Is antibiotic prophylaxis for bacterial endocarditis cost-effective?
BACKGROUND
Antibiotic prophylaxis for bacterial endocarditis is recommended by the American Heart Association (AHA) before undergoing certain dental procedures. Whether such antibiotic prophylaxis is cost-effective is not clear. The authors' objective is to estimate the cost-effectiveness of predental antibiotic prophylaxis in patients with underlying heart disease.


METHODS
The authors conducted a cost-effectiveness analysis using a Markov model to compare cost-effectiveness of 7 antibiotic regimens per AHA guidelines and a no prophylaxis strategy. The study population consisted of a hypothetical cohort of 10 million patients with either a high or moderate risk for developing endocarditis.


RESULTS
Prophylaxis for patients with moderate or high risk for endocarditis cost $88,007/quality-adjusted life years saved if clarithromycin was used. Prophylaxis with amoxicillin and ampicillin resulted in a net loss of lives. All other regimens were less cost-effective than clarithromycin. For 10 million persons, clarithromycin prophylaxis prevented 119 endocarditis cases and saved 19 lives.


CONCLUSIONS
Predental antibiotic prophylaxis is cost-effective only for persons with moderate or high risk of developing endocarditis. Contrary to current recommendations, our data demonstrate that amoxicillin and ampicillin are not cost-effective and should not be considered the agents of choice. Clarithromycin should be considered the drug of choice and cephalexin as an alternative drug of choice. The current published guidelines and recommendations should be revised.
Agha
Zia
Z
Division of General Internal Medicine, Medical College of Wisconsin, Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin 53295, USA. zia@mcw.edu
Lofgren
Richard P
RP
VanRuiswyk
Jerome V
JV
D000328:Adult; D000572:American Heart Association; D019072:Antibiotic Prophylaxis / Q000009:adverse effects / Q000191:economics / Q000706:statistics & numerical data*; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D004697:Endocarditis, Bacterial / Q000150:complications / Q000209:etiology / Q000401:mortality / Q000517:prevention & control*; D005260:Female; D006331:Heart Diseases / Q000150:complications; D006801:Humans; D008297:Male; D008390:Markov Chains; D019647:Oral Surgical Procedures / Q000009:adverse effects*; D010517:Periodontics; D019057:Quality-Adjusted Life Years; D018570:Risk Assessment; D012307:Risk Factors; D012984:Software; D016019:Survival Analysis; D016896:Treatment Outcome