Regional Divergence in Infective Endocarditis Prophylaxis: A Multi-center Analysis of Clinical Practice vs. International Guidelines from the Pan Arab Congenital Heart Disease Association (PACHDA)

Current infective endocarditis (IE) prophylaxis guidelines recommend a restrictive approach, excluding low-risk lesions such as patent ductus arteriosus, isolated ventricular septal defect, and valvular stenosis. In many countries, delayed cardiac defect repair and a high prevalence of dental disease may create a distinct risk profile that warrants further investigation. The Pan Arab Congenital Heart Disease Association (PACHDA) conducted a multinational cross-sectional online survey targeting cardiovascular specialists to evaluate perceptions of IE prophylaxis guidelines, adherence patterns, and the influence of oral health and socioeconomic factors on clinical decision-making. Statistical analyses included Spearman rank correlation, Chi-square testing, Fisher's exact test, and qualitative thematic synthesis. The questionnaire was completed by 72 specialists, of whom only 25% reported strict adherence to restrictive international guidelines for isolated simple congenital heart defects. Respondents who identified socioeconomic barriers (e.g., poverty and limited access to dental care) as a primary concern were more likely to deviate from restrictive guideline recommendations than their peers (83.7% vs. 41.4%; p = 0.001). Clinicians with higher IE case exposure (> 5 IE cases in the preceding 5 years) also demonstrated significantly greater rates of guideline deviation (p = 0.047). Fewer than 50% of respondents considered current AHA/ESC guidelines "fit for purpose" in their local practice. Many cardiovascular specialists across the Arab/MENA region perceive current international IE prophylaxis recommendations as insufficiently reflective of local clinical and socioeconomic realities. However, these findings represent clinician perceptions and practice patterns rather than patient-level outcomes and should therefore be considered hypothesis-generating. The observed divergence between guideline recommendations and clinical practice highlights the need for regional epidemiological and outcome-based studies to determine whether local factors influence IE risk and whether adaptation of current prophylaxis strategies is warranted.