What is the recommended antibiotic prophylaxis for infective endocarditis in children post device (percutaneous closure device) closure?

Infective Endocarditis Prophylaxis in Children Post Device Closure

Direct Recommendation

Children who have undergone percutaneous device closure of congenital heart defects require antibiotic prophylaxis for dental procedures during the first 6 months post-procedure, after which prophylaxis is only needed if residual defects persist at or adjacent to the device. 1, 2

Time-Based Prophylaxis Algorithm

First 6 Months Post-Device Closure

• All children require prophylaxis for dental procedures that involve manipulation of gingival tissue, periapical region of teeth, or perforation of oral mucosa 1, 2
• This applies regardless of complete closure status because endothelialization of prosthetic material occurs within 6 months 1
• The standard regimen is amoxicillin 50 mg/kg orally (not to exceed adult dose) given 30-60 minutes before the procedure 1, 2

After 6 Months Post-Device Closure

• Prophylaxis is discontinued if the defect is completely repaired with no residual defects 1, 2
• Prophylaxis continues indefinitely if residual defects exist at or adjacent to the prosthetic device, as these inhibit endothelialization 1

Antibiotic Regimens for Dental Procedures

Standard Regimen (No Penicillin Allergy)

• Oral: Amoxicillin 50 mg/kg as single dose 1, 2
• Unable to take oral: Ampicillin 50 mg/kg IM or IV, OR cefazolin or ceftriaxone 50 mg/kg IM or IV 1

Penicillin Allergy

• Oral options: Cephalexin 50 mg/kg, OR clindamycin 20 mg/kg, OR azithromycin or clarithromycin 15 mg/kg 1, 2
• Parenteral options: Cefazolin or ceftriaxone 50 mg/kg IM or IV, OR clindamycin 20 mg/kg IM or IV 1
• Critical caveat: Cephalosporins should NOT be used in patients with history of anaphylaxis, angioedema, or urticaria with penicillins 1, 3

Prophylaxis During the Device Closure Procedure Itself

Most interventional cardiologists provide antibiotic coverage (typically a cephalosporin) during and after device placement procedures. 1 This is standard practice despite the lack of formal guidelines, reflecting the theoretical risk during the immediate peri-procedural period when the device is being implanted.

Procedures That Do NOT Require Prophylaxis

• Diagnostic cardiac catheterization does not require routine prophylaxis, as infective endocarditis as a complication is exceedingly rare 1, 2
• Gastrointestinal or genitourinary procedures do not require prophylaxis solely to prevent endocarditis 1
• Respiratory tract procedures (unless involving incision of respiratory mucosa) do not require prophylaxis 2

Critical Context and Evidence Quality

The evidence base for antibiotic prophylaxis effectiveness is weak, with no randomized controlled trials demonstrating significant protective effect. 1, 4 A UK study of 373 children found no change in infective endocarditis incidence after cessation of prophylaxis guidelines, though this remains the strongest pediatric study available. 1

Despite weak evidence, prophylaxis is still recommended for the first 6 months post-device closure because:

• The mortality and morbidity from infective endocarditis in children with prosthetic material is severe 2
• The 6-month window represents the period before complete endothelialization 1
• The risk-benefit ratio favors prophylaxis during this vulnerable period 2

Emphasis on Oral Hygiene

Daily oral hygiene and regular dental care are likely more important than single-dose prophylaxis in preventing endocarditis. 1, 5 The 2015 American Heart Association guidelines recommend shifting focus from disproportionate emphasis on antibiotic prophylaxis to oral hygiene and prevention of oral disease. 1

Common Pitfalls to Avoid

• Do not continue prophylaxis indefinitely after 6 months if the device is completely endothelialized with no residual defects 1
• Do not use cephalosporins in patients with severe penicillin allergies (anaphylaxis, angioedema, urticaria) due to cross-reactivity 1, 3
• Do not provide prophylaxis for non-dental procedures (GI/GU) as this is no longer recommended 1
• Do not forget to assess for residual defects at the 6-month mark via echocardiography, as this determines whether prophylaxis should continue 1