Antibiotics to prevent bacterial endocarditis following dental procedures

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Infective endocarditis is rare with a reported incidence of 15 cases per 100,000 in the USA in 2011. It is by infected vegetations that often occur on previously damaged or congenitally malformed cardiac valves or endocardium. Bacteria are usually the infecting organism although fungi of the Candida species may be involved.  Previously endocarditis developed in people with a re-existing cardiac defect but more recently up to have of cases had no known previous cardiac disease.  Most dental procedures lead to a bacteraemia which could result in bacterial endocarditis and it has been estimated that 12% of endocarditis cases in the USA in 2011 were dentally related.

The main aim of this Cochrane review update was to determine whether prophylactic antibiotic administration, compared to no antibiotic administration or placebo, before invasive dental procedures in people at risk or at high risk of bacterial endocarditis, influences mortality, serious illness, or the incidence of endocarditis.


Searches were conducted in the Cochrane Oral Health’s Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL, Medline, Embase,, and the World Health Organization International Clinical Trials Registry Platform with no restrictions on language, publication year or publication status. Randomised controlled trials (RCTs), cohort and case-control studies with suitably matched control or comparison groups were considered. Outcomes included mortality or serious adverse events requiring hospitalisation; development of endocarditis following any dental procedure in a defined time; development of endocarditis due to other non-dental causes; any recorded adverse effects of the antibiotics; and the cost of antibiotic provision compared to that of caring for patients who developed endocarditis.  Standard Cochrane selection, data collection and analyses process were planned or used.


  • No new studies were included since the 2013 version of this review
  • 1 case-control study (48 cases, 200 controls) was included in earlier version of the review which found no significant effect of penicillin prophylaxis on the incidence of endocarditis.
  • The certainty of the evidence is very low


The authors concluded: –

There remains no clear evidence about whether antibiotic prophylaxis is effective or ineffective against bacterial endocarditis in at-risk people who are about to undergo an invasive dental procedure. We cannot determine whether the potential harms and costs of antibiotic administration outweigh any beneficial effect. Ethically, practitioners should discuss the potential benefits and harms of antibiotic prophylaxis with their patients before a decision is made about administration.


This review was initially published in 2004 and first updated in 2013 (Dental Elf – 14th Oct 2013). The review’s discussion highlights the very low certainty of the evidence related to antibiotic prophylaxis to prevent bacterial endocarditis. The reviewers also point out the large number of patients and multicentre participation that would be required for any randomised trial, cohort study of case-controlled study to improve the levels of certainty over antibiotic prophylaxis.  Since 2004 clinical guidelines have moved away from blanket recommendations of antibiotic prophylaxis for all at-risk patients. In 2008 National Institute for Health and Care Excellence (NICE) stated that antibiotic prophylaxis was required for any interventional procedure which led to significant reduction in antibiotic prescribing with no apparent increase in antibiotic prophylaxis was required for any interventional procedure. The NICE guidance was updated in 2016 and subsequently, the Scottish Dental Clinical Effectiveness Programme produced guidance for clinicians in Scotland to help overcome any concerns regarding implementation (SDCEP 2018).


Primary Paper

Rutherford SJ, Glenny AM, Roberts G, Hooper L, Worthington HV. Antibiotic prophylaxis for preventing bacterial endocarditis following dental procedures. Cochrane Database Syst Rev. 2022 May 10;5:CD003813. doi: 10.1002/14651858.CD003813.pub5.. PMID: 35536541.

Other references

Cochrane Oral Health Blog – Can giving antibiotics before dental treatment prevent infections to the inner lining of the heart in people at risk of developing serious complications?

NICE Clinical Guideline 64  Prophylaxis Against Infective Endocarditis

SDCEP Implementation advice for NICE Clinical Guideline 64 Prophylaxis Against Infective Endocarditis

Dental Elf – 14th Oct 2013

No evidence on whether antibiotic prophylaxis is effective or ineffective against bacterial endocarditis in people at risk who need invasive dental procedures



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