NICE refuses to change dental guidelines on preventing a serious heart infection

The National Institute for Health and Care Excellence (NICE) has today (16 September 2015) announced it will not change its guidelines advising dentists against giving antibiotics before invasive treatment to patients at risk of developing the life-threatening heart disease infective endocarditis (IE).

NICE refused to alter current guidelines, despite research showing a rise in the number of people diagnosed with the condition since the introduction of this guideline, alongside a large fall in the prescribing of antibiotic prophylaxis (AP) to dental patients.

This decision comes just two weeks after the European Society of Cardiology (ESC) guideline committee announced that after evaluation of the same evidence as reviewed by NICE, it had drawn the conclusion that "the balance of evidence/opinion was in favour of the usefulness/efficacy of antibiotic prophylaxis for those at high-risk of IE" and "it therefore continues to recommend that dentists should give antibiotic prophylaxis to patients at high-risk of IE because it considers the risks of IE outweigh any risks from giving antibiotic prophylaxis".

The pioneering study, which identified the increase in cases of IE in England, is the largest and most comprehensive study into the impact of the current NICE guidelines, which were introduced in March 2008 despite the lack of any new scientific evidence to suggest they were beneficial.

A team of international researchers, led by Professor Martin Thornhill from the University of Sheffield's School of Clinical Dentistry, discovered that since March 2008 there has been an increase in IE cases above the expected trend and by March 2013 this accounted for an extra 35 cases per month in England.

They also identified that the prescribing of antibiotic prophylaxis fell by 89 per cent from 10,900 prescriptions a month, before the 2008 guidelines, to 1,235 a month by March 2013. In a further study published in the Journal of Antimicrobial Chemotherapy in March this year, they also showed that for the majority of patients, antibiotic prophylaxis is a lot safer than was previously thought.

Martin Thornhill, Professor of Translational Research in Dentistry at the University of Sheffield, said: "The decision by NICE to dismiss evidence that their decision in 2008 to recommend cessation of antibiotic prophylaxis could be wrong, as well as evidence that antibiotic prophylaxis is safer than previously thought, will cause understandable disbelief and confusion on the part of many cardiologists, dentists and patients in the UK.

"This is particularly the case, when only two weeks ago, following a review of the same information, the European guidelines committee advised dentists that they should give antibiotic prophylaxis to patients at high-risk of infective endocarditis because in their view the risk of not giving antibiotic prophylaxis to these patients far outweighed any risk of giving it."

The studies were carried out by an international team of experts from the University of Sheffield, Oxford University Hospitals NHS Trust, Guy's and St Thomas' NHS Trust, Taunton and Somerset NHS Trust, and the University of Surrey in the UK, as well as from the Mayo Clinic and the Carolinas HealthCare System's Carolinas Medical Centre in the US.

These studies were funded by a grant from national charity Heart Research UK, health plan provider Simplyhealth and the National Institute for Dental and Craniofacial Research (NIDCR).

Heart Research UK National Director, Barbara Harpham, said: "We are baffled as to why NICE has not fully taken account of this new information from Professor Thornhill's research and changed its advice to dentists.

"His evidence shows clearly there has been a marked increase in cases of IE since the advice was given to stop giving antibiotics and this should have at least prompted further investigation by NICE. It seems ludicrous that the UK now stands out on a limb against advice routinely given to dentists in the USA and the rest of Europe to use this preventative treatment that could further protect at-risk patients."

Romana Abdin, Simplyhealth Chief Executive, said: "We need to take a more preventative approach to IE rather than focusing on curing the condition at a more serious stage. Offering an antibiotic to at risk patients is far less distressing than the prospect of being hospitalised for treatment following diagnosis.

"The research also shows it is more cost effective to administer an antibiotic than to perform surgery which, at a time when NHS resources are stretched, is in itself a reason to update the guidelines. We are committed to supporting evidence based research that supports a healthy nation."