prophylaxis for a dental procedure he is having next week. He had his aortic valve replaced 5 years ago and shortly afterwards he had some dental work done where he was given prophylactic antibiotics to stop his heart valve becoming infected. This time he has been told that he doesn’t need any antibiotics and yet he is having the same
dental procedure done. He’s wondering why he needed
antibiotics before and not now? What has changed? He’s very anxious and has come to you looking for guidance.
1) The British Society for Antimicrobial Chemotherapy
2) The National Institute for Health and Care Excellence
3) The American Heart Association and Infectious Diseases
Society of America
4) The European Society of Cardiology
Which one is correct or the best as there are slight variations between them and who is the most “expert”? It’s really difficult for healthcare professionals to be able to distinguish the good guidelines from the not so good.
So why do we have guidelines or even need them?!
Guidelines cover investigations, diagnostics, infection control
and management of conditions as well as treatments. They help to ensure whichever doctor the patient sees in whatever hospital or GP practise, they receive the same standard of care. They also enable the sharing of best practice based on evidence and research. Therefore guidelines help doctors stay up-to-date without having to read the original papers themselves and ensure patients receive a consistently high standard of care.
Microbiologists are most often involved with antibiotic and infection control guidelines which can cover any speciality. Empirical antibiotic guidelines are broad treatments that cover the common causes /pathogens before results identifying specific causes are available (definitive treatments).
However there are problems associated with national or expert guidelines:
• Many are published in pay-for-access journals; if you don’t have a subscription you cannot read them. This is unhelpful and in my opinion, any guideline wishing to be adopted as a “national” guideline should be open access to all
• The healthcare professional has to know whether a guideline actually exists or not as there is no single repository of guidelines in the UK
• Someone may not have written a guideline; not that the subject is uninteresting but that no one has put pen to paper. Remember: the absence of evidence doesn’t necessarily mean evidence of absence. I hear a lot of
healthcare professionals say “but there is no evidence that that works” as an excuse for not doing something! My favourite counter argument is that there is no evidence that wearing gloves is the correct thing to do when performing a
rectal examination on a patient, but really...do you want to do this without wearing gloves? There is no evidence; best practice is self-evident, it’s just good-old common sense. So don’t be caught out by the absence of evidence, sometimes the evidence has just not been assessed
So what can the healthcare professional with little time do to find infection-related guidelines?
In order to help you I’ve put together a list of what I consider to be the most useful and important guidelines in microbiology and infection. They are drawn from numerous expert groups both from the UK and also from overseas if good UK guidance doesn’t exist yet. I have not listed them here in this blog as I will endeavour to keep just one list online up-to-date as new infection guidelines become available. Let me know what you think, and if you know of any other infection related guidelines you think should be
included I would be glad to hear from you.
By the way Mr Jones doesn’t need antibiotics for his routine
filling. Previously the guidelines stated antibiotics were required however this guideline was based on a lack of evidence; now the evidence suggests that prophylactic
antibiotics do not make any difference to the risk of infective endocarditis from routine dental work. However, Mr Jones would still require prophylactic antibiotics for endodontic work.