Surgical antibiotic prophylaxis in children: adherence to indication, choice of agent, timing, and duration

Study of the Practice of Surgical Antibiotic Prophylaxis Use for Elective Neurosurgical Cases in a Tertiary Hospital and Understanding the Rationale

BACKGROUND

This study aims to evaluate the adherence to surgical antibiotic prophylaxis (SAP) guidelines in elective neurosurgery and assess the impact on surgical site infection (SSI) rates in a tertiary teaching hospital in Malaysia.

METHOD

A retrospective review was conducted on patients who underwent elective neurosurgical procedures from January 1, 2021, to December 31, 2021, in a 1600-bed tertiary teaching hospital. The study assessed adherence to national and hospital SAP guidelines, focusing on the choice of antibiotic, dosage, timing, and duration. Additionally, a survey was conducted among neurosurgeons to evaluate their knowledge, attitudes, and practices regarding SAP.

RESULT

Out of 202 patients included, there was a 99% compliance rate with antibiotic choice and 69.8% with the antibiotic duration. The SSI rate was identified at 6.4%. The knowledge, attitudes, and practices survey highlighted a strong awareness of SAP guidelines among surgeons, albeit with variations in practice, particularly in antibiotic duration and choice of antibiotics.

CONCLUSIONS

While there is high adherence to the correct choice of antibiotic for SAP in elective neurosurgery, there are gaps in compliance with the recommended duration of antibiotic use. The study highlights the need for targeted interventions to improve adherence to SAP guidelines, which could potentially reduce the incidence of SSI in neurosurgery. Ongoing education and auditing are essential to optimize SAP practices and enhance patient outcomes in neurosurgery.

Quantifying Procedure-level Prophylaxis Misutilization in Pediatric Surgery: Implications for the Prioritization of Antimicrobial Stewardship Efforts

OBJECTIVE

To quantify procedure-level inappropriate antimicrobial prophylaxis utilization as a strategy to identify high-priority targets for stewardship efforts in pediatric surgery.

BACKGROUND

Little data exist to guide the prioritization of antibiotic stewardship efforts as they relate to prophylaxis utilization in pediatric surgery.

METHODS

This was a retrospective cohort analysis of children undergoing elective surgical procedures at 52 children's hospitals from October 2015 to December 2019 using the Pediatric Health Information System database. Procedure-level compliance with consensus guidelines for prophylaxis utilization was assessed for indication, antimicrobial spectrum, and duration. The relative contribution of each procedure to the overall burden of noncompliant cases was calculated to establish a prioritization framework for stewardship efforts.

RESULTS

A total of 56,845 cases were included with an overall inappropriate utilization rate of 56%. The most common reason for noncompliance was unindicated utilization (43%), followed by prolonged duration (32%) and use of excessively broad-spectrum agents (25%). Procedures with the greatest relative contribution to noncompliant cases included cholecystectomy and repair of inguinal and umbilical hernias for unindicated utilization (63.2% of all cases); small bowel resections, gastrostomy, and colorectal procedures for use of excessively broad-spectrum agents (70.1%) and pectus excavatum repair and procedures involving the small and large bowel for prolonged duration (57.6%). More than half of all noncompliant cases were associated with 5 procedures (cholecystectomy, small bowel procedures, inguinal hernia repair, gastrostomy, and pectus excavatum).

CONCLUSIONS

Cholecystectomy, inguinal hernia repair, and procedures involving the small and large bowel should be considered high-priority targets for antimicrobial stewardship efforts in pediatric surgery.

Procedure-level Misutilization of Antimicrobial Prophylaxis in Pediatric Surgery: Implications for Improved Stewardship and More Effective Infection Prevention

BACKGROUND

The objective of this study was to quantify prophylaxis misutilization to identify high-priority procedures for improved stewardship and SSI prevention.

METHODS

This was a multicenter analysis including 90 hospitals participating in the NSQIP-Pediatric Antibiotic Prophylaxis Collaborative from 6/2019 to 6/2020. Prophylaxis data were collected from all hospitals and misutilization measures were developed from consensus guidelines. Overutilization included use of overly broad-spectrum agents, continuation of prophylaxis >24 h after incision closure, and use in clean procedures without implants. Underutilization included omission (clean-contaminated cases), use of inappropriately narrow-spectrum agents, and administration post-incision. Procedure-level misutilization burden was estimated by multiplying NSQIP-derived misutilization rates by case volume data obtained from the Pediatric Health Information System database.

RESULTS

9861 patients were included. Overutilization was most commonly associated with overly broad-spectrum agents (14.0%), unindicated utilization (12.6%), and prolonged duration (8.4%). Procedure groups with the greatest overutilization burden included small bowel (27.2%), cholecystectomy (24.4%), and colorectal (10.7%). Underutilization was most commonly associated with post-incision administration (6.2%), inappropriate omission (4.4%), and overly narrow-spectrum agents (4.1%). Procedure groups with the greatest underutilization burden included colorectal (31.2%), gastrostomy (19.2%), and small bowel (11.1%).

CONCLUSION

A relatively small number of procedures account for a disproportionate burden of antibiotic misutilization in pediatric surgery.

TYPE OF STUDY

Retrospective Cohort.

LEVEL OF EVIDENCE

III.

Correlation Between Postoperative Antimicrobial Prophylaxis Use and Surgical Site Infection in Children Undergoing Nonemergent Surgery

Importance

Use of postoperative antimicrobial prophylaxis is common in pediatric surgery despite consensus guidelines recommending discontinuation following incision closure. The association between postoperative prophylaxis use and surgical site infection (SSI) in children undergoing surgical procedures remains poorly characterized.

Objective

To evaluate whether use of postoperative surgical prophylaxis is correlated with SSI rates in children undergoing nonemergent surgery.

Design, Setting, and Participants

This is a multicenter cohort study using 30-day postoperative SSI data from the American College of Surgeons' Pediatric National Surgical Quality Improvement Program (ACS NSQIP-Pediatric) augmented with antibiotic-use data obtained through supplemental medical record review from June 2019 to June 2021. This study took place at 93 hospitals participating in the ACS NSQIP-Pediatric Surgical Antibiotic Prophylaxis Stewardship Collaborative. Participants were children (<18 years of age) undergoing nonemergent surgical procedures. Exclusion criteria included antibiotic allergies, conditions associated with impaired immune function, and preexisting infections requiring intravenous antibiotics at time of surgery.

Exposures

Continuation of antimicrobial prophylaxis beyond time of incision closure.

Main Outcomes and Measures

Thirty-day postoperative rate of incisional or organ space SSI. Hierarchical regression was used to estimate hospital-level odds ratios (ORs) for SSI rates and postoperative prophylaxis use. SSI measures were adjusted for differences in procedure mix, patient characteristics, and comorbidity profiles, while use measures were adjusted for clinically related procedure groups. Pearson correlations were used to examine the associations between hospital-level postoperative prophylaxis use and SSI measures.

Results

Forty thousand six hundred eleven patients (47.3% female; median age, 7 years) were included, of which 41.6% received postoperative prophylaxis (hospital range, 0%-71.2%). Odds ratios (ORs) for postoperative prophylaxis use ranged 190-fold across hospitals (OR, 0.10-19.30) and ORs for SSI rates ranged 4-fold (OR, 0.55-1.90). No correlation was found between use of postoperative prophylaxis and SSI rates overall (r = 0.13; P = .20), and when stratified by SSI type (incisional SSI, r = 0.08; P = .43 and organ space SSI, r = 0.13; P = .23), and surgical specialty (general surgery, r = 0.02; P = .83; urology, r = 0.05; P = .64; plastic surgery, r = 0.11; P = .35; otolaryngology, r = -0.13; P = .25; orthopedic surgery, r = 0.05; P = .61; and neurosurgery, r = 0.02; P = .85).

Conclusions and Relevance

Use of postoperative surgical antimicrobial prophylaxis was not correlated with SSI rates at the hospital level after adjusting for differences in procedure mix and patient characteristics.

Improving knowledge on safe medication management of inpatient children and adolescents: a pre-post study

OBJECTIVE

The primary aim of this study was to assess the impact of an education intervention on knowledge regarding medication use in hospitalized children and adolescents.

METHODS

A pre-post multicentre study was conducted in pediatric wards of the hospitals in Lazio Region between July 2019-March 2021. An in-person education intervention was provided to hospitalized patients aged 6-15 years, able to understand spoken and written Italian language. Topics included: correct intake and management of medications at home. Prior and after the education intervention, we evaluated patient knowledge with a self-administered test.

RESULTS

One-hundred-and-four (n = 104) patients participated in the study. In the pre-education period, 79.8% of the patients answered correctly to at least 60% of the questions of the test; the lowest number of correct answers concerned medication intake (36.5%; 33.6%), food-drug interactions (44.2%), appropriate indication to use of antibiotics (36.5%) and antibiotic resistance (55.8%). After the education intervention, 100% of the patients completed the test correctly.

CONCLUSION

The education intervention increased knowledge on several areas of interest, in children of different age-groups and including patients with chronic diseases.

PRACTICE IMPLICATIONS

Children's education is essential to encourage gradual transfer of responsibility for medication use, in ways that respect parental responsibilities and the health status and capabilities of the child.

Audit of pre-operative antibiotic prophylaxis usage in elective surgical procedures in two teaching hospitals, Islamabad, Pakistan: An observational cross-sectional study

An audit of the antibiotic prophylaxis in surgical procedures is the basic area of antimicrobial stewardship programme. The current research aimed to evaluate the adherence-proportion of the pre-operative antibiotic prophylaxis (PAP) practices in common elective surgical procedures. It was an eight-month (January 2017 to August 2017) observational cross-sectional patients’ treatment record-based study conducted at two tertiary care teaching hospitals of Islamabad, Pakistan. We investigated the three most commonly performed elective general surgical procedures at the hospitals in adults aged > 18 years with no previous infection or surgery. The required data were extracted from the medical charts. Current prescribing practices were compared with the standard prescribing guidelines. A total of 660 (Government Hospital (GH), n = 330 and Private Hospital (PH), n = 330) procedures were observed. The most commonly performed elective general surgical procedures were laparoscopic cholecystectomy 307/660 (46.5%), followed by direct inguinal hernia 197/660 (29.8%) and total thyroidectomy 156/660 (23.6%). Non-use of PAP was observed in 64/660 (9.7%) cases. PAP was given to 90.3% (n = 596/660) cases (300/330 (90.9%) patients in GH and 296/330 (89.7%) in PH; P = 0.599). Based on the existing guidelines, the choice of antibiotics was correct in only 4.2% (25/596) patients (10/300; 3.3% cases at GH and 15/296; 5% at PH). The appropriate use of antibiotics was significantly greater in direct inguinal hernia (n = 19/193; 9.8%) cases compared with that in total thyroidectomy (n = 4/152; 2.6%) and laparoscopic cholecystectomy (n = 2/251; 0.8%) cases; P = 0.001. Compliance to the timing was only 51% (n = 304/596) of the total patients received PAP which was significantly lower in GH 97/300 (32.3%) as compared with that in PH 207/296 (69.9%); P = 0.001. Administration timing of antibiotics was observed to be more appropriate in total thyroidectomy (n = 79/152; 51.9%) cases than in laparoscopic cholecystectomy (n = 130/251; 51.8%) and direct inguinal hernia (n = 95/193; 49.2%) cases; P = 0.001. The route and dose were appropriate in accordance with the guidelines in all cases (100%). Most of the patients received ceftriaxone, a third-generation cephalosporin that is no longer recommended by the latest international guidelines. The current analysis revealed an alarmingly poor adherence rate with the guidelines in the three elective surgical procedures at both hospitals. To improve the situation, training and awareness programs about the antimicrobial stewardship interventions on the institutional level may be valuable.

Assessment of Surgical Antibiotic Prophylaxis Compliance in Pediatrics: A Pre-post Quasi-experimental Study

OBJECTIVE

Data from rigorous evaluations of the impact of interventions on improving surgical antibiotic prophylaxis (SAP) compliance in pediatrics are lacking. Our objective was to assess the impact of a multifaceted intervention on improving pediatric SAP compliance in a hospital without an ongoing antimicrobial stewardship program.

STUDY DESIGN

A multidisciplinary team at the Montreal Children's Hospital performed a series of interventions designed to improve pediatric SAP compliance in June 2015. A retrospective, quasi-experimental study was performed to assess SAP compliance before and following the interventions. Our study included patients under 18 years old undergoing surgery between April and September in 2013 (preintervention) and in 2016 (postintervention). A 10-week washout period was included to rigorously assess the persistence of compliance without ongoing interventions. SAP, when indicated, was qualified as noncompliant, partially compliant (adequate agent and timing) or totally compliant (adequate agent, dose, timing, readministration, duration).

RESULTS

A total of 982 surgical cases requiring SAP were included in our primary analysis. The composite partial and total compliance increased from 51.4% to 55.8% [adjusted odds ratio 1.3; 95% confidence interval: 1.0-1.8; P = 0.06]. Although improvements in correct dose and readministration were significant, there was no significant improvement in correct timing, agent selection or duration.

CONCLUSION

Our study demonstrated that overall SAP compliance did not significantly improve following a washout period, illustrating the importance of ongoing surveillance and feedback from an antimicrobial stewardship program. Our strict approach in evaluating the timing criterion may also explain the lack of a significant impact on SAP compliance.

Adherence to surgical antibiotic prophylaxis guidelines in children: A cohort study

AIMS

Surgical antimicrobial prophylaxis (SAP) is an important measure to reduce post-operative infections. Guidelines exist, but their efficacy and performance in children is poorly understood compared with adults. To review adherence to SAP guidelines, this study assesses risk factors for non-adherence and rate of early post-surgical infections.

METHODS

A retrospective cohort study of paediatric surgical cases (0-<18 years) at a tertiary children's hospital was performed. Patient characteristics, surgical factors and antimicrobial details were evaluated against hospital guidelines for overall adherence and domains of: antimicrobial choice, dose, re-dosing, timing and duration. Multiple regression analysis was used to determine risk factors for non-adherence. Hospital records were reviewed for post-operative infections at 7 and 30 days.

RESULTS

Among 326 cases, overall guideline adherence was 39.6% but varied by domain and surgical subspecialty. Incorrect wound classification was associated with overall non-adherence on multivariate regression (odds ratio (OR): 2.59; P < 0.001). Incorrect antimicrobial choice was more likely in children with penicillin hypersensitivity (OR 138.34, P = 0.004) and incorrect dosing more likely in adolescent patients (OR 4.33; P = 0.004). Presence of invasive devices was associated with prolonged duration of antimicrobials (OR 2.92, P = 0.016). Only two post-operative infections were documented by 30 days, but data were insufficient to exclude mild infections managed in the community.

CONCLUSIONS

SAP was suboptimal in children, with areas for improvement including better guidance on wound classification, allergy management and care for adolescent patients. Documented infections were rare, but mild infections were unable to be excluded due to limited post-discharge information.

Trends in the use of surgical antibiotic prophylaxis in general pediatric surgery: Are we missing the mark for both stewardship and infection prevention?

BACKGROUND

The purpose of this study was to assess compliance with antimicrobial spectrum guidelines in the use of surgical antibiotic prophylaxis (SAP) in pediatric surgery.

METHODS

A retrospective cohort study of children undergoing elective clean-contaminated and clean surgical procedures with foreign body implantation using the Pediatric Health Information System database (10/2015-6/2018) was performed. Compliance rates with consensus guidelines surrounding appropriate spectrum of SAP coverage were calculated for each procedure. Undertreatment was defined as the use of SAP with inappropriately narrow coverage (or omission altogether), while overtreatment was defined as inappropriately broad coverage.

RESULTS

Eight procedure groups including a total of 15,708 patients were included. Overall, 44% of cases received inappropriate prophylaxis, of which 58% were considered undertreatment and 42% overtreatment. Procedures with the highest rates of overtreatment included small bowel procedures (77%), colorectal procedures (29%), and hepatobiliary procedures (20%), while the highest rates of undertreatment were associated with placement of tunneled central venous catheters and ports (43%), hepatobiliary procedures (24%), and colorectal procedures (20%).

CONCLUSION

Noncompliance with the recommended spectrum of coverage for surgical antibiotic prophylaxis is common in pediatric surgery, with both over and undertreatment being common themes. Improved compliance is needed to optimize both antibiotic stewardship and infection prevention.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

Level III.

Surgical antimicrobial prophylaxis and its dose appropriateness among paediatric patients in a Nigerian teaching hospital

Surgical antimicrobial prophylaxis (SAP) prevents incision site infection. We assessed SAP compliance with existing international guidelines, evaluated the appropriateness of the antimicrobial doses, and determined the risk factors for antimicrobial under-dosing. A retrospective chart review was performed for patients who under-went surgery and administered antimicrobial prophylaxis. Compliance with SAP guidelines was evaluated. Antimicrobial doses were categorized as under-, normal-, or over-dose. Of the 303 surgical patients, 97.7% received SAP and complete compliance was achieved in 5.6%. Of the 550 antimicrobial prescriptions, metronidazole (42.7%) and cefuroxime (34.7%) were the most prescribed. Over- (31.5%), under- (44.5%), and normal- dosing (24.0%) were recorded, respectively. None of the factors evaluated predicted the risk of antimicrobial under-dosing. Full compliance with international SAP guidelines was poor in our study. Correct timing, re-dosing, and duration of antimicrobial use were the most violated. Most antimicrobials were under-dosed, suggesting a need for national and institutional SAP guidelines.

Prevalence of antibiotic use in a tertiary care hospital in Italy, 2008-2016

BACKGROUND

Few data are available about temporal trends of antibiotic use in hospitalized children. The aim of the current study was to investigate the pattern and trends of antibiotic use over the years 2008-2016 in the largest children's hospital in Italy.

METHODS

Annual point prevalence surveys of antibiotic use were conducted by reviewing medical charts of 0-17 year-old children hospitalized for ≥48 h. Prevalence of antibiotic use was computed by year, type of ward and indication. Trends in prevalence over time were evaluated using the Cochrane-Armitage test. Possibile determinants of antibiotic use were assessed at univariate analysis and through a logistic regression model.

RESULTS

Out of 3015 children, 1516 (50.3%) received antibiotics, 58.1% of which for medical/surgical prophylaxis. Prevalence of antibiotic use increased from 42.0% in 2008 to 56.2% in 2016 (p = 0.001). The prevalence of patients receiving antibiotics for medical prophylaxis increased from 6.1% in 2008 to 24.2% in 2016 (p < 0.001), whereas the prevalence of patients receiving antibiotics for surgical prophylaxis significantly decreased (from 13.7 to 11.8%; p = 0.04); no significant temporal trends were found in antibiotic use for treating infections. The administration of third-generation cephalosporins for surgical and medical prophylaxis significantly decreased over time, while the proportion of antibiotics prescribed to treat infections after microbiological investigations significantly increased. Year (ORadj: 1.8 in 2016 compared to 2008, p < 0.001), age (ORadj ≥1.5 in children ≥1 year, compared to infants ≤2 months, p < 0.001), length of stay (LOS) (ORadj: 1.4 in case of LOS between 8 and 30 days compared to LOS ≤ 7 days, p < 0.001), and type of ward (ORadj: ≥1.3 in intensive-care, surgical and medical-subspecialty units compared to medical units, p < 0.001) were significantly and independently associated with antibiotic use.

CONCLUSIONS

Comparing prevalence rates of antibiotic use among hospitals and over time should consider differences in patient characteristics, such as age, ward of hospitalization and length of stay. Over the years, we documented an improvement in the choice of antibiotics prescribed for medical and surgical prophylaxis. However, further efforts are needed to avoid antibiotic misuse for medical prophylaxis, and to reduce the empirical use of broad spectrum antibiotics.

Surgical Antimicrobial Prophylaxis Among Pediatric Patients in South Africa Comparing Two Healthcare Settings

BACKGROUND

Appropriate use of surgical antimicrobial prophylaxis (SAP) is a concern in view of its impact on morbidity, mortality and costs. Little is currently known about SAP in South Africa.

OBJECTIVE

To assess compliance to SAP guidelines for pediatric patients undergoing surgery in 1 of 4 surgical subspecialties among hospitals in South Africa.

METHODS

An eight-month retrospective chart review in both a teaching hospital and a private hospital between February and August 2015. Prescriptions of antimicrobials as SAP were compared with current SAP Guidelines, consolidated from a literature review, regarding 5 criteria-appropriate antimicrobial selection, dosing, timing of administration, redosing and duration of treatment.

RESULTS

We reviewed 224 charts, 112 from each hospital type. The majority (P = 1.000) of patients received SAP when indicated (77.3% and 100.0%, respectively, from the teaching and private hospitals). A noteworthy 21.1% and 45.9% of patients received antimicrobials without an indication, respectively, from teaching and private hospitals. Compliance to all 5 of the criteria was not met by either hospital type. Overall, the teaching hospital met the most criteria (3 out of 5) in 58.8% of situations.

CONCLUSIONS

Current SAP practices in South Africa's teaching and private hospitals diverge from current SAP Guidelines. Inappropriate overuse of SAP occurs in both hospital sectors, while underuse was found in the teaching hospital. Full compliance to the 5 criteria was not met by either hospital. Noncompliance was largely attributed to inappropriate selection and dosing. Quality improvement interventions, continued surveillance and local standardized evidence-based SAP Guidelines are needed to improve care. This is already happening.

Prophylactic antibiotics in pediatric neurological surgery

PURPOSE

Surgical antibiotic prophylaxis (SAP) in pediatric neurosurgery has poorly been characterized until now. This review gives an overview on the current literature extracting recommendations and guidelines.

METHODS

The current literature on SAP with special forcus on pediatric neurosurgerical procedures was reviewed. Further, available recommendations in online databases were checked. Clean neurosurgical, shunt, and implant surgeries are considered separately.

RESULTS

To date, evidence-based data on SAP in pediatric neurosurgery remain sparse and there are no standardized approaches to an adequate use of antimicrobial agents for SSI prevention for this age group.

CONCLUSION

Due to statistical needs, multi-center surveillance studies are needed for implementing SAP recommendations in pediatric neurosurgery.

Pattern of antibiotics use, incidence and predictors of surgical site infections in a Tertiary Care Teaching Hospital

Objective

Surgical site infections (SSIs) were the most common healthcare-associated infection mainly in developing countries. Inappropriate use of surgical antibiotic prophylaxis, in terms of antibiotic choice, timing, and duration, can lead to the selection of resistant microorganisms and high costs. The aim of this study was to investigate the pattern of antibiotic use, incidence and predictors of SSIs at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia.

Results

From 131 patients, 55.7% were male study participants. Ninety (68.7%) patients received preoperative prophylaxis. Ceftriaxone was the most 76 (84.5%) prescribed agent for prophylaxis. Twenty-seven (20.6%) patients developed surgical site infection. Previous surgery AOR = 3.22 (95% CI [1.14–9.13]) and alcohol use AOR = 7.04 (95% CI [2.56–23.12, p = 0.000]) were independent predictors of SSIs in multivariate logistic regression analysis.

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3643-8) contains supplementary material, which is available to authorized users.

Is surgical antibiotic prophylaxis necessary for pediatric orchiopexy?

INTRODUCTION

Surgeons frequently use surgical antibiotic prophylaxis (SAP), despite limited evidence to support its efficacy. Potential adverse events associated with antibiotic use include allergic reaction (including anaphylaxis), Clostridium difficile infection, and selecting for resistant bacteria. Surgical site infections (SSI) are very rare in patients undergoing clean pediatric urologic procedures. Current guidelines are unclear about the efficacy of surgical antibiotic prophylaxis for prevention of SSI in the pediatric population.

OBJECTIVE

It was hypothesized that children who received SAP prior to orchiopexy would have no reduction in surgical site infection (SSI) risk but an increased risk of antibiotic-associated adverse events.

METHODS

A retrospective cohort study was conducted of all males aged between 30 days and 18 years who underwent an orchiopexy (ICD-9 CM 62.5) in an ambulatory or observation setting from 2004 to 2015 using the Pediatric Health Information System database. Inpatients and those with concomitant procedures were excluded. Chi-squared or Fisher's exact tests were used to determine the association between SAP and allergic reaction (defined as a charge for epinephrine or ICD-9 diagnosis code for allergic reaction on the date of surgery) and any of the following within 30 days: SSI, hospital readmission or any repeat hospital encounter. Mixed effects logistic regression was performed, controlling for age, race, and insurance, and clustering of similar practice patterns by hospital.

RESULTS

A total of 71,767 patients were included: median age was 4.6 years, 61.4% were white, and 49.3% had public insurance; 33.5% received SAP. Of these participants, 996/71,767 (1.4%) had a perioperative allergic reaction and <0.1% were diagnosed with an SSI. On mixed effects logistic regression, those who received SAP had 1.2 times the odds of a perioperative allergic reaction compared with those who did not receive SAP (P = 0.005). Surgical antibiotic prophylaxis was not associated with decreased rates of SSI, lower hospital readmission, nor a lower chance of a repeat encounter within 30 days.

CONCLUSIONS

In patients undergoing orchiopexy, it was found that SAP did not reduce the risk of postoperative SSI, readmissions, or hospital visits. Patients who received SAP had significantly increased odds of perioperative allergic reaction. This demonstrated that the risks of SAP outweigh the benefits in children undergoing orchiopexy.

Monitoring adherence to guidelines of antibiotic use in pediatric pneumonia: the MAREA study

Background

Children are the most vulnerable population exposed to the use of antibiotics often incorrectly prescribed for the treatment of infections really due to viruses rather than to bacteria. We designed the MAREA study which consisted of two different studies: i) a surveillance study to monitor the safety/efficacy of the antibiotics for the treatment of pneumonia (CAP), pharyngotonsillitis and acute otitis media in children younger than 14 yrs old, living in Liguria, North-West Italy and ii) a pre−/post-interventional study to evaluate the appropriateness of antibiotic prescription for the treatment these infections. In this paper, we show only results of the appropriateness study about the antibiotic prescription for the treatment of pneumonia.

Methods

Patients included in this study met the following inclusion criteria: i) admission to the Emergency/Inpatient Dpt/outpatient clinic of primary care pediatricians for pneumonia requiring antibiotics, ii) informed written consent. The practice of prescribing antibiotics was evaluated before-and-after a 1 day-educational intervention on International/National recommendations.

Results

Global adherence to guidelines was fulfilled in 45%: main reason for discordance was duration (shorter than recommended). Macrolide monotherapy and cephalosporins were highly prescribed; ampicillin/amoxicillin use was limited. 61% of patients received >1 antibiotic; parenteral route was used in 33%. After intervention, i) in all CAP, cephalosporin prescription decreased (−23%) and the inappropriate macrolide prescriptions was halved and, ii) in not hospitalized CAP (notH-CAP), macrolides were prescribed less frequently (−25%) and global adherence to guidelines improved (+39%); and iii) in H-CAP antibiotic choice appropriateness increase.

Conclusion

Prescribing practices were sufficiently appropriate but widespread preference for multidrug empirical regimens or macrolide in monotherapy deserve closer investigation.

A collaborative intervention to improve surgical antibiotic prophylaxis in children: results from a prospective multicenter study

PURPOSE

The use of surgical antibiotic prophylaxis (SAP) in children is poorly characterized. Our aim was to evaluate the effectiveness of a quality improvement (QI) intervention targeting SAP in children, by means of a multicenter prospective intervention study, with a before and after design.

METHODS

We prospectively investigated elective surgical procedures performed in children <18 years, prior to the QI intervention, after the intervention and at 9-month follow-up. The primary outcomes were adherence to SAP indications and SAP appropriateness, defined considering antibiotic choice, timing of first dose and duration of administration. We compared SAP adherence and appropriateness prior the QI intervention, to the post-intervention and the follow-up. We considered patient and procedure characteristics as covariates in two logistic regression models to assess the effect of the QI intervention on SAP adherence and appropriateness.

RESULTS

We collected information on 2383 procedures (pre-intervention: 784; post-intervention: 790; follow-up: 809). The QI intervention had a significant impact on the adherence to SAP indications (86.6% in the post-intervention, compared to 82.0% prior to the intervention; p < 0.05), and on its appropriateness (35.7% compared to 19.9%; p < 0.01). The impact of the intervention on SAP appropriateness was maintained at follow-up (38.3%; p < 0.01 compared to pre-intervention). All components of SAP appropriateness significantly improved after the intervention and at follow-up. The logistic regression analyses confirmed the effect of intervention in improving adherence to SAP indications and appropriateness.

CONCLUSIONS

Following the QI intervention, there was a significant improvement in quality of SAP in pediatric surgery, though more efforts are needed to increase SAP appropriateness.

Appropriateness of Surgical Antibiotic Prophylaxis in Pediatric Patients in Italy

OBJECTIVES

Appropriate use of surgical antibiotic prophylaxis (SAP) reduces intraoperative wound contamination in pediatric surgery, thus minimizing the risk of surgical site infection (SSIs). Conversely, inappropriate use of SAP exposes patients to the risk of antibiotic side effects and contributes to the emergence of antimicrobial resistance. Our aims were to describe SAP administration and to analyze factors associated with nonadherence in pediatric patients.

DESIGN

Descriptive study.

SETTING

Overall, 955 pediatric patients underwent 1,038 surgical procedures.

METHODS

We assessed adherence to SAP international guidelines for surgical procedures performed on children aged <18 years in 2015 in 4 randomly selected hospitals in Calabria (Italy). The clinical records of these patients were retrospectively reviewed.

RESULTS

Appropriate SAP administration or nonadministration pertained to 754 surgical procedures (72.6%). Surgical antibiotic prophylaxis was administered in 88.5% of 358 procedures with an SAP indication. Adherence to guidelines for appropriate drug choice were followed in 5.7% of cases, for route of administration in 76.7% of cases, for timing in 48.6% of cases, for duration in 14.5% of cases, and for dose in 91.5% of cases, and for all components in only 5 cases (1.6%). Among 680 procedures without SAP indication, 35.7% case patients received antibiotics. Inappropriate administration of antibiotics in procedures without SAP indication was associated with surgical specialty wards (P=.008), ordinary admission (P<.001), head and neck surgical procedures (P=.020), clean surgery (P=.017), and surgical duration (P=.010).

CONCLUSIONS

Discrepancies between SAP guidelines and actual practice behavior more frequently indicate excessive use of antibiotics than underuse. Increased awareness of SAP guidelines is required.

Infect Control Hosp Epidemiol 2017;38:823–831

Perioperative antibiotic use in vagus nerve stimulator implantation: a clinical series

PURPOSE

Preoperative antibiosis contributes up to one third of total antibiotic use in major hospitals. Choice of antibiotic is not uniformly standardized, and polypharmacy regimens may be used without knowing the effect on rates of surgical site infection, nonsurgical infections, or antibiotic resistance. Careful examination of trends in surgical prophylaxis is warranted. In this study, we aimed to examine our institution's experience with vagus nerve stimulator (VNS) implantation, focusing on association between perioperative antibiotic practices and postoperative infectious outcomes.

METHODS

We conducted a single-center case-control study using a retrospective chart review of 50 consecutively operated patients undergoing VNS implantation over 24 months by two experienced surgeons at our institution from April 2014 to March 2016. In each surgery, the technical procedure, operating room, and surgical team were the same, while surgeon's preference in antibiotic prophylaxis differed. Group 1 received a single dose of intravenous (IV) cefazolin (n = 26), and Group 2 received IV cefazolin, paired with one or both of gentamicin/vancomycin, in addition to a 10-day outpatient oral course of clindamycin (n = 24). Patient demographics, perioperative details, and minimum 3-month follow-up for infection and healthcare utilization were recorded. Student t tests were computed for significance.

RESULTS

Group 1 patients on average were older than group 2 patients (10.2, 7.1 years, p = 0.01), and length of surgery was longer (115.5, 91.9 min, p = 0.007). There were no differences in number of surgeons gowned (p = 0.11), presence of tracheostomy (p = 0.43) or gastrostomy (p = 0.20) tube, nonsurgical infections (p = 0.32), and number of postoperative emergency department (ED) visits (p = 0.22) or readmissions (p = 0.23). Neither group had VNS infections in the follow-up period.

CONCLUSION

Single preoperative dosing of one antibiotic appropriately chosen to cover typical skin flora conferred equal benefit to perioperative prophylactic polypharmacy in this study. There were no differences in postoperative infection events or ED visits/readmissions. Restraint with preoperative antibiosis shows equipoise in postoperative infection and overall resource utilization.

Clinical practice audit concerning antimicrobial prophylaxis in paediatric neurosurgery: results from a German paediatric oncology unit

BACKGROUND

Perioperative antimicrobial prophylaxis (PAP) has been identified as an important target for internal audits, concerning the judicious use of antibiotics. Paediatric oncology patients with brain tumours face an increased risk of surgical site infection (SSI) after neurosurgery and receive routine PAP in this setting.

PATIENTS AND METHODS

All patients younger than 18 years admitted to the paediatric oncology centre (POC) with a neurosurgical intervention. Systematic audit of routine clinical data is divided in two groups: retrospective (Jan 01, 2012-March 31, 2014) and prospective (April 01, 2014-March 31, 2015) referring to an internal PAP guideline, invented in Jan. 2014). Surveillance of SSI up to 30 days after the operation with standard criteria (Centres for Disease Control and Prevention, USA).

RESULTS

In total, 53 neurosurgical operations were analysed in 33 paediatric oncology patients. Twelve patients received more than one operation. The detailed analysis of PAP revealed prophylactic cefuroxim doses about 30 mg/kg instead of 50 mg/kg and no repeated dosing in operations lasting longer than 4 h. In addition, Cefotaxim, which is not indicated as PAP in neurosurgery, was used instead of Cefuroxim (or Ampicillin-Sulbactam) in 23 % of all cases in the retrospective and 18 % of all cases in the prospective audit. PAP for more than 3 doses (>24 h) was administered in 66 % in the retrospective group and in 60 % in the prospective group (p = n.s.). In both groups, no SSI was detected.

DISCUSSION

This first comprehensive audit of PAP in paediatric oncology patients undergoing neurosurgery outlines significant opportunities to improve clinical practice in terms of correct dosing, the correct choice of the antibiotic, a correct timing schedule and a shorter duration of PAP. In addition, our results illustrate in detail the challenges in clinical practice when an evidence-based approach to improve a standard workflow has to be implemented.

Surgical antibiotic prophylaxis in children: a mixed method study on healthcare professionals attitudes

BACKGROUND

Qualitative and quantitative research investigating determinants of adherence to clinical guidelines (GLs) on surgical antibiotic prophylaxis (SAP) are scarce. We conducted a mixed-method study aimed at investigating barriers and at describing attitudes of healthcare professionals (HCPs) regarding SAP in three Italian children's hospitals.

METHODS

The study comprised two sequential phases: 1) collection of qualitative data through focus groups; 2) conduction of a survey on HCPs attitudes towards SAP. Focus groups were carried out in each hospital with a theoretical convenience sample of 10-15 HCPs. Categorical analysis was conducted. Emerging categories and additional topics derived by literature search were used to develop the survey questionnaire, which included 13 questions expressed through a 4-point Likert scale. Members of surgical teams were invited by e-mail to fill in the questionnaire. We summed up the points assigned to each 4-point Likert scale response and calculated a cumulative score expressing overall concordance to expected HCPs attitudes on SAP. We conducted univariate and multivariate analysis to evaluate the relationship among characteristics of respondents and concordance with expected attitudes.

RESULTS

The main categories identified in the qualitative phase included determinants of general adherence to GLs (e.g., relevance of clinical judgment), individual determinants (e.g., poor knowledge on hospital data) and organizational/structural determinants (e.g., patient flows). A total of 357 HCPs participated in the survey (response rate: 82.1%). Among respondents, 75% reported that SAP should be performed with first or second-generation cephalosporins, 44% that 2-3 days of antibiotic administration are useful as a precaution after surgery, 32% that SAP is needed for all surgical procedures. At multivariate analysis, professional category (physicians vs nurses; OR: 3.31; 95%CI: 1.88-5.82), and hospital (hospital 1 and 2 vs hospital 3; ORs: 2.79, 95%CI: 1.22-6.36; 2.40, 95%CI: 1.30-4.43, respectively) were significantly and independently associated with higher concordance with expected attitudes on SAP.

CONCLUSIONS

Results from this study were useful to identify obstacles to appropriate SAP use in children. In our setting, findings support that a quality-improvement intervention should take into account local contexts, with development of hospital policies, education on SAP recommendations, and dissemination of data on adherence to recommendations.

An Evaluation of Surgical Prophylaxis Procedures in Turkey: A Multi-Center Point Prevalence Study

OBJECTIVE

The purpose of this study was to evaluate compliance with guidelines in surgical prophylaxis (SP) procedures in Turkey.

MATERIALS AND METHODS

A point prevalence study involving 4 university, 5 education and research and 7 public hospitals was performed assessing compliance with guidelines for antibiotic use in SP. Compliance was based on the "Clinical Practice Guidelines for Antimicrobial Surgery (CPGAS) 2013" guideline.

RESULTS

Sixteen centers were included in the study, with 166 operations performed at these being evaluated. Parenteral antibiotic for SP was applied in 161 (96.9%) of these. Type of antibiotic was inappropriate in 66 (40.9%) cases and duration of use in 47 (29.1%). The main antibiotics used inappropriately in SP were ceftriaxone, glycopeptides and aminoglycosides. No significant difference was observed between secondary and tertiary hospitals in terms of inappropriate selection. Duration of prophylaxis was also incompatible with guideline recommendations in approximately half of surgical procedures performed in both secondary and tertiary hospitals, however statistical significance was observed between institutions in favor of tertiary hospitals.

CONCLUSION

Antibiotics are to a considerable extent used in a manner incompatible with guidelines even in tertiary hospitals in Turkey. It must not be forgotten that several pre-, intra- and postoperative factors can be involved in the development of surgical site infections (SSI), and antibiotics are not the only option available for preventing these. A significant improvement can be achieved in prophylaxis with close observation, educational activities, collaboration with the surgical team and increasing compliance with guidelines. All health institutions must establish and apply their own SP consensus accompanied by the guidelines in order to achieve success in SP.