Incidence of infective endocarditis in England, 2000–13: a secular trend, interrupted time-series analysis

Selected in The Lancet by R. Dworakowski

References

Authors

Mark J Dayer, Simon Jones, Bernard Prendergast, Larry M Baddour, Peter B Lockhart, Martin H Thornhill

Reference

The Lancet, Early Online Publication, 18 November 2014

Link

Read the Abstract

My Comment

What is known

Based on the lack of strong evidence regarding prophylaxis in infective endocarditis (IE), recent guidelines in Europe and USA reduced the recommendation for antibiotic prophylaxis before dental procedures. In the UK, NICE (National Institute of Health and Clinical Excellence) went a step farther and recommended complete cessation of IE prophylaxis.

Major findings

  • Data of antibiotic prescriptions for IE prophylaxis and hospital discharges were analysed between Jan 2000 and March 2013
  • Significant fall in prescriptions of antiobiotics for IE prophylaxis from 10,900 per month to 2,236 per month after introduction of NICE guidance were noted
  • Number of cases of infective endocarditis increased significantly above the projected trend, by 0.11 cases per 10 million people per month, equivalent to 35 more cases per month than predicted at the end of the studied period
  • This increase in the incidence of infective endocarditis was significant for all risk groups

My comments 

Authors identified temporal association between the fall in antibiotic prescriptions and the increased prevalence of infective endocarditis. This study does not give definite answers about causation because there are numerous limitations, but basing oneself on the lack of strong data it brings to light the very important point of changing practice. IE prophylaxis was used for many years as IE is potentially life-threatening condition with a mortality approaching 20-30%. The clinical risk of giving antibiotic prophylaxis is minimal (risk of fatal anaphylaxis is around 0.1%), as well as minimal costs (120.000 prescriptions a year will give a cost of around 200.000Euros) in comparison to IE treatment (average cost might be as high as 40.000 Euros per patient). Does the lack of data justify a change in practice or do we need a trial before?

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