Endocarditis prophylaxis – indications, application and current controversies

Links between infective endocarditis (IE) and dental and other invasive procedures were first identified in the 1920s, leading to the first recommendation by the American Heart Association (AHA) in 1955 that antibiotic prophylaxis (AP) should be used to prevent IE. Recognising the weak evidence to support this practice and the wider risks of anaphylaxis and antibiotic resistance, guidelines in the USA and Europe have been rationalised in the last two decades, restricting the use of AP to the highest risk patients (and the complete cessation of AP for all invasive procedures in the UK). However, recent data demonstrate that AP is safe and effective in reducing the incidence of IE in high-risk individuals undergoing invasive dental procedures and support current European Society of Cardiology (ESC) and AHA guidance,. Nonetheless, debate continues, and several questions remain. Which patients should receive AP? Which dental and non-dental procedures require AP? And which AP regimens and other preventive measures are safest and most cost-effective? In this narrative review, we address these controversies with reference to recent literature and clinical experience.