NICE guideline on antibiotic prophylaxis against infective endocarditis: attitudes to the guideline and implications for dental practice in Ireland

World Workshop on Oral Medicine VIII: Dentists' compliance with infective endocarditis prophylaxis guidelines for patients with high-risk cardiac conditions: a systematic review

OBJECTIVE

To determine dentists' awareness and/or adherence to antibiotic prophylaxis (AP) guidelines for preventing infective endocarditis (IE) in patients with high-risk heart conditions.

STUDY DESIGN

A systematic literature review was performed on MEDLINE/PubMed, Scopus, Web of Science, Cochrane Library, Proquest, Embase, Dentistry, and Oral Sciences Source databases, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Nationwide studies based on questionnaires, surveys, and interviews completed by dentists and published since 2007 were included.

RESULTS

From 2907 articles screened, 28 studies were selected (across 20 countries). The quality of included studies was poor due to a lack of standard evaluation tools, low response rates, and lack of questionnaire validity and/or reliability. Approximately 75% of surveyed dentists reported being knowledgeable about AP guidelines, but only ∼25% complied. Reported compliance with American Heart Association (AHA) guidelines was 4 times higher than with the National Institute for Health and Care Excellence (NICE) recommendations. Some of the highest adherence rates were reported for other national AP guidelines. Significant geographic differences were observed in the estimated adherence to AHA guidelines and the percentage of dentists who reported seeking advice from physicians and/or cardiologists.

CONCLUSION

Rates of compliance and/or adherence were substantially different from rates of knowledge and/or awareness, including relevant geographic dissimilarities. Compliance/adherence was higher for AHA than NICE.

Perception Regarding the NICE Guideline on Antibiotic Prophylaxis against Infective Endocarditis Following Dental Procedures: A Cross-Sectional Study

This study explores the opinions of Malaysian clinical specialists on the antibiotic prophylaxis against infective endocarditis (IE) as described in the 2008 National Institute for Health and Care Excellence (NICE) guideline. This cross-sectional study was performed from September 2017 to March 2019. The self-administered questionnaire comprised two sections: background information of the specialists and their opinions on the NICE guideline. The questionnaire was distributed to 794 potential participants, and 277 responded (response rate of 34.9%). In general, 49.8% of the respondents believed that clinicians should adhere to the guideline, although the majority of oral and maxillofacial surgeons (54.5%) actually disagreed with this view. The dental procedures that were perceived as presented moderate-to-high risk for IE were minor surgery for an impacted tooth with a recent episode of infection, dental implant surgery, periodontal surgery and dental extraction in patients with poor oral hygiene. The cardiac conditions that were strongly recommended for antibiotic prophylaxis were severe mitral valve stenosis or regurgitation and previous IE. Less than half of Malaysian clinical specialists agreed with the changes in the 2008 NICE guideline, contributing to their insistence that antibiotic prophylaxis is still needed for high-risk cardiac conditions and selected invasive dental procedures.

The use and misuse of antibiotics in dentistry: A scoping review

BACKGROUND

To describe antibiotic prescribing behaviors in dentistry, including clinical and nonclinical indications for their use, the type and regimen of antibiotics prescribed, and factors influencing their prescription, the authors conducted a scoping review.

TYPES OF STUDIES REVIEWED

The authors conducted a scoping review of published literature by searching multiple databases. Key search terms included dentist, antibiotic, antimicrobial, antibacterial, prophylaxis, prescription, pattern, habit, knowledge, and practice. Two authors independently reviewed titles and abstracts by using detailed eligibility criteria. The authors placed no restrictions on study design or publication year. The authors qualitatively assessed studies by using a modified version of the Center for Evidence-Based Management's critical appraisal of a survey checklist.

RESULTS

The authors identified 1,912 studies but considered only 118 studies eligible for review. Most included studies were either cross-sectional surveys (81 studies) or prescription audits (25 studies) from various geographic locations. Publication dates ranged from 1982 through 2017. The authors examined prophylactic and therapeutic antibiotic use in 48 and 29 studies, respectively. Another 29 studies examined the use of both prophylactic and therapeutic antibiotics in dentistry. Overall, dentists prescribed a wide variety of antibiotic regimens for various clinical and nonclinical indications. Dentists have acquired their prescribing knowledge from a variety of sources and have changed their antibiotic prescribing practices throughout their careers for various reasons.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

Considering the seriousness of antibiotic resistance, the authors highlight trends in antibiotic prescribing practices, characterize factors contributing to the use and misuse of antibiotics in dentistry, provide insight into the importance of antibiotic stewardship in the oral health setting, and encourage dentists to reflect on their antibiotic prescription practices.

Preprocedure prophylaxis against endocarditis among United States pediatric cardiologists

This study aimed to determine current practices regarding prophylaxis against infective endocarditis among pediatric cardiologists in the United States 5 years after publication of the most recent American Heart Association (AHA) recommendations. A descriptive, analytical, cross-sectional study was conducted from June 2012 to November 2012 in the format of an anonymous self-administered e-mailed questionnaire among pediatric cardiologists across the United States. The questionnaire inquired about demographic information of cardiologists and their current practices of prescribing preprocedure antibiotic prophylaxis against endocarditis to patients with specific preexisting cardiac conditions. Descriptive analyses were done in percentages. Frequency and exploratory statistical analyses were done by the Chi-square method. Of the 980 cardiologists invited, 221 (23 %) responded to the survey. The findings showed that pediatric cardiologists generally follow the AHA guidelines. The most common cardiac conditions in which antibiotics were administered despite AHA guidelines not requiring prophylaxis were rheumatic heart disease with aortic insufficiency, transposition of the great vessels after the Mustard procedure, bicuspid aortic valve with severe aortic stenosis, cardiac transplantation without valvar disease, and bicuspid aortic valve with severe aortic insufficiency. More experienced pediatric cardiologists were significantly more likely to administer prophylaxis to certain patients than their less experienced peers. Many pediatric cardiologists in the United States continue to administer preprocedure antibiotic prophylaxis against endocarditis even when not recommended to do so per the 2007 AHA guidelines. With certain lesions, highly experienced pediatric cardiologists are more likely to administer prophylaxis than their less experienced counterparts.

NICE guidance on antibiotic prophylaxis to prevent infective endocarditis: a survey of clinicians' attitudes

BACKGROUND

Since the introduction of the National Institute for Health and Clinical Excellence (NICE) guideline (CG064) in 2008 recommending cessation of antibiotic prophylaxis (AP) against infective endocarditis (IE), low level prescribing persists in the UK and is a potential reason why there has been no significant change in the general upward trend in cases of IE.

AIM

To undertake a survey of dentists (Ds), cardiologists and cardiothoracic surgeons (C/CTSs) and infection specialists (ISs) to determine why this might be the case.

DESIGN

Internet questionnaire-based survey.

METHODS

A questionnaire was distributed by email to specialists via UK national societies.

RESULTS

A total of 1168 responses were received. All the specialist groups are aware of the guideline (99%). Ds are broadly satisfied, whereas C/CTSs are not. Most Ds follow the NICE guidance (87%), whereas many C/CTSs (39%) do not; ISs adopt a middle course (56%). Even amongst Ds, a significant proportion believe that patients with a prosthetic heart valve (25%) or previous history of IE (38%) should receive AP. A total of 36% of Ds have prescribed AP since March 2008 and many have undertaken procedures where AP has been prescribed by someone else. The majority of respondents (65%) feel that more evidence is required, preferably in the form of a randomized controlled trial.

CONCLUSION

Many patients perceived to be at high risk of IE are still receiving AP in conflict with current NICE guidance.

Bonded molar tubes: a survey of their use by specialist orthodontists

OBJECTIVE

To investigate the use of bonded molar tubes (BMTs) by specialist orthodontists.

DESIGN

Prospective postal questionnaire.

SETTING

Ireland.

PARTICIPANTS

Registered members of the Orthodontic Society of Ireland.

METHODS

A questionnaire was posted to registered members of the Orthodontic Society of Ireland. It investigated demographics, pattern of use, reasons for use and techniques for placement of BMTs.

RESULTS

A 74% response rate was obtained. In more than 80% of cases, BMTs were used on first and second permanent molars by 52% and 33% of orthodontists respectively. BMT usage was adopted by 97% of respondents in the previous decade. Direct bonding was used by all for BMT placement. Etch times for molars, compared to other teeth, increased from 15 to 30 seconds by 51% of orthodontists. Of the respondents, 97% used light-cured adhesives and 17% used self-etching primers. Molar tube holders were preferred by 54% for placement. Only with a history of epilepsy, were bands preferred to BMTs. BMTs were regarded as more cost-effective than molar bands by 66% of responding clinicians.

CONCLUSIONS

Specialist orthodontists preferred BMTs to bands on first permenent molars. Direct bonding was favoured using a 30-second etch, a light-cured primer and adhesive with specialized molar tube holders. BMTs were perceived to be more cost-effective than molar bands.

Antibiotic prophylaxis in dentistry: part II. A qualitative study of patient perspectives and understanding of the NICE guideline

BACKGROUND

The National Institute for Health and Clinical Excellence (NICE) recommendations in 2008 for antibiotic prophylaxis before dental treatment contradict previous practice. There is a potential difficulty in explaining the new guidance to patients who have long believed that they must receive antibiotics before their dental treatment.

AIM

This study investigated the patient-related barriers and facilitating factors in implementation of the NICE guidance.

METHODS

In-depth interviews were conducted with nine patients concerning their views about barriers and factors that could influence the implementation of the NICE guidance on antibiotic prophylaxis before dental treatment. Data were analysed using framework analysis.

RESULTS

For patients the rationale for the NICE guidance was unclear. They understood that at the population level the risk of infective endocarditis was less than the risk of adverse reaction to antibiotics. However, on an individual level they felt that the latter risk was negligible given their previous experience of antibiotics. They were aware that standards of care change over time but were concerned that this may be an example where a mistake had been made. Patients felt that the characteristics of the person advising them about the new guidance were important in whether or not they would accept them - they wished to be advised by a clinician that they knew and trusted, and who was perceived as having appropriate expertise.

CONCLUSIONS

Patients generally felt that they would be most reassured by information provided by a clinician who they felt they could trust and who was qualified to comment on the issue by respecting their autonomy. The implications of the findings for the development of patient information are discussed.