Here you can find some of the most common questions surrounding antibiotic prophylaxis, and read our advice on this and NICE guidance. Members are also invited to
contact us for with specific queries if they cannot find an answer applying to their situation.
Has the situation with antibiotic cover for patients at risk of endocarditis changed?
07 March 2016
I have heard that following the NICE guidance may no longer be appropriate and wonder what my responsibilities should be.
In light of recent studies, NICE reviewed all of the relevant evidence to establish if there was any basis for changing the recommendations in their current guidance. Although some published opinions have suggested that the use of antibiotic prophylaxis may be appropriate, the weight of available evidence is such that NICE does not consider that there is any justification for changing the current guidance as there is no proven benefit from the routine administration of antibiotics purely as a precautionary measure when dental procedures are undertaken. Practitioners have a responsibility to be aware of current guidance and to follow this appropriately. It should also be remembered that due to NHS regulations some practitioners will also be under a contractual obligation to comply with NICE guidance.
Does the Montgomery case have implications for advising patients about antibiotic prophylaxis?
07 March 2016
Patients have a right to be informed of the risks and benefits of available treatment options. When advising patients who have a cardiac abnormality which may cause them to have a greater chance of developing endocarditis if they have an infection, it is important that he/she understands that the current guidance does not consider dental procedures to constitute a risk of causing this.
The guidance therefore does not recommend the routine prescription of antibiotics prior to dental treatment due to a lack of evidence that this is beneficial. To help preserve antibiotic efficacy these should not be prescribed without a clear clinical justification.
What should I do if the patient still insists on having antibiotic prophylaxis following such a discussion?
07 March 2016
If, in spite of your discussion, the patient insists on having antibiotics prescribed prior to proceeding with dental treatment then they should be advised that as this is contrary to the established guidance for dentists, it would be necessary to clarify the situation with his or her cardiologist. If there is clear written advice from the cardiologist regarding the prescription of antibiotics, in the full knowledge that this contrary to the NICE guidance, then the dentist can make a professional judgement on whether it is reasonable to follow the advice of the cardiologist in that specific case.
Clinical guidance is there to help clinicians understand the expected standard. It is important to consider the appropriate guidance in managing any aspect of clinical care and if a decision is made contrary to the guidance then it is important that the dentist can justify such a decision. The reason(s) for making any final decision that differs from the recognised guidance should also be clearly documented in the clinical records.
My patient has been told by their doctor that because of their heart condition they should have antibiotics before undergoing dental procedures. Should these be prescribed?
07 March 2016
There is no indication for the blanket prescription of antibiotics prior to dental procedures. Any patient who has a spreading infection should of course be treated both surgically and with the appropriate antimicrobial agent but it is the presence of an infection that dictates the need for an antibiotic rather than any particular structural feature. If a physician feels that his/her patient requires an antibiotic then it is a matter for that doctor to judge and prescribe appropriately.
It should be remembered that NICE also has guidance in relation to the wider issue of ensuring that antibiotics are only prescribed where it is appropriate to do so.
(See NICE Guidance NG15)
In other countries antibiotic prophylaxis is routinely used. Would a dentist who followed the UK guidance be criticised if a patient did develop endocarditis?
Prescribing patterns for antibiotics vary widely across Europe and the rest of the world. In some countries antibiotics are more widely available and in some places can be purchased over-the-counter much like common analgesics in the UK.
The emergence of drug resistant bacteria in recent years has given rise to concerns that antibiotics have been, and continue to be, over-used. There have been efforts to encourage prescribers to more carefully consider what is prescribed and when.
The situation in the UK is that NICE does not recommend the routine prescription of antibiotics if there is no infection which would justify the use of antibiotics.
The NICE guidance also makes it clear however that it is important that any infection should be managed promptly and effectively in patients who are at a higher risk of developing endocarditis. A dentist who follows the recognised guidance would not be in breach of his/her duty.
Is NICE guidance applicable to all parts of the UK?
NICE guidance exists to ensure consistency and best practice is followed in the NHS in England and Wales. Dentists working in other jurisdictions in the UK should refer to the guidance which is considered to be appropriate in the particular part of the UK in which s/he is working (for example SMC [Scottish Medicines Consortium] as well as SIGN Scotland).
In the absence of recent recognised guidance on a particular topic specific to other parts of the UK, the NICE guidance can be considered as being an appropriate standard to follow.
Are there other UK organisations like NICE?
07 March 2016
The All Wales Medicines Strategy Group (AWMSG)
AWSG also makes decisions about which medicines should be available within the NHS in Wales. Like NICE, the AWMSG is a group of specialist doctors, pharmacists, other health professionals, patients and drug company representatives. The AWMSG work with NICE and don’t usually review a medicine if NICE is planning to look at it in the next 12 months. If the AWMSG says that a medicine should not be available and then later NICE decides it should be, the NICE decision is the one that is followed.
Healthcare Improvement Scotland (HIS) was set up in 2010. HIS supports the Scottish Government's Healthcare Strategy for NHS Scotland by developing guidance for clinical practice, and assessing and supporting improvement of healthcare. The Scottish Intercollegiate Guidelines Network (SIGN) and the Scottish Medicines Consortium (SMC) are part of HIS.
Scottish Intercollegiate Guidelines Network (SIGN)
SIGN develop evidence based guidelines on how particular conditions, including cancer, should be treated. This network includes patients and their carers, health professionals and other professionals involved in caring for people, such as social workers and managers.
Scottish Medicines Consortium (SMC)
The SMC advises the NHS Health Boards about medicines in Scotland. The advice aims to make sure that people have the same access to treatment wherever they live in Scotland. View more information about the SMC and how it works.
Northern Ireland
The Department of Health,Social Services and Public Safety (HPSS) in Northern Ireland agreed in July 2006 to link to NICE. This means that the Department looks at any guidance issued by NICE and decides if it is relevant for Northern Ireland.
If NICE’s guidance isn’t relevant, or if the HPSS decides it’s only partly relevant, it advises on any changes that need to be made. The HPSS is likely to approve most NICE guidance. The Department usually makes a decision shortly after NICE has made its own decision.
Scottish Dental Clinical Effectiveness Programme
SDCEP (Scottish Dental Clinical Effectiveness Programme) is, as the name suggests, focused specifically on dental care.
It is an initiative of the National Dental Advisory Committee and is part of NHS Education for Scotland (NES). It aims to develop user-friendly evidence-based guidance to support dental teams in providing safe and effective high quality healthcare.
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