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They found no link between invasive dental procedures and the development of IE; however, there were a number of important methodological issues with this paper which are beyond the scope of this article.It is clear from these studies that IE caused by dental procedures can, at most, only cause a small number of cases, and that studies have to enrol many thousands of patients to detect a small difference.

Of these, a total of four patients developed IE within three months of an invasive dental procedure after receiving AP, whereas 10 who did not receive AP developed IE within three months of the procedure. In the first group no patient developed IE.

In the second group, six developed IE within 14 days.In 1990, Imperiale and Horwitz published a very small case control study [22]. It is a subject which divides clinicians.

Importantly, during the three months preceding oral streptococcal IE, only 5.1% of patients had an invasive dental procedure, emphasising that most cases of oral streptococcal IE are not related to dental procedures.The most recent study to look at the link is by Chen et al (a different group to the above) [17]. Oral streptococcal IE incidence rates were 78.1 per 100,000 person-years (95% CI: 1.6-154.6) during the three months following an invasive dental procedure when AP was given, whereas they were 149.5 per 100,000 person-years (95% CI: 56.8-242.2) during the three months following an invasive dental procedure without AP. Thus far, those data have proved elusive.Van der Meer et al looked at whether or not dental procedures preceded cases of IE across the Netherlands and published their results in 1992 [11]. Six cases and six controls received AP. The previous iteration in 1997 [25] had recommended AP for patients at high risk and moderate risk of developing IE.

The 2007 guidance restricted AP to those at high risk of developing or suffering an adverse outcome from IE.

The second study was a case-control study that examined the efficacy of AP to prevent IE in patients with native valve disease [23]. AP was used by 1/8 patients and by 15/24 controls.

The AHA guidelines are very similar.Other procedures, such as respiratory or urological procedures, for which AP was recommended in earlier versions of the guidelines, are no longer regarded as high-risk, and AP is no longer advised, unless procedures are being undertaken in the context of active infection.

- In the past, “moderate-risk” patients, such as those with native valve disease or less severe congenital heart disease, have been covered by AP, but this is no longer the case.The class of evidence is given as IIa, the level of evidence as C. Class IIa is defined as “The weight of evidence/opinion is in favour of usefulness/efficacy”. In 2007, the American Heart Association released new guidelines for AP [24].

They adopted a similar approach to the Americans, moving from advising that patients at moderate or high risk should have AP, to just recommending it for patients at high risk.

They used a case-crossover design (where patients serve as their own controls). Heart Attack and Stroke Symptoms

This difference was not statistically significant.In 1998, Strom et al undertook a case control study in the USA [13]. When no dental procedure had taken place within three months, the incidence rate of oral streptococcal IE was 94.6 per 100,000 person-years (95% CI: 82.5-106.6). Prophylaxis against infective endocarditis: antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures.

The 2015 update was triggered by a study suggesting that the incidence of infective endocarditis may have been affected by the 2008 guidance.

It is also important to realise that there are no ICD-9 or 10 codes that identify OVGS specifically.

Over the time periods studied there have been many changes other than to guidelines for AP. Many similar studies using rabbit and other animal models also showed that antibiotics given prior to injections of bacteria could prevent IE, supporting the use of AP.If AP is of benefit, a number of observations must be true.

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