditis associated with the dental procedure 
  (see ‘At-risk’ dental procedures and Patient discussion aid for more information) 
• why antibiotic prophylaxis should be considered
  (see ‘At-risk’ dental procedures and Patient discussion aid for more information) 
• the potential harms of antibiotic prophylaxis 
  (see Prescribing advice for more information)
• the patient’s values and preferences and any information provided by the cardiac team

to inform a shared decision about antibiotic prophylaxis.

See Management of patients at increased risk of infective endocarditis for more information.

Go to 7. Patient choice

7. Patient choice - following the discussion, has the patient chosen antibiotic prophylaxis for the planned dental procedure?

If yes: go to 8. Patient has chosen antibiotic prophylaxis

If no: go to 9. Patient has not chosen antibiotic prophylaxis

8. Patient has chosen antibiotic prophylaxis

• Prescribe antibiotic prophylaxis at the appointment prior to the planned dental procedure(s) unless you hold a supply of prophylactic antibiotics in your practice. 
• Advise the patient to bring the antibiotic on the day of the procedure(s). Alternatively, the patient can take the antibiotic at home in certain situations.
• Give advice on possible adverse events.

See Prescribing advice for more information.

9. Patient has not chosen antibiotic prophylaxis

• Ensure that discussions around their decision are clearly recorded in the clinical notes.
• For an extraction or oral surgery procedure, ensure that the patient is aware that their decision may expose them to a higher risk of infective endocarditis.  

10. Emergency treatment

If the patient requires urgent dental treatment and you are unable to obtain the relevant information about prophylaxis from the patient or from their cardiac team/GP, assume that the patient has a high risk cardiac condition and make a shared decision on whether antibiotic prophylaxis is appropriate.

See Management of emergency patients for more information

For all patients at high and moderate risk of infective endocarditis:

• ensure that they are aware of their risk of IE 
  (see Patients at risk of infective endocarditis for more information) 
• provide advice on prevention 
  (see Prevention of infective endocarditis for more information)
• provide advice on symptoms that may indicate IE and when to seek expert advice 
  (see Patient discussion aid for more information)
• ensure that any episodes of dental infection are investigated and treated promptly