Article Text

Original research
Prophylactic antibiotic use for infective endocarditis: a systematic review and meta-analysis
  1. Sue S H Lean1,
  2. Eric Jou2,
  3. Jamie Sin Ying Ho3,
  4. Ernest G L Jou1
  1. 1Department of Dental Medicine, Wei Gong Memorial Hospital, Miaoli, Taiwan
  2. 2Queens' College, University of Cambridge, Cambridge, UK
  3. 3Department of Medicine, National University Health System, Singapore
  1. Correspondence to Dr Eric Jou; ej290{at}


Objectives Infective endocarditis (IE) is a devastating disease with a 50% 1-year mortality rate. In recent years, medical authorities across the globe advised stricter criteria for antibiotic prophylaxis in patients with high risk of IE undergoing dental procedures. Whether such recommendations may increase the risk of IE in at-risk patients must be investigated.

Design Prospectively registered systematic review and meta-analysis.

Data sources Medline, Embase, Scopus and were searched through 23 May 2022, together with an updated search on 5 August 2023.

Eligibility criteria All primary studies reporting IE within 3 months of dental procedures in adults >18 years of age were included, while conference abstracts, reviews, case reports and case series involving fewer than 10 cases were excluded.

Data extraction and synthesis All studies were assessed by two reviewers independently, and any discrepancies were further resolved through a third researcher.

Results Of the 3771 articles screened, 38 observational studies fit the inclusion criteria and were included in the study for subsequent analysis. Overall, 11% (95% CI 0.08 to 0.16, I2=100%) of IE are associated with recent dental procedures. Streptococcus viridans accounted for 69% (95% CI 0.46 to 0.85) of IE in patients who had undergone recent dental procedures, compared with only 21% (95% CI 0.17 to 0.26) in controls (p=0.003). None of the high-risk patients developed IE across all studies where 100% of the patients were treated with prophylactic antibiotics, and IE patients are 12% more likely to have undergone recent dental manipulation compared with matched controls (95% CI 1.00 to 1.26, p=0.048).

Conclusions Although there is a lack of randomised control trials due to logistic difficulties in the literature on this topic, antibiotic prophylaxis are likely of benefit in reducing the incidence of IE in high-risk patients after dental procedures. Further well-designed high-quality case-control studies are required.

Trial registration number CRD42022326664.

  • infectious diseases
  • valvular heart disease
  • cardiology
  • immunology

Data availability statement

All data relevant to the study are included in the article or uploaded as online supplemental information. All data relevant to the study are included in the article or uploaded as online supplemental information. No additional data available.

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:

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Data availability statement

All data relevant to the study are included in the article or uploaded as online supplemental information. All data relevant to the study are included in the article or uploaded as online supplemental information. No additional data available.

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  • SSHL and EJ are joint first authors.

  • JSYH and EGLJ are joint senior authors.

  • SSHL and EJ contributed equally.

  • JSYH and EGLJ contributed equally.

  • Contributors SSHL, EJ, JSYH and EGLJ were involved in the conceptualisation of the study, designed the study, collected and analysed the data. All authors contributed to writing the manuscript and approved for the final version of the paper to be published. EJ is responsible for the overall content as the guarantor.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.