A major NICE update: why infective endocarditis prevention is back on the agenda

UK guidance on infective endocarditis (IE) prevention has undergone its most significant change in nearly two decades, and every dentist needs to understand what it means for their clinical practice.

IE is a serious infection of the heart valves. Some 30% of patients die within one year of diagnosis, and survivors face significant long-term health problems (Cahill and Prendergast, 2015). Oral bacteria are implicated in 35-45% of IE cases (Thornhill et al, 2024).

Before 2008, UK guidelines recommended antibiotic prophylaxis (AP) before invasive dental procedures for all patients at increased IE risk. 

In 2008, NICE made the contested decision to recommend against all use of AP for IE prevention, stating: ‘Antibiotic prophylaxis against infective endocarditis is not recommended for people undergoing dental procedures.’ Dentists working for the NHS in England and Wales were contractually required to follow NICE guidance, and compliance was high (Dayer et al, 2015).

The UK stood alone in this position. All other international guideline committees continued to recommend that individuals at high risk of IE (see Table one) should receive AP before at-risk dental procedures: any procedure involving manipulation of the gingival or periapical region of the teeth (Delgado et al, 2023; Wilson et al, 2021).

What has changed?

In November 2024, NICE updated the wording of its guidance. It now reads: ‘Antibiotic prophylaxis against infective endocarditis is not recommended routinely for people undergoing dental procedures. 

For advice on antibiotic prophylaxis for people at high risk of infective endocarditis undergoing dental procedures and for relevant patient information, see the Scottish Dental Clinical Effectiveness Programme’s (SDCEP) implementation advice on antibiotic prophylaxis against infective endocarditis.’ (NICE, 2024)

This is a landmark shift. For the first time, NICE has acknowledged the existence of high-risk individuals who may benefit from AP. For the first time, it has also recommended that all dentists across the UK, not only those in Scotland, should follow SDCEP implementation advice.

Recent research reinforced the link between at-risk dental procedures and subsequent IE in high-risk patients, and demonstrated the value of AP in reducing that risk (Thornhill et al, 2024; Thornhill et al, 2025).

A coroner’s case and a successful negligence claim against a dentist, both involving high-risk patients who developed IE after at-risk dental procedures performed without AP cover, are also understood to have contributed to NICE’s decision to revise its position (Mahase, 2024).

The SDCEP advice was out of date when NICE made its referral. SDCEP committed to a full update, and the revised second edition was published on 24 March 2026. It is available at: www.antibioticprophylaxis.sdcep.org.uk

What the new guidance says

Taken together, the updated NICE guidance and SDCEP implementation advice have fundamentally transformed the UK position. The shift is from recommending against all AP use in 2008, to recommending in 2026 that AP should be offered to all high-risk individuals undergoing extractions and oral surgery, and should be considered for all other at-risk procedures involving manipulation of the gingival or periapical region (see box below and Table two).

Importantly, SDCEP now classifies all scaling procedures, including supragingival scale and polish, the basic periodontal examination, and placement and removal of orthodontic separators and bands, as at-risk dental procedures for which AP should be considered in high-risk patients. This represents a change from previous SDCEP guidance, which had not classified these as at-risk procedures (SDCEP, 2026).

Informed consent

SDCEP emphasises the importance of informed consent discussions with all patients at increased IE risk, whether moderate or high. The risks associated with any proposed dental procedure should be discussed alongside the potential risks and benefits of AP. The outcome of these discussions must be recorded in the patient’s clinical record. A recent British Dental Journal article and the SDCEP website provide further detail on the information that should be covered in these discussions (SDCEP, 2026; Thornhill et al, 2024).

Updated antibiotic regimens

SDCEP has updated its recommendations on AP regimens (see Table three). For most patients, a single oral dose of amoxicillin is recommended, taken 30-60 minutes before the procedure. 

SDCEP recommends the 3g sugar-free amoxicillin powder sachet, mixed with water to form a drink, which was widely used before 2008 and remains available. Alternatively, a 2g dose (four 500mg capsules) is recommended, in line with other international guidance.

Clindamycin is no longer recommended for patients with a penicillin allergy, due to the risk of adverse reactions (Thornhill et al, 2015). A single 500mg oral dose of clarithromycin or azithromycin is now recommended instead.

What this means for your practice

This is one of the most significant changes to UK dental prescribing guidance in a generation. It brings AP guidance in the UK into line with the rest of the world. 

All dental professionals need to be aware of this change and to implement it as quickly as possible, to protect high-risk patients from a preventable and potentially fatal infection.

References:

1. ​Cahill TJ, Prendergast BD. Infective endocarditis. Lancet. 2015;387(10021):882–93.
2. Thornhill M, Prendergast B, Dayer M, Frisby A, Baddour LM. Endocarditis prevention: time for a review of NICE guidance. Lancet Reg Health Eur. 2024;39:100876.
3. Dayer MJ, Jones S, Prendergast B, Baddour LM, Lockhart PB, Thornhill MH. Incidence of infective endocarditis in England, 2000-13: a secular trend, interrupted time-series analysis. Lancet. 2015;385(9974):1219–28.
4. Delgado V, Ajmone Marsan N, de Waha S, Bonaros N, Brida M, Burri H, et al. 2023 ESC Guidelines for the management of endocarditis. Eur Heart J. 2023;44(39):3948–4042.
5. Wilson WR, Gewitz M, Lockhart PB, Bolger AF, DeSimone DC, Kazi DS, et al. Prevention of Viridans Group Streptococcal Infective Endocarditis: A Scientific Statement From the American Heart Association. Circulation. 2021;143(20):e963–e78.
6. Thornhill MH, Lockhart PB, Dayer MJ, Prendergast BD, Baddour LM. Infective Endocarditis Risk After Invasive Dental Procedures. Mayo Clin Proc Innov Qual Outcomes. 2025;9(6):100676.
7. Mahase E. Infective endocarditis: Coroner’s report questions NICE guidance on prevention. BMJ. 2024;385:q1081.
8. National Institute for Health and Care Excellence. Prophylaxis against infective endocarditis: antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures. Clinical Guideline 64 2024 [Available from: https://www.nice.org.uk/guidance/cg64.
9. Scottish Dental Clinical Effectiveness Programme. Antibiotic Prophylaxis Against Infective Endocarditis Implementation Advice, 2nd edition 2026 [updated 24–03–2026. 2nd:[Available from: https://www.sdcep.org.uk/published-guidance/antibiotic-prophylaxis/.
10. Thornhill M, Prendergast B, Dayer M, Frisby A, Lockhart P, Baddour LM. Prevention of infective endocarditis in at-risk patients: how should dentists proceed in 2024? British dental journal. 2024;236(9):709–16.
11. Thornhill MH, Dayer MJ, Prendergast B, Baddour LM, Jones S, Lockhart PB. Incidence and nature of adverse reactions to antibiotics used as endocarditis prophylaxis. J Antimicrob Chemother. 2015;70(8):2382–8.

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