National Institute for Health and Care Excellence
Other
Action Planned
NICE has committed to review the current evidence relating to prophylaxis against infective endocarditis this financial year to determine whether any new information supports a further update of existing NICE guidance. (AI summary)
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Dear Ms Lomas,
I write in response to your regulation 28 report of regarding the very sad death of Mr Michael Briggs. I would like to express my sincere condolences to Mr Briggs’ family.
We have considered the circumstances in your letter regarding dental extraction and the prescribing of antibiotics.
As you have noted in your report, in our guideline on prophylaxis against infective endocarditis: antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures [CG64] we do not routinely recommend antibiotic prophylaxis against infective endocarditis (IE) for people undergoing dental procedures (recommendation 1.1.3).
The recommendation is worded as “do not routinely”, which emphasises NICE's standard advice on healthcare professionals' responsibilities. Doctors and dentists should offer the most appropriate treatment options, in consultation with their patients. In doing so, they should take account of the recommendations in this guideline and the values and preferences of patients, and apply their clinical judgement.
Therefore, if Mr Briggs’ clinical history and circumstances suggested to the dentist that antibiotics might have been appropriate, to prescribe them would have been entirely in line with the discretion supported by the guideline as outlined above.
When we publish our guidelines, we include tools and resources to support implementation. In terms of the Scottish Dental Clinical Effectiveness Programme (SDCEP) implementation advice on antibiotic prophylaxis against infective endocarditis, a link to this endorsed resource is included in the tools and resources section for CG64.
In the 2015 review of CG64, the guideline committee agreed that current evidence was insufficient to support the hypothesis that interventional procedures, including dental extraction, lead to the development of infective endocarditis in people with pre-existing cardiac conditions. Furthermore, the committee concluded that there is insufficient evidence to recommend prophylactic use of antibiotics in those at risk of infective endocarditis undergoing interventional procedures, including dental extraction. From the evidence examined, the committee were unable to establish whether or not prophylaxis was effective.
The issue of conflicting information on the need for antibiotic prophylaxis being provided by cardiologists, dental practitioners and hygienists was raised by the committee as a potential significant problem and the committee discussed the importance of clear and consistent information
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for patients and families and also that a balanced view of the lack of evidence indicating effectiveness of prophylaxis for infective endocarditis as well as any potential harms of prophylaxis should be fully explained to the person considering treatment. This will in turn allow the patient to make an informed decision about continuing/discontinuing prophylaxis.
We have committed to review the current evidence relating to prophylaxis against infective endocarditis this financial year and will determine whether any new information, studies or research would support the case for a further update of existing NICE guidance.
Please do let me know if you require any further information and again, I offer my sincerest condolences to Mr Briggs’ family.
I write in response to your regulation 28 report of regarding the very sad death of Mr Michael Briggs. I would like to express my sincere condolences to Mr Briggs’ family.
We have considered the circumstances in your letter regarding dental extraction and the prescribing of antibiotics.
As you have noted in your report, in our guideline on prophylaxis against infective endocarditis: antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures [CG64] we do not routinely recommend antibiotic prophylaxis against infective endocarditis (IE) for people undergoing dental procedures (recommendation 1.1.3).
The recommendation is worded as “do not routinely”, which emphasises NICE's standard advice on healthcare professionals' responsibilities. Doctors and dentists should offer the most appropriate treatment options, in consultation with their patients. In doing so, they should take account of the recommendations in this guideline and the values and preferences of patients, and apply their clinical judgement.
Therefore, if Mr Briggs’ clinical history and circumstances suggested to the dentist that antibiotics might have been appropriate, to prescribe them would have been entirely in line with the discretion supported by the guideline as outlined above.
When we publish our guidelines, we include tools and resources to support implementation. In terms of the Scottish Dental Clinical Effectiveness Programme (SDCEP) implementation advice on antibiotic prophylaxis against infective endocarditis, a link to this endorsed resource is included in the tools and resources section for CG64.
In the 2015 review of CG64, the guideline committee agreed that current evidence was insufficient to support the hypothesis that interventional procedures, including dental extraction, lead to the development of infective endocarditis in people with pre-existing cardiac conditions. Furthermore, the committee concluded that there is insufficient evidence to recommend prophylactic use of antibiotics in those at risk of infective endocarditis undergoing interventional procedures, including dental extraction. From the evidence examined, the committee were unable to establish whether or not prophylaxis was effective.
The issue of conflicting information on the need for antibiotic prophylaxis being provided by cardiologists, dental practitioners and hygienists was raised by the committee as a potential significant problem and the committee discussed the importance of clear and consistent information
Page | 2
for patients and families and also that a balanced view of the lack of evidence indicating effectiveness of prophylaxis for infective endocarditis as well as any potential harms of prophylaxis should be fully explained to the person considering treatment. This will in turn allow the patient to make an informed decision about continuing/discontinuing prophylaxis.
We have committed to review the current evidence relating to prophylaxis against infective endocarditis this financial year and will determine whether any new information, studies or research would support the case for a further update of existing NICE guidance.
Please do let me know if you require any further information and again, I offer my sincerest condolences to Mr Briggs’ family.