Sweden is one of few countries to have removed the dental health recommendation to give prophylactic antibiotics to people at a higher risk of infection of the heart valves, or so-called infective endocarditis. Since the recommendation was removed in 2012, there has been no increase in this disease, a registry study from Karolinska Institutet shows.
Infective endocarditis is a rare but life-threatening disease caused by bacterial infection of the heart valves that affects some 500 people a year in Sweden. Individuals with congenital heart disease, prosthetic heart valves or previous endocarditis are at higher risk of infection.
People at a higher risk of infective endocarditis in Sweden used to receive the antibiotic amoxicillin as a prophylactic before certain dental procedures, such as tooth extraction, tartar scraping and surgery. This recommendation was lifted in 2012 due to a lack of evidence that the treatment was necessary, and to help prevent antibiotic resistance by reducing antibiotic use.
A collaborative project examined how the decision has affected the incidence of infective endocarditis.
Supports the change in recommendation
“We can see only small, statistically non-significant variations in morbidity, nothing that indicates a rise in this infection in the risk group since 2012,” said the study’s corresponding author Niko Vähäsarja, dentist and doctoral student at the Department of Dental Medicine, Karolinska Institutet.
“Our study therefore supports the change in recommendation. This is an internationally debated issue and Sweden and the UK are the only countries in Europe to restrict antibiotic use like this.”
The registry study encompassed 76,762 high-risk individuals and 396,048 individuals at a low risk of infective endocarditis, who were monitored from 2008 to 2018 with the help of the Medical Birth Registry, the National Patient Register and the Swedish Endocarditis Registry.
The recommendation was supplemented in 2016 with an instruction to consider prophylactic antibiotic treatment if prescribed by the patient’s doctor. It is unclear how this addition has influenced the prescription of antibiotics by dentists.
Reduction of amoxicillin prescriptions
After the change in recommendation in 2012, prescriptions of amoxicillin in dentistry declined by approximately 40%. However, the study is unable to demonstrate that this was an effect of the amended recommendation, and, amoxicillin has other uses in dental medicine.
“The next step is to examine which dental procedures the individuals in the risk group underwent during the 2008-2018 period, since this is information we lack and it could add to our knowledge of what is to date a poorly studied issue,” said Vähäsarja. “This and our study that we’ve just published could inform similar recommendation changes in other countries, resulting in a reduction in antibiotic use.”
The study was published in the journal Clinical Infectious Diseases.
Study details
Infective endocarditis among high-risk individuals – before and after the cessation of antibiotic prophylaxis in dentistry: a national cohort study.
Niko Vähäsarja, Bodil Lund, Anders Ternhag, Bengt Götrick, Lars Olaison, Margareta Hultin, Anna Warnqvist, Carina Krüger Weiner, Aron Naimi-Akbar.
Published in Clinical Infectious Diseases on 4 February 2022;
Abstract
Background
A few years after the publication of the British guidelines, national recommendations were published by the Swedish Medical Products Agency in October 2012, promoting the cessation of antibiotic prophylaxis in dentistry for the prevention of infective endocarditis (IE). The aim of this study was to evaluate whether the incidence of oral streptococcal IE increased among high-risk individuals after October 2012.
Methods
This nationwide cohort study included all adult individuals (>17 years) living in Sweden from January 2008 to January 2018, with a diagnose code or surgical procedure code indicating high risk of IE. Cox proportional hazard models were performed to calculate adjusted ratios of oral streptococcal IE before and after October 2012 between high-risk individuals and references.
Results
This study found no increased incidence of oral streptococcal IE among high-risk individuals during the five years after the cessation, compared to before. Hazard rate ratios were 15.4 (95% CI: 8.3 to 28.5) before and 20.7 (95% CI: 10.0 to 42.7) after October 2012 for prevalent high-risk individuals. Corresponding ratios for incident high-risk individuals were 66.8 (95% CI: 28.7 to 155.6) and 44.6 (95% CI: 22.9 to 86.9). Point estimates for interaction with time period: 1.4 (95% CI: 0.6 to 3.5) and 0.8 (95% CI: 0.5 to 1.3) for prevalent and incident high-risk individuals respectively.
Conclusion
The results suggest that the current Swedish recommendation not to administer antibiotic prophylaxis for the prevention of IE in dentistry has not led to an increased incidence of oral streptococcal IE among high-risk individuals.
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