Subacute Bacterial Endocarditis Prophylaxis for PFO Closure
SBE prophylaxis is reasonable for patients undergoing patent foramen ovale (PFO) closure during the first 6 months after the procedure, as these patients have completely repaired congenital heart defects with prosthetic material placed by catheter intervention. 1
Indications for SBE Prophylaxis with PFO Closure
PFO closure devices are considered prosthetic material placed in the heart, and current guidelines specifically address this scenario:
- Prophylaxis is reasonable for patients with completely repaired congenital heart defects with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure 1
- This recommendation is based on the fact that endothelialization of prosthetic material occurs within 6 months after the procedure 1
- After 6 months post-procedure, SBE prophylaxis is no longer recommended if there are no residual defects 1
Specific Considerations for PFO Closure Devices
PFO closure carries specific considerations regarding endocarditis risk:
- Cases of infective endocarditis associated with PFO closure devices have been reported, though extremely rare (0.001% incidence) 2
- Most PFO closures use double-disk occlusion devices followed by antiplatelet therapy 3
- Recent literature suggests that late endocarditis (>6 months post-procedure) may be more common than previously thought, potentially associated with changes in antiplatelet therapy protocols 2
Prophylaxis Recommendations When Indicated
When prophylaxis is indicated (within 6 months of PFO closure), it should be administered for dental procedures that involve:
- Manipulation of gingival tissue 1
- Manipulation of the periapical region of teeth 1
- Perforation of oral mucosa 1
The recommended antibiotic regimen for dental procedures is:
- Oral: Amoxicillin 2g for adults (50 mg/kg for children) as a single dose 30-60 minutes before the procedure 1
- For patients allergic to penicillin: Clindamycin 600mg for adults (20 mg/kg for children) or cephalexin 2g (50 mg/kg for children) 1
When Prophylaxis is NOT Needed
SBE prophylaxis is NOT recommended for:
- PFO closure patients beyond 6 months after the procedure if there are no residual defects 1
- Non-dental procedures such as transesophageal echocardiography, diagnostic bronchoscopy, esophagogastroduodenoscopy, or colonoscopy in the absence of active infection 1
- Routine dental procedures that don't involve gingival manipulation (dental radiographs, adjustment of orthodontic appliances, etc.) 1
Clinical Rationale for Current Guidelines
The current focused approach to SBE prophylaxis is based on several key principles:
- Infective endocarditis is more likely to result from frequent exposure to random bacteremias associated with daily activities than from bacteremia caused by a dental procedure 1
- Prophylaxis may prevent an exceedingly small number of cases of infective endocarditis (if any) 1
- The risk of antibiotic-associated adverse effects may exceed the benefit from prophylactic antibiotic therapy 1
- Maintenance of optimal oral health and hygiene is more important than prophylactic antibiotics for reducing endocarditis risk 1
Common Pitfalls to Avoid
- Continuing prophylaxis beyond 6 months post-procedure when not indicated 1
- Administering prophylaxis for non-dental procedures when not indicated 1
- Failing to recognize that the risk of adverse outcomes from endocarditis (not just lifetime risk of acquisition) is the key factor in determining prophylaxis need 1
- Overlooking the importance of optimal oral hygiene as a preventive measure 1