BCS President's statement on NICE Guideline to prophylaxis against infective endocarditis

29 April 2008

British Cardiovascular Society
Antibiotic Prophylaxis against Infective Endocarditis
Position Statement

The National Institute for Health and Clinical Excellence (NICE) published new guidance on the use of antibiotic prophylaxis against infective endocarditis last month . This recommends an end to the long-established practice of prescribing antibiotics for “at risk patients” undergoing routine dental, upper and lower GI tract, genito-urinary tract and respiratory tract procedures.

The Society recognises that many of its members may question this approach; indeed 70% of those who participated in a debate at last year’s conference were opposed to the adoption of similar recommendations proposed by the American Heart Association.

The BCS contributed to the development of the NICE guidelines in its capacity as a registered stakeholder and has hosted discussions on the guidance at meetings of its Executive, Board and Council. In all these deliberations there has been broad agreement on a number of points:-

1. The available evidence is not conclusive or definitive.
2. The evidence that we do have suggests that, on first principles, antibiotic prophylaxis is likely to be ineffective.
3. It would be very unfortunate if credible authorities produce contradictory guidelines. (The new NICE guidance is broadly in agreement with current American Guidelines, forthcoming ESC guidelines, and the existing British Society for Antimicrobial Therapy guidelines).
4. It is essential to monitor the impact of any change in practice by monitoring the incidence of infective endocarditis closely.

In the light of all this the Officers of the BCS have concluded that we should endorse the new NICE guidance whilst recognising that it may create difficulties for some cardiologists and patients. We anticipate that most practising cardiologists will no longer recommend antibiotic prophylaxis to new patients but will not necessarily advise existing patients, some of whom have had the need for antibiotic cover drummed into them over many years, to abandon the practice instantly. Nevertheless, practitioners may wish to explain the change in thinking to existing patients before agreeing how to proceed. We certainly hope that none of our members will feel under undue pressure to change their practice and that patients who wish to continue with antibiotic prophylaxis will be allowed to do so. Indeed, in the absence of definitive evidence, the Society views this issue as “a matter of conscience” and will support any member who chooses to recommend antibiotic prophylaxis in selected circumstances.

Dr Nicholas Boon
President
On behalf of the BCS Executive and Guidelines and Practice Committee