title: Impact of the NICE guideline recommending cessation of antibiotic prophylaxis for prevention of infective endocarditis: before and after study.
abstract: OBJECTIVE
  To quantify the change in prescribing of antibiotic prophylaxis before invasive dental procedures for patients at risk of infective endocarditis, and any concurrent change in the incidence of infective endocarditis, following introduction of a clinical guideline from the National Institute for Health and Clinical Excellence (NICE) in March 2008 recommending the cessation of antibiotic prophylaxis in the United Kingdom.
  
  
  METHODS
  Before and after study.
  
  
  METHODS
  England. Population All patients admitted to hospital in England with a primary or secondary discharge diagnosis of acute or subacute infective endocarditis.
  
  
  METHODS
  Monthly number of prescriptions for antibiotic prophylaxis consisting of a single 3 g oral dose of amoxicillin or a single 600 mg oral dose of clindamycin, and monthly number of cases of infective endocarditis, infective endocarditis related deaths in hospital, or cases of infective endocarditis with a possible oral origin for streptococci.
  
  
  RESULTS
  After the introduction of the NICE guideline there was a highly significant 78.6% reduction (P < 0.001) in prescribing of antibiotic prophylaxis, from a mean 10,277 (SD 1068) prescriptions per month to 2292 (SD 176). Evidence that the general upward trend in cases of infective endocarditis before the guideline was significantly altered after the guideline was lacking (P = 0.61). Using a non-inferiority test, an increase in the number of cases of 9.3% or more could be excluded after the introduction of the guideline. Similarly an increase in infective endocarditis related deaths in hospital of 12.3% or more could also be excluded.
  
  
  CONCLUSIONS
  Despite a 78.6% reduction in prescribing of antibiotic prophylaxis after the introduction of the NICE guideline, this study excluded any large increase in the incidence of cases of or deaths from infective endocarditis in the two years after the guideline. Although this lends support to the guideline, ongoing data monitoring is needed to confirm this, and further clinical trials should determine if antibiotic prophylaxis still has a role in protecting some patients at particularly high risk.
authors.affiliation: University of Sheffield School of Clinical Dentistry, Sheffield S10 2TA, UK. m.thornhill@sheffield.ac.uk
authors.forename: Martin H
authors.initials: MH
authors.lastname: Thornhill
authors.forename: Mark J
authors.initials: MJ
authors.lastname: Dayer
authors.forename: Jamie M
authors.initials: JM
authors.lastname: Forde
authors.forename: G Ralph
authors.initials: GR
authors.lastname: Corey
authors.forename: Vivian H
authors.initials: VH
authors.lastname: Chu
authors.forename: David J
authors.initials: DJ
authors.lastname: Couper
authors.forename: Peter B
authors.initials: PB
authors.lastname: Lockhart
mesh_terms: D000208:Acute Disease; D000284:Administration, Oral; D000658:Amoxicillin / Q000008:administration & dosage*; D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D019072:Antibiotic Prophylaxis; D002981:Clindamycin / Q000008:administration & dosage*; D004696:Endocarditis / Q000517:prevention & control*; D006760:Hospitalization; D006801:Humans; D017410:Practice Guidelines as Topic
chemical_list: D000900:Anti-Bacterial Agents; D002981:Clindamycin; D000658:Amoxicillin