AMOXICILLIN IS THE MOST EFFECTIVE ORAL ANTIBIOTIC PROPHYLAXIS REGIMEN FOR REDUCING POST-INVASIVE DENTAL PROCEDURE BACTEREMIA

Subjects or Study Selection This systematic review compared the efficacy of different antibiotic prophylaxis (AP) regimens for reducing the incidence of post-invasive dental procedure bacteremia. The key words "prevention", "bacteremia", and "dental procedure" were used to search ClinicalKey, Cochrane CENTRAL, EMBASE, ProQuest, PubMed, ScienceDirect, Web of Science, and ClinialTrials.gov from inception to December 4, 2018, and 217 citations were identified. After exclusions, 24 studies, covering 2147 participants, were identified that met the inclusion criteria of reporting randomized controlled trials (RCTs) with a placebo- or active-controlled design (comparison of different prophylactic interventions) and included adult or pediatric participants. To make these comparisons, a network meta-analysis (NMA) also known as a multiple-treatment comparison meta-analysis was performed. This is a meta-analysis in which multiple treatments, that is, three or more, are compared using both direct comparisons of interventions within RCT and indirect comparisons across trials based on a common comparator.(1) Key Study Factor The main purpose of AP before invasive dental procedures is to prevent infective endocarditis (IE) in those at high risk of the condition. It may also be used to prevent other distant site infections, for example, prosthetic joint infections, in those at risk. Ideally, the efficacy of AP would be tested in RCTs that compared any reduction in the incidence of IE after invasive dental procedures performed with and without AP cover. As the incidence of IE is low, and studies would need to be performed on individuals at high risk of IE, ethical concerns and the size and cost of such studies have precluded any to date. As a surrogate for such studies, RCTs measuring the effect of AP on the incidence of bacteremia after invasive dental procedures have been used instead, and these are the type of studies evaluated in this systematic review. The data, therefore, while important, highly clinically relevant, and among the best currently available, may not directly translate to efficacy in preventing IE. Main Outcome Measure The main outcome evaluated was the reduction in incidence of post-invasive dental procedure bacteremia that occurred with different AP regimens. Main Results The study found that the oral AP regimen that was most effective in reducing overall postprocedural bacteremia was 3 g of amoxicillin (odds ratio [OR], 0.1; 95% confidence interval [CI], 0.02-0.44). An OR, 1 indicates that there is less incidence of postprocedural bacteremia than with placebo/control. The smaller the OR, the more effective that regimen is in reducing postprocedural bacteremia, and the reduction is likely to be significant if the CI does not include 1. The next most effective regimen was 2 g of amoxicillin (OR, 0.16; 95% CI, 0.05-0.54). For intravenous regimens, 1000/200 mg of amoxicillin/clavulanate provided the least incidence of postprocedural bacteremia (OR, 0.03; 95% CI, 0.00-0.63). Some other intravenous regimens were also effective. Conclusions This NMA suggests that 3 g of oral amoxicillin and 1000/200 mg of intravenous amoxicillin/clavulanate are likely the best AP interventions for preventing post-invasive dental procedure bacteremia.