Cardiology / Dentistry · NICE

Infective endocarditis prevention

NICE

Source:NICE Clinical Guideline CG64 — Prophylaxis Against Infective Endocarditis (2008, updated 2016)

Verified Apr 2026

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Red Flags

New murmur with fever in patient with prosthetic valve, prior IE, or unrepaired cyanotic congenital heart disease — admit; blood cultures × 3, echocardiography, urgent cardiology^[1]
Suspected IE during dental or invasive procedure period — culture and treat early; multidisciplinary review^[1]
Heart-brain embolic event in IE — emergency MDT (cardiology, cardiac surgery, neurology); valve surgery often indicated despite stroke^[1]
Prophylaxis failure or recurrent IE — investigate dental/other portals; cardiology and cardiothoracic surgery; oral health intensification^[1]

First-line treatment

Interventions

NICE position — antibiotic prophylaxis NOT routinely offered^[1]
NICE CG64 (2008, updated 2016) does not recommend routine antibiotic prophylaxis to prevent IE for dental or non-dental procedures, regardless of cardiac risk; emphasise oral hygiene as primary prevention. NB: 2016 update permits prophylaxis to be considered for specified high-risk individuals on case-by-case basis after shared decision making
Oral health as primary prevention^[1]
Twice-yearly dental review, daily brushing and flossing, treat periodontitis and dental caries proactively; daily bacteraemia from poor oral hygiene exceeds procedure-related risk
Discuss benefits and risks with high-risk patients^[1]
Patients with prosthetic valves, prior IE, congenital heart disease at risk should have informed discussion. NICE notes lack of definitive evidence either way; if patient values prophylaxis, discuss with cardiologist
Patient and family education^[1]
Wallet card with cardiac risk status; counsel about red-flag symptoms (fever, weight loss, night sweats, new heart murmur) requiring same-day cardiology review with blood cultures BEFORE empiric antibiotic
Avoid unnecessary procedures and reduce bacteraemia risk^[1]
Limit cardiac catheterisation in unprotected aortic stenosis where alternative imaging suffices; avoid IV drug use; manage piercings/tattoos with hygienic practice; daily oral hygiene throughout life

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
Amoxicillin (selected high-risk, shared decision-making)^[1]	Aminopenicillin	3 g PO 30–60 min before procedure (NICE-permitted dose where prophylaxis selected by shared decision making)	Per local protocol	Used in patients who choose prophylaxis after informed discussion; NICE 2016 update permits this; use of higher 3 g dose was traditional UK practice
Clindamycin (penicillin allergy alternative)^[1]	Lincosamide	600 mg PO 30–60 min before procedure	20 mg/kg PO (max 600 mg)	Where prophylaxis chosen and penicillin allergic; AHA 2021 update has moved toward azithromycin alternative due to C. difficile signal — UK practice variable
Azithromycin (penicillin allergy alternative)^[1]	Macrolide	500 mg PO 30–60 min before procedure	15 mg/kg PO (max 500 mg)	Alternative for severe penicillin allergy with anaphylaxis history; QTc caution with concurrent QT-prolonging agents

Amoxicillin (selected high-risk, shared decision-making)^[1]

Aminopenicillin

Adult: 3 g PO 30–60 min before procedure (NICE-permitted dose where prophylaxis selected by shared decision making)
Paediatric: Per local protocol

Used in patients who choose prophylaxis after informed discussion; NICE 2016 update permits this; use of higher 3 g dose was traditional UK practice

Clindamycin (penicillin allergy alternative)^[1]

Lincosamide

Adult: 600 mg PO 30–60 min before procedure
Paediatric: 20 mg/kg PO (max 600 mg)

Where prophylaxis chosen and penicillin allergic; AHA 2021 update has moved toward azithromycin alternative due to C. difficile signal — UK practice variable

Azithromycin (penicillin allergy alternative)^[1]

Macrolide

Adult: 500 mg PO 30–60 min before procedure
Paediatric: 15 mg/kg PO (max 500 mg)

Alternative for severe penicillin allergy with anaphylaxis history; QTc caution with concurrent QT-prolonging agents

Safety-net

Daily oral hygiene and regular dental review prevent more endocarditis than any antibiotic — make these your priority^[1]
Tell every dentist, GP, surgeon, and pharmacist about your prosthetic valve, prior IE, or congenital heart disease — informs procedure planning^[1]
Unexplained fever, fatigue, weight loss, or new heart murmur — same-day medical review with blood cultures BEFORE empiric antibiotic^[1]

Referral criteria

Suspected infective endocarditisCardiology with blood cultures, echocardiogram, infectious diseases^[1]
Pre-cardiac surgery or pre-prosthetic valve placementDental review for clearance and oral health optimisation^[1]
High-risk patient seeking informed prophylaxis discussionCardiology and dentistry shared decision-making review^[1]
Penicillin allergy requiring documentation/de-labellingAllergy clinic for risk assessment and possible delabelling^[1]

Clinical summary

Risk-based antibiotic prophylaxis and oral health for adults at high risk of infective endocarditis undergoing dental and other procedures (NICE pathway).

References

1.NICE Clinical Guideline CG64 — Prophylaxis Against Infective Endocarditis (2008, updated 2016) (2016)

Drug

Class

Adult

Paediatric

Notes

Amoxicillin (selected high-risk, shared decision-making)^[1]

Aminopenicillin

3 g PO 30–60 min before procedure (NICE-permitted dose where prophylaxis selected by shared decision making)

Per local protocol

Used in patients who choose prophylaxis after informed discussion; NICE 2016 update permits this; use of higher 3 g dose was traditional UK practice

Clindamycin (penicillin allergy alternative)^[1]

Lincosamide

600 mg PO 30–60 min before procedure

20 mg/kg PO (max 600 mg)

Where prophylaxis chosen and penicillin allergic; AHA 2021 update has moved toward azithromycin alternative due to C. difficile signal — UK practice variable

Azithromycin (penicillin allergy alternative)^[1]

Macrolide

500 mg PO 30–60 min before procedure

15 mg/kg PO (max 500 mg)

Alternative for severe penicillin allergy with anaphylaxis history; QTc caution with concurrent QT-prolonging agents