Summary

AHA 2023 Science Advisory revisiting the link between nondental invasive procedures (NDIPs) and infective endocarditis (IE) risk, prompted by large nationwide case-crossover studies from Sweden (Janszky 2018) and England (Thornhill 2022) showing temporal association between several NDIPs and subsequent IE in high-risk patients. The advisory does not change current AHA guidance (which since 2007 restricts antibiotic prophylaxis [AP] to invasive dental procedures in high-risk patients) but calls for future guideline committees to reconsider AP, infection-prevention measures, and clinician awareness for NDIPs in high-risk individuals. No new prophylaxis regimens are mandated.

Key Recommendations

Current AHA guidance is unchanged: routine antibiotic prophylaxis is recommended only before invasive dental procedures in patients at high risk of IE, not before nondental invasive procedures.
Recognize NDIPs with the strongest temporal association with subsequent IE in high-risk patients: CIED implantation, upper and lower GI endoscopy, bronchoscopy, bone marrow biopsy, and blood transfusion/exchange.
Maintain strict sterility and infection-prevention practices during NDIPs in high-risk IE patients rather than relying on repeated/long-term antibiotic prophylaxis (which promotes resistance).
For procedures with routine surgical site infection prophylaxis (CIED implantation, ERCP, transurethral/transrectal prostate procedures), select perioperative antibiotic regimens that also cover likely IE pathogens in high-risk patients.
Consider antibacterial-impregnated envelopes (WRAP-IT) to reduce CIED infection in high-risk patients.
Maintain a low threshold to evaluate for IE in high-risk patients presenting within 3 months of an NDIP.
Guideline committees should consider whether AP targeted at typical colonizing flora is warranted before specific NDIPs (e.g., endoscopy) in high-risk IE patients.
High IE-risk patients (prosthetic valves, prior IE, certain congenital heart disease, valve repair with prosthetic material) remain the population where any preventive intervention should be focused.
Randomized trials are not feasible due to low IE incidence; large observational/registry studies are the best available evidence for future guidance.

Thresholds & Doses

3-month (12-week) window: case period used in Janszky and Thornhill studies for procedure–IE temporal association; clinically the period of heightened post-procedural IE suspicion in high-risk patients.
Janszky 2018 (Sweden, n=7013 IE cases): inpatient ORs — bronchoscopy 16.0, CABG 13.8, pacemaker/ICD or cardiac surgery 9.75, blood transfusion 6.69, cystoscopy 4.40, coronary angiography 4.23, upper GI endoscopy 3.97, PCI 3.50.
Thornhill 2022 (England, n=14,731 IE cases, hinge model): significant ORs — upper GI endoscopy 1.30, lower GI endoscopy 1.23, CIED implantation 1.29, bone marrow biopsy 1.28, bronchoscopy 1.33, blood transfusion 1.20.
Garcia-Albeniz 2016: excess 7.3 IE cases per 10,000 colonoscopies (with biopsy/polypectomy) vs no colonoscopy in high-risk Medicare patients.
Mohee 2014: transurethral endoscopic procedure OR 8.21 for enterococcal IE.
AHA 2007 guidance: AP Class IIb LOE B for GU/GI/skin procedures with established infection; Class IIa LOE C for respiratory procedures with incision/biopsy in high-risk; Class III LOE B against routine GI/GU AP.

Citations

Abstract and Introduction — rationale: Swedish and English nationwide data prompting revisit of NDIP–IE association.
Current International Guidelines / Table 1 — AHA, ESC, BSAC, NICE prophylaxis recommendations across procedures and eras.
AHA 2021 (Wilson et al, Ref 8) — most recent AHA guidance limiting AP to high-risk patients undergoing invasive dental procedures for viridans streptococcal IE prevention.
Study by Janszky et al 2018 (Ref 3) / Table 3 — case-crossover ORs for NDIPs in Swedish IE cohort.
Study by Thornhill et al 2022 (Ref 4) / Table 3 and Figure — step/hinge model ORs and attributable IE risk per 100,000 procedures by risk group.
Study by Garcia-Albeniz et al 2016 (Ref 20) — colonoscopy and IE risk in elderly Medicare cohort.
Future Considerations — clinical implications: sterility, targeted perioperative antibiotics, antibiotic-impregnated CIED envelope (WRAP-IT, Ref 24), clinician alertness within 3 months post-NDIP.
Current Position — synthesis of 8 reviewed studies and limitations (lack of microbiology, no AP data, ICD-based diagnoses).