Congenital heart defect:
Does your child need prophylactic antibiotics?

My son is three years old and had a heart operation (VSD repair) when he was eight months old. He is doing well. Does he really have to take antibiotics for every single illness or procedure that comes down the pike?

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Robert Steele

Robert W. Steele, MD, is a board certified pediatrician at St. John's Regional Health Center in Springfield, MO. He graduated from medical... Read more

I am happy to hear of your son's successful heart operation, and that he is doing well.

As you know, children with congenital heart defects are at greater risk for developing infections of the heart. When an infection of the heart occurs, called endocarditis, it is always fatal if not treated. And even if treated promptly, the infection can cause substantial damage to the heart. Therefore, a lot of emphasis has been placed upon trying to prevent endocarditis from occurring in the first place.

The reasoning behind the liberal use of antibiotics in these children goes something like this:

  1. We know that endocarditis is caused by bacteria.
  2. This bacteria has to get to the heart in some manner which is usually by the bloodstream
  3. There are certain procedures and situations that make the likelihood of bacteria getting into the bloodstream greater.
  4. By giving antibiotics before and during these procedures, we can decrease the chance of live bacteria reaching the heart and causing endocarditis.

However, in the face of all the news of resistant bacteria due to the overuse of antibiotics, where does this leave us when it comes to the recommendations of antibiotics in these special children? Essentially, the use of antibiotics comes down to weighing the risks and benefits.

There are certain heart conditions that place the person at higher risk of developing endocarditis. Here is a sample of those defects and their risk:

Heart Disorders Which Have a High Risk of Developing Endocarditis

Any heart defect which makes the baby blue
Ventricular Septal Defect (VSD)
Coarctation of the aorta
Previous heart surgery in which a patch or foreign material was used in the repair
Patent ductus arteriosis (PDA)
Heart surgery which did not completely correct the defect

Heart Disorders Which Have an Intermediate Risk of Developing Endocarditis

Pulmonary stenosis
Heart surgery <6 months ago in which the repair was complete or almost complete

Heart Disorders Which Have a Very Low Risk if Any of Developing Endocarditis

Heart surgery >6 months ago in which the repair was complete or almost complete

In addition, there are certain procedures that put the person more at risk for getting bacteria in the bloodstream. Here are a few procedures done in children and their risk of introducing bacteria into the bloodstream:
Oral surgery - 88%
Tooth extraction - 60%
Tonsillectomy - 35%

Based upon what we know the risks are, the American Heart Association has come out with recommendations of when children with heart defects ought to receive antibiotics. However, it is interesting to note the procedures in which routine antibiotics are NOT recommended. These include ear tube insertion and when the primary teeth fall out.

Everyone gets bacteria in the blood at one time or another. Interestingly, each time we brush our teeth, we run a 40% chance of introducing bacteria into the bloodstream. Usually, we have no trouble killing these bacteria on our own. However, certain heart defects may allow for the bacteria to get stuck in the heart, multiply easily, and cause illness. Therefore, each time a child who has or had a heart defect gets an illness or has a procedure done, the risk of that illness or procedure introducing bacteria into the bloodstream has to be assessed. And despite the risk of resistant bacteria, antibiotics are a better option for certain children with current or previous heart defects. Luckily, most illnesses in children are caused by viruses, not bacteria, so these do not require antibiotics. In addition, there are many heart defects where once repaired, do not require special consideration during illnesses or procedures. According to the American Heart Associations recommendations, a person who has had a successfully complete VSD repair and is six months past the surgery, does not require special treatment with respect to antibiotics.

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