Inappropriate antibiotic prophylaxis before dental procedures in congenital heart disease: Insights from a nationwide Korean cohort

Background: The 2007 American Heart Association (AHA) guidelines strictly restrict antibiotic prophylaxis (AP) before dental procedures to patients at the highest risk of infective endocarditis (IE). However, national adherence to these guidelines in Korea, a country with high outpatient antibiotic use, remains unevaluated. Methods: This population-based, retrospective cohort study using National Health Insurance Service System claims (2002–2022) included patients with atrial septal defect, ventricular septal defect, tetralogy of Fallot, or prosthetic cardiac valves. Dental claims within 14 days were clustered into one encounter. AP was defined as amoxicillin dispensed within 7 days (same day included) before the index visit, with an identical daily and single-dose IE prophylaxis regimen. Guideline adherence was assessed from January 1, 2008 onward (AP was appropriate only for invasive procedures performed during a high-risk period). Predictors of inappropriate AP were examined using multivariable logistic regression. Results: Of 35,386 dental visits by 14,257 patients, 59.6 % were invasive procedures. AP was appropriate in 7491 visits (21.2 %) and inappropriate in 27,895 (78.8 %). Inappropriate prescriptions clustered in patients aged < 20 years (76.1 %) and during moderate- (51.4 %) or low-risk periods (38.9 %). Inappropriate use decreased from 86.6 % in 2008–2012–72.9 % in 2018–2022. Independent predictors of inappropriate AP included age < 5 years (adjusted odds ratio [aOR] 3.78) and 5–19 years (aOR 5.84); female sex (aOR 1.41); clinic setting (aOR 1.75 vs. tertiary hospitals); and pediatric dentistry (aOR 1.76) or pediatric prescriptions (aOR 1.21). Thoracic surgery providers were least likely to prescribe inappropriately (aOR 0.35). Conclusions: A high proportion of dental AP prescriptions for Korean patients with CHD are still inappropriate according to the 2007 AHA guideline, particularly among pediatric populations and in primary-care clinics. Targeted stewardship—focused on pediatric dentists and clinic settings—is imperative to curb unnecessary antibiotic exposure while preserving prophylaxis for truly high-risk patients.