Infective Endocarditis Prophylaxis

Current to NICE CG64 (2008, amended 2016 and 2024) and the SDCEP implementation advice, 2nd edition, March 2026.

Why this matters

Infective endocarditis (IE) is a microbial infection of the endocardial surface of the heart, most often affecting the valves. It is uncommon but serious, carrying an in-hospital mortality of roughly 15-20% and frequently requiring prolonged intravenous antibiotics or cardiac surgery. Oral viridans group streptococci are among the commonest causative organisms in community-acquired native valve disease, which is why dentistry has long been implicated in its prevention.

Invasive dental procedures produce a transient bacteraemia. So, however, do toothbrushing, flossing and chewing, and these everyday activities occur thousands of times a year against a handful of dental visits. This cumulative exposure argument, together with the absence of randomised trial evidence that prophylaxis works, underpinned the restrictive position NICE took in 2008 and explains why good oral health is regarded as more protective than any single antibiotic dose.

How the UK guidance has evolved

Which patients?

SDCEP divides cardiac patients into high risk, moderate risk and everyone else. Identification and assessment of risk requires liaison with the patient's cardiac team or general medical practitioner. If a cardiac condition or procedure is not on either list (a coronary artery stent, for example), the patient is not considered to be at high or moderate risk.

High risk: prophylaxis is recommended

• Previous episode of infective endocarditis

• Surgically implanted prosthetic valves, and any material used for surgical cardiac valve repair

• Transcatheter implanted aortic and pulmonary valvular prostheses

• Untreated cyanotic congenital heart disease

• Cyanotic congenital heart disease treated surgically with post-operative palliative shunts, conduits or other prostheses (for the first 6 months after repair, and indefinitely if a residual shunt or valvular regurgitation persists)

• Ventricular assist devices

Prophylaxis should be considered, rather than recommended outright, for patients with transcatheter mitral or tricuspid valve repair, and for the first 6 months after implantation of septal defect or left atrial appendage closure devices. It may be considered in heart transplant recipients.

Moderate risk: prophylaxis is not recommended

• Rheumatic heart disease

• Non-rheumatic degenerative valve disease

• Congenital valve abnormalities, including bicuspid aortic valve disease

• Cardiovascular implanted electronic devices (pacemakers, implantable defibrillators)

• Hypertrophic cardiomyopathy

Prophylaxis may still be considered for an individual in this group where there are complex cardiac risk factors or comorbidities such as diabetes or immunosuppression. If the cardiac team advises prophylaxis for a moderate risk patient, manage that patient as high risk.

Which procedures?

The procedure lists apply only once a patient has been placed in the high risk group. A procedure is "at risk" if it involves manipulation of the gingival or periapical tissues, or perforation of the oral mucosa.

What to give?

A single dose is given 30 to 60 minutes before the procedure. No post-operative dose is required. Where several at-risk procedures are planned, group them into as few visits as possible to limit the number of antibiotic exposures.

Oral regimens