Matters of the heart; antibiotic prophylaxis for prevention of infective endocarditis—are we getting it right?

A Commentary on Sperotto F, France K, Gobbo M et al.

Antibiotic prophylaxis and infective endocarditis incidence following invasive dental procedures: a systematic review and meta-analysis. JAMA Cardiol 2024; 9:599. https://doi.org/10.1001/jamacardio.2024.0873.

Objectives

This systematic review evaluates the association between antibiotic prophylaxis (AP) and the incidence of infective endocarditis (IE) following invasive dental procedures (IDPs).

Materials and methods

A systematic search was conducted across PubMed, Cochrane-CENTRAL, Scopus, Web of Science, Proquest, and Embase, from inception to May 2023. Observational studies, including case-control, case-crossover, cohort, self-controlled case-series, and time-trend studies were included. Data were extracted independently, and structured tools were used to evaluate study quality. A random-effects meta-analysis estimated the pooled-relative risk (RR) of developing IE in high-risk subjects who received AP compared to those who did not.

Results

Of 11,217 identified records, 30 studies met inclusion criteria, comprising 1,152,345 IE cases. Among 12 relevant studies, five found a significant protective effect of AP in high-risk subjects. Four studies were combined in meta-analysis and showed AP was associated with a significantly lower IE risk in high-risk individuals (pooled-RR = 0.41, 95% CI: 0.29–0.57). No significant association was found for moderate- or low/unknown-risk subjects. Time-trend studies showed mixed results: some indicated increased IE incidence after AP guideline changes, while others found no change or a decrease.

Conclusions

Despite limitations, this review provides an important update on AP use in preventing IE after IDPs. Evidence supports AP use for high-risk individuals, while data remain inconclusive for moderate-risk populations, highlighting the need for further research.