Webinar recording and Q&As
Antibiotic Prophylaxis Against Infective Endocarditis webinar recording
On 11 May 2026, Andrew Paterson, Chair of the SDCEP short-life working group, gave a webinar on the updated implementation advice.
A recording of this webinar is available via the Turas platform.
A large number of questions were submitted during the webinar. As it was not possible to address all of these at the time, it was noted that responses would be provided after the event. The collated questions and answers are presented below, grouped by topic.
Webinar questions and answers
Please note that some questions have been edited for clarity.
| Question | Answer |
| What are the high-risk cardiac conditions? | See High risk patients. |
| Would a patient with an aortic arch and valve replacement (porcine) be regarded as high risk? | A cardiac valve made with porcine material is a bioprosthetic valve and patients with these valves are in the high risk group. See High risk patients. |
| In paediatric patients with congenital valve abnormalities, would they always be classed as moderate risk and therefore we would not need to seek advice from the cardiologist, or do we seek advice in case there are other considerations or the parent doesn't fully understand the cardiac condition (e.g. those with pulmonary stenosis who have had balloon valvuloplasty)? | Patients with congenital valve abnormalities including bicuspid aortic valve disease are at moderate risk of infective endocarditis. Their IE risk classification will not change unless their cardiac condition changes. If in doubt about a patient’s cardiac condition or IE risk, seek advice from the patient’s cardiac team. See Patients at risk of infective endocarditis. |
| If a patient has stent, do they need antibiotic cover for invasive procedures? | In the absence of any other cardiac issues, a stent is not in the high or medium risk cardiac group, so antibiotic prophylaxis is not required. See Patients at risk of infective endocarditis. |
| If a patient has had any bypass surgeries or has stents, should antibiotic prophylaxis be given for any dental procedure? | If a patient has a cardiac condition or has undergone a cardiac procedure that is not listed in the high and moderate risk groups, for example insertion of a stent, they are not considered to be at high or moderate risk of IE and antibiotic prophylaxis is not required. See Patients at risk of infective endocarditis. |
| What would be an example of a CIED? | Cardiac devices such as pacemakers or defibrillators. See Glossary of cardiac terms. |
| Question | Answer |
| I am a Dental Hygienist, should it be the dentist that discusses antibiotic prophylaxis with the patient before they are referred to us? Not sure patients would be happy to pay for a visit to the hygienist if we can’t do any treatment for them apart from OH advice. | It is the responsibility of the prescriber (i.e. the dentist) to discuss the potential risks and benefits of antibiotic prophylaxis with the patient to inform a shared decision. However, dental hygienists and dental therapists have a pivotal role in providing individualised oral hygiene advice to patients at increased risk and can also give relevant advice on the prevention of infective endocarditis. All members of the dental team have a responsibility to encourage good oral hygiene in this patient group. See Prevention of infective endocarditis. |
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Does the dental hygienist also need to have a separate discussion with patient regarding risks? |
See answer above. |
| Question | Answer |
| Does suture removal in a high risk patient require antibiotic cover? | Antibiotic prophylaxis is not recommended for removal of sutures. See 'At-risk' dental procedures. |
| Does ID nerve block put patient at risk? | Infiltration or block local anaesthetic injections in non-infected soft tissues are not ‘at-risk’ dental procedures. See 'At-risk' dental procedures. |
| For patients with unstable perio would non-surgical periodontal treatment including subgingival PMPR be considered as moderate risk still? | For PMPR in patients with a high risk cardiac condition, take account of the patient’s oral health status, any advice from the cardiac team, and the patient’s values and preferences to make a shared decision on whether prophylaxis is required. Antibiotic prophylaxis is not recommended for PMPR in moderate risk patients. See 'At-risk' dental procedures. |
| "All oral surgery procedures". Does that include biopsies given that soft tissue trauma does not require cover? | A biopsy is a planned oral surgery procedure where prophylaxis can be given beforehand. See 'At-risk' dental procedures. |
| Should antibiotic prophylaxis be considered for a patient attending for 4-6 monthly hygiene visits for supragingival scaling when BPE recording will be required? | Antibiotic prophylaxis should be considered for procedures that involve manipulation of the gingival or periapical region of the teeth in high risk patients. This includes the BPE and supra- and subgingival scaling. The consideration of antibiotic prophylaxis for these dental procedures must involve reaching a shared decision with the patient. See 'At-risk' dental procedures. |
| Question | Answer |
| Is there a length of time between valve surgery and a moderate risk treatment that treatment is classed as high risk? I had a patient who had valve surgery 3 weeks before his check-up and I chose not to do a BPE because surgery was so recent. | For patients who have had recent valve surgery, it is good practice to delay, where possible, 'at-risk' dental procedures (such as BPE) until 6 months post-surgery. This is one of the reasons that cardiac teams ask for patients to be made dentally fit prior to cardiac surgery. |
| Do you have any advice if faced with a situation where a patient currently has IE and the medics are looking for a dental source as it may be difficult to fully rule out an oral source (e.g. an apical area on a recent root treated tooth, or some mild gingivitis)? | In this situation, look for a potential oral source (radiographs may sometimes be necessary) and report on any recent dental treatment and the patient’s oral health status to the cardiac team. Keep a copy of your communication with the cardiac team in the patient’s records. |
| Where do we stand if patients do not wish antibiotic prophylaxis so will not to consent to periodontal probing/examination where necessary as they perceive it to be too risky to their medical wellbeing? | In this situation, record the discussion in the patient’s notes, including the advice given on the dental risks of non-compliance (i.e. missed diagnosis and effect on oral health), and proceed with the parts of examination that the patient consents to. This process may be required repeatedly, and the patient may change their mind depending on the dental treatment needed. |
| How frequently can a prophylaxis be given to a high-risk patient who fails to maintain good OH so frequently requires PMPR? | If the patient has chosen to have prophylaxis for an ‘at-risk’ procedure, antibiotic cover can be given every time the procedure is performed. Combining several ‘at-risk’ procedures in one appointment (e.g. BPE, PMPR and a subgingival restoration) will reduce the number of instances that the patient will have to take prophylaxis. The patient should be encouraged to improve their oral hygiene to reduce their risk of IE, as well as to improve their overall oral health. |
| Do we also respect the decisions of patients at high risk of IE undergoing high risk treatment who do not want prophylaxis, and do treatment without antibiotic cover? Specifically in cases of patients who present at emergency clinics for extractions who often do not otherwise engage with medical or dental services. | In this situation, record the discussion in the patient’s notes, including the advice given on the risks of not choosing prophylaxis (i.e. they may be exposed to a higher risk of infective endocarditis), and proceed with the treatment without antibiotic cover. As the patient may change their mind in future, this process should be repeated every time an ‘at-risk’ procedure is required. See Management of patients at increased risk of infective endocarditis. |
| What age does a child become adult with regarding to antibiotic prophylaxis/IE risk? | In the BNF, a child is considered to be any individual up to the age of 17 years. Those 18 years and above are considered to be adults. Antibiotic prophylaxis doses for children are based on the child’s weight, with the maximum child dose defined as the full adult dose. In terms of consent and discussion of risk, there is no minimum age at which a child is considered an adult; this is based on capacity to consent. See Shared decision making. |
| Question | Answer |
| Why is there a lot of emphasis on “adverse effects of antibiotics for prophylaxis against IE” when GDPs prescribe antibiotics commonly with very rare adverse effects (from my experience at least)? | Presenting the potential risks and benefits of antibiotics is necessary for good antibiotic stewardship. In addition, antibiotic treatment will be of benefit for patients with a dental abscess (if prescribed appropriately) but there is less certainty about the benefits of antibiotic prophylaxis. Therefore, the balance of risks and benefits for antibiotic prophylaxis is different and the patient needs to be fully aware of the potential risks to make an informed choice. |
| What is the alternative for true penicillin allergy? | The alternatives for oral prophylaxis in patients with a true penicillin allergy are clarithromycin (500 mg) or azithromycin (500 mg). See Oral antibiotic prophylaxis regimens. |
| What if patient is allergic to all the antibiotics listed in the implementation advice? | If the antibiotics in the SDCEP 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 be contacted for advice. The ESC guideline also includes information on other appropriate prophylaxis regimens. See Prescribing advice. |
| When antibiotic prophylaxis is taken, how long does this provide cover for (e.g. 3 hours)? | This will depend on the drug and individual patient factors but if the prophylaxis is taken 30-60 minutes before the procedure, the antibiotic cover is likely to last for several hours and will be sufficient for most dental procedures. |
| Can prophylaxis be taken after procedure in case of emergency? | This is not covered in the SDCEP implementation advice. The American Heart Association guideline (Wilson et al. Circulation. 2021;143(20)) states: If AP is inadvertently not administered before a dental procedure, then it may be administered up to 2 hours after the procedure. |
| Is it recommended to give post-op antibiotic prophylaxis the day following treatment? | No, this is not recommended. |
| If prescribing 4 x 500 mg Amoxicillin capsules, is the absorption rate different compared with the 3 g sachet? | The bioavailability of each preparation is similar. Oral prophylaxis should be given 30-60 minutes prior to the ‘at-risk’ dental procedure. |
| A patient has a mitral valve replacement, taking 500 mg amoxicillin three times daily 5 day course for oral swelling. Requires tooth extraction of tooth causing swelling; how do I proceed? | In this situation, the patient can replace one of the 500 mg doses that they are taking for the infection (e.g. the morning dose if their dental appointment is in the morning) and take 2 g amoxicillin prophylaxis 30-60 min before procedure, then take their next 500 mg dose as indicated (e.g. mid-afternoon). |
| If a patient has recently had a course of antibiotics for a recent unrelated issue (say a chest infection) does that impact on decision making for what to choose for prophylaxis? Similarly, if a patient is already on long term prophylaxis for an unrelated issue (lifelong penicillin for a splenectomy or as UTI prophylaxis for catheterised patients), would that impact on decision making? | 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. Regarding long-term prophylaxis being taken for a medical issue, an antibiotic from another class for the dental prophylaxis should be used. If there are any concerns, contact an expert, such as a consultant microbiologist, community pharmacist or the UK Dental Medicines Advisory Service for advice. See Prescribing advice. |
| Some of the high-risk patients will be taking warfarin. Can any of the antibiotic prophylaxis regimes increase INR and impact bleeding risk? | A single dose of antibiotic prophylaxis is unlikely to have a substantial impact on the patient’s anticoagulation status. Note that it is good practice to consult the most recent BNF for information on drug interactions between antibiotics and anticoagulants and any other drugs that patients are taking. If the antibiotics in the SDCEP 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 be contacted for advice. The ESC guideline also includes information on other appropriate prophylaxis regimens. See Prescribing advice. |
| I have a patient who is at high risk for IE (non-treated cyanotic congenital heart condition) who requires a higher risk procedure. She is on warfarin and is allergic to penicillin. What antibiotic regime would be recommended for this? | A single dose of antibiotic prophylaxis is unlikely to have a substantial impact on the patient’s anticoagulation status. Note that it is good practice to consult the most recent BNF for information on drug interactions between antibiotics and anticoagulants and any other drugs that patients are taking. If the antibiotics in the SDCEP 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 be contacted for advice. The ESC guideline also includes information on other appropriate prophylaxis regimens. See Prescribing advice. |
| Could you offer any insight on to how long to leave between doses of prophylaxis (or whether antibiotic selection be changed)? For example, for perio patients who may require 6PPC and staged PMPR or those with long/extensive treatment plans requiring many visits. | The American Heart Association guideline suggests a delay of 10 days between procedures that require antibiotic prophylaxis if the same antibiotic will be used for prophylaxis. See Prescribing advice. |
| Can you clarify times recommended between appointments for treatment in patients who are high risk who are to get antibiotic cover? | The American Heart Association guideline (Wilson et al. Circulation. 2021;143(20)) suggests a delay of 10 days between procedures that require antibiotic prophylaxis if the same antibiotic will be used for prophylaxis. See Prescribing advice. In a scenario where, for example, you extract a tooth in a high risk patient who is offered and chooses prophylaxis and 2-3 days later patient comes back with an infected socket that needs to be curetted (an oral surgery procedure for which prophylaxis should be offered), you may wish to use an antibiotic from a different class for each episode of prophylaxis (i.e. visit 1: amoxicillin, visit 2: clarithromycin). |
| Is there a minimum time between appointments for antibiotic prophylaxis? I'm not sure if I heard you say 10 days between. | The American Heart Association guideline (Wilson et al. Circulation. 2021;143(20)) suggests a delay of 10 days between procedures that require antibiotic prophylaxis if the same antibiotic will be used for prophylaxis. See Prescribing advice. |
| If more than 1 visit is needed for an 'at risk' dental treatment in a high risk patient, how long between visits and what is the maximum number of antibiotic prophylaxis courses? | If the patient has chosen to have prophylaxis for an ‘at-risk’ procedure, antibiotic cover can be given every time the procedure is performed. The American Heart Association guideline suggests a delay of 10 days between procedures that require antibiotic prophylaxis if the same antibiotic will be used. Combining several ‘at-risk’ procedures in one appointment (e.g. BPE, PMPR and a subgingival restoration) will reduce the number of instances that the patient will have to take prophylaxis. See Prescribing advice. |
| How do you differentiate between normal or expected GI disturbances and potential life-threatening issues? | Dental teams are not qualified to diagnose GI medical problems. If there is uncertainty about whether a patient’s GI symptoms are serious, the patient should be signposted to seek prompt medical advice. |
| Can I clarify we need to report yellow card with GI disturbances?! | GI disturbance is considered a side effect of antibiotic therapy. More serious adverse events (e.g. anaphylaxis or C. difficile infection) should be reported to MHRA via the Yellow Card Scheme. |
| Is it appropriate to use second line antibiotics where first line has caused GI disturbances? | If the patient has reported previous GI disturbance with the first line drug (i.e. amoxicillin) it is reasonable to make a shared decision with the patient to use an alternative second line drug (e.g. clarithromycin). Note the reasons for this in the patient’s clinical record. |
| Now the SDCEP drug prescribing advice does not state the antibiotics and dose under Infective Endocarditis, will this be updated? | The SDCEP Dental Prescribing website has been updated and there are now links to the SDCEP Antibiotic Prophylaxis website. |
| Question | Answer |
| What is the current practice or guidance amongst cardiac teams for themselves to advise patients on these risks? It seems the biggest impact on lifetime risk of IE would be from simple oral hygiene measures, which could come from cardiac teams. and this could be of particular benefit to the many unregistered patients. | The SDCEP implementation advice has been endorsed by several UK cardiac societies. It includes specific information for cardiac teams that notes the importance of advising that patients should maintain good oral health. However, specific individualised oral hygiene advice (e.g. interdental brush size) can only be provided by a dental professional. See Advice for cardiology and cardiac surgery teams. |
| My letters to cardiac teams sometimes go unanswered... any advice? | The SDCEP implementation advice includes a glossary of cardiac terms which may reduce the requirement to liaise with cardiac teams. A template letter has been developed to facilitate communication with cardiac teams. It may also be helpful to send a query via the patient’s general medical practitioner See Supporting tools. |
| Couldn't the cardiologist provide the patients with an alert type of card if antibiotic cover is recommended? My experience is that patients don't fully understand their cardiac condition and we often have to wait a long time for the specialist responses. | It would be considered good practice for cardiac teams to provide information/alert cards on antibiotic prophylaxis to patients, and some cardiac teams already do this. A template alert card was developed to facilitate this communication and is available to download from the SDCEP Antibiotic Prophylaxis website. However, it is up to individual cardiac teams to decide what advice they provide to patients. See Supporting tools. |
| Question | Answer |
| I’ve worked in general practice for over 30 years. When it changed from giving antibiotic prophylaxis to all patients with specific heart problems, what has been the incidence of IE since we stopped? | There has been a general, worldwide increase in incidence of infective endocarditis. This is observed in countries that strongly recommend antibiotic prophylaxis and in countries that have more conditional recommendations (i.e. the UK). This increase is likely to be related to a number of factors, including the increase in the number of implanted devices, such as prosthetic valves, and aging populations with multimorbidities. |
| To clarify, has the incidence of IE increased since we have given less antibiotic cover? | See answer above. |
| Question | Answer |
| With the addition of the "consideration" group, whereby antibiotic cover is not recommended but may be modulated by additional patient specific risk factors/patient choice (as per the IECD scenario presented) might this open the conversation around orthopaedic protheses again? | The SDCEP implementation advice only covers infective endocarditis and is not relevant for patients orthopaedic prostheses. |
| What is your view on period of time between joint replacement and hygiene visit for PMPR? | The SDCEP implementation advice only covers infective endocarditis and is not relevant for patients with joint replacements. |