Antibiotic Prophylaxis for Pyloromyotomy in Children: An Opportunity for Better Stewardship

Reevaluating Surgical Antibiotic Prophylaxis in Pediatric Pyloromyotomy: Insights From the NSQIP-Pediatric Database

BACKGROUND

Pyloromyotomy is a clean surgical procedure with a low risk of surgical site infections (SSIs). Despite this, surgical antibiotic prophylaxis (SAP) is often administered, raising concerns about unnecessary antibiotic exposure and antimicrobial resistance. This study aims to evaluate whether SAP reduces SSI rates in infants undergoing pyloromyotomy for hypertrophic pyloric stenosis and to propose a guideline for selective SAP omission.

METHODS

This retrospective cohort study analyzed data from the National Surgical Quality Improvement Program-Pediatric database. Infants undergoing pyloromyotomy between January 1, 2021 and December 31, 2023 were included. The primary outcome was the occurrence of SSIs within 30 days postoperatively. Secondary outcomes included stratified rates of superficial, deep incisional, and organ/space SSIs.

RESULTS

Among 4917 infants (age <1 year; 84.26 % male), 49.48 % received SAP. Additionally, 81 patients (1.65 %) received post-operative antibiotics beyond the intraoperative period. The overall SSI rate was 1.42 %, primarily comprised of superficial SSIs. There was no significant difference in SSI rates between infants receiving SAP (1.15 %) and those not receiving SAP (1.69 %) (p = 0.110). The rate of unplanned readmission and unplanned return to the operating room within 30 days was 2.44 % and 1.04 %, respectively, with no significant difference between those who received post-operative antibiotics and those who did not (p > 0.2 for both comparisons).

CONCLUSIONS

Routine SAP administration in pyloromyotomy is unnecessary given the low risk of SSIs. SAP in ASA Class I or II infants undergoing isolated pyloromyotomy without mucosal perforation, immune-compromising conditions, infections, or trauma should be omitted. These findings support efforts to optimize antibiotic stewardship in pediatric surgical practice.

TYPE OF STUDY

Original Research Article.

LEVEL OF EVIDENCE

III.

Role of Prospective Audit in Antimicrobial Stewardship at the Surgery Department of a Tertiary Hospital in Lagos

BACKGROUND

Prospective audit with intervention and feedback is one of the core strategies of antimicrobial stewardship. Goal is to preserve the current and future antibiotics against the threat of antimicrobial resistance, while improving patient safety and reducing healthcare costs.

OBJECTIVE

To perform a prospective audit of antimicrobial prescription and feedback as an antimicrobial stewardship strategy.

METHODOLOGY

This audit was carried out in the Department of Surgery of a Teaching Hospital. Data were gathered from patients' clinical records. Each filled checklist was analyzed, and recommendations given based on the antibiotic guidelines. These recommendations were communicated to the prescriber(s) through the head of the antimicrobial stewardship committee in surgery department. Compliance to recommendations and reasons for non-compliance were noted.

RESULTS

Of 655 prescriptions audited, 133 (20%) were for surgical prophylaxis, while 522 (80%) were for treatment. Community acquired infections accounted for 464 (89%) of the treatment while those acquired in the hospital were 58 (11%). Reasons for antibiotic were documented for 522 (80%), sample collection before antibiotics administration in 56 patients (21%) of which 32 (57%) antibiotics were de-escalated based on laboratory results. Stop/review dates were indicated only in 77 (15%) of the treatment prescriptions. Appropriate prescribing was observed in 323 (49%) of 655 prescriptions (53 of 133 antibiotics for surgical prophylaxis and 270 of 522 for treatment).

CONCLUSION

The compliance rate to the consensual antibiotic guidelines is still below average. The areas of inappropriateness included wrong choice of antibiotic, prolonged use, too many antibiotics. Engaging the prescribers to identify the reasons for non-compliance with the guidelines is crucial to improve appropriate antibiotic prescribing.

Utility of preoperative prophylactic antibiotics for preventing surgical site infections in children with infantile hypertrophic pyloric stenosis: a systematic review and meta-analysis

PURPOSE

The aim of this study was to determine the utility of prophylactic antibiotics before pyloromyotomy for the prevention of Surgical Site Infections (SSI) among children with Infantile Hypertrophic Pyloric Stenosis (IHPS).

METHODS

A systematic search of PubMed, Scopus, Embase, and Web of Science databases was performed to identify papers published till 30th July 2024. The main outcome of interest was the incidence of SSIs. The relative risk (RR) with 95% confidence interval (CI) was calculated using a random effects model. The I2 statistic was used to calculate the heterogeneity. The Newcastle-Ottawa-Scale (NOS) was used to assess the methodological quality of the included studies.

RESULTS

Five studies, published between 1999 and 2024, were included in this systematic review and meta-analysis. The risk of developing SSI among those treated was RR = 0.97, 95% CI 0.53 to 1.78, with I2 = 0%, indicating no incremental benefit of administration of prophylactic antibiotics. A sensitivity analysis was performed by excluding the database studies. Results from this analysis (RR = 0.79, 95% CI 0.29 to 2.20, I2 = 0%) demonstrated that no significant difference was observed after excluding studies with large sample sizes. All included studies were of good methodological quality as assessed with the NOS.

CONCLUSION

The findings of this review demonstrate no incremental benefit of the administration of prophylactic antibiotics before pyloromyotomy in preventing SSIs in children with IHPS. However, randomized, double-blinded, placebo-controlled trials need to be conducted in the future before any definite conclusions are drawn in this regard.

The Utility of Prophylactic Antibiotics for Laparoscopic Pyloromyotomy

INTRODUCTION

Laparoscopic pyloromyotomy (LP) for the treatment of infantile hypertrophic pyloric stenosis (IHPS) is a clean case with low expected rates of postoperative surgical site infection (SSI). Previous studies have shown a low risk of SSI following LP but also large variations in the utilization of prophylactic antibiotics. The goal of this study was to review the use of preoperative antibiotics for LP and to compare this with SSI incidence.

METHODS

We performed a retrospective single-center analysis of patients undergoing LP for infantile hypertrophic pyloric stenosis at a large quaternary children's hospital from January 2017 to June 2020. Subjects were <4 mo old. Exclusion criteria were those lost to follow-up within 30 d postoperatively and those who required open conversion intraoperatively. Statistical analysis was performed using Fisher's exact test, two-tailed independent t-tests, and descriptive statistics.

RESULTS

Two-hundred twenty-seven patients were included, mean population age was 5.7 wk, and 81.1% were male. Preoperative antibiotics were administered in 39% of patients. Only 1.3% (n = 3) of all patients developed an SSI within 30 d of their operation. Analysis between patients who received preoperative antibiotics and those who did not revealed no difference in age (5.72 wk versus 5.72 wk, t (225) = 0.38, P = 0.70), sex (41% of males versus 32% of females, P = 0.39), length of stay (t(225) = -0.94, P = 0.35), or postoperative SSI (1.1% versus 1.4%, P > 0.999). Large variability was noted in antibiotic utilization by surgeon.

CONCLUSIONS

In patients undergoing LP, there was no difference in SSI rates whether or not patients received preoperative antibiotics and, there is large variation in utilization. Measures are needed to decrease usage of prophylactic antibiotics before LP.

[Update Perioperative Antibiotic Prophylaxis in Neonatology]

This narrative review discusses basic principles of the perioperative antibiotic prophylaxis (PAP) in premature and at term newborns and refers to some particularities concerning the indication and dosing issues. Although this is a vulnerable patient population, the spectrum of activity should not be unnecessarily broad and the regular PAP must not be prolonged beyond 24 hours.

Surgical Antibiotic Prophylaxis in Children Undergoing Surgery: A Systematic Review and Meta-Analysis

Background: To establish the role of surgical antibiotic prophylaxis (SAP) in the prevention of surgical site infection (SSI) in children undergoing surgery. Design: A systematic review and meta-analysis of six databases: MEDLINE (PubMed), EMBASE, CINAHL Plus, Cochrane Library, Web of Science, and Scopus. Study Selection: Included studies (irrespective of design) compared outcomes in children undergoing surgery, aged 0 to 21 years who received SAP with those who did not, with SSI as an outcome, using the U.S. Centers for Disease Control and Prevention (CDC) definitions for SSI. Data Extraction: Two independent reviewers applied eligibility criteria, assessed the risk of bias, and extracted data. Results: A total of six randomized control trials and 26 observational studies including 202,593 surgical procedures among 202,405 participants were included in the review. The pooled odds ratio of SSI was 1.20; (95% confidence interval [CI], 0.91-1.58) comparing those receiving SAP with those not receiving SAP, with moderate heterogeneity in effect size between studies (τ² = 0.246; χ² = 69.75; p < 0.001; I² = 57.0%). There was insufficient data on many factors known to be associated with SSI, such as cost, length of stay, re-admission, and re-operation; it was therefore not possible to perform subanalyses on these. Conclusions: This review and metanalysis did not find a preventive action of SAP against SSI, and our results suggest that SAP should not be used in surgical wound class (SWC) I procedures in children. However, considering the poor quality of included studies, the principal message of this study is in highlighting the absence of quality data to drive evidence-based decision-making in SSI prevention in children, and in advocating for more research in this field.

Surgical Antimicrobial Prophylaxis in Abdominal Surgery for Neonates and Paediatrics: A RAND/UCLA Appropriateness Method Consensus Study

Surgical site infections (SSIs), i.e., surgery-related infections that occur within 30 days after surgery without an implant and within one year if an implant is placed, complicate surgical procedures in up to 10% of cases, but an underestimation of the data is possible since about 50% of SSIs occur after the hospital discharge. Gastrointestinal surgical procedures are among the surgical procedures with the highest risk of SSIs, especially when colon surgery is considered. Data that were collected from children seem to indicate that the risk of SSIs can be higher than in adults. This consensus document describes the use of preoperative antibiotic prophylaxis in neonates and children that are undergoing abdominal surgery and has the purpose of providing guidance to healthcare professionals who take care of children to avoid unnecessary and dangerous use of antibiotics in these patients. The following surgical procedures were analyzed: (1) gastrointestinal endoscopy; (2) abdominal surgery with a laparoscopic or laparotomy approach; (3) small bowel surgery; (4) appendectomy; (5) abdominal wall defect correction interventions; (6) ileo-colic perforation; (7) colorectal procedures; (8) biliary tract procedures; and (9) surgery on the liver or pancreas. Thanks to the multidisciplinary contribution of experts belonging to the most important Italian scientific societies that take care of neonates and children, this document presents an invaluable reference tool for perioperative antibiotic prophylaxis in the paediatric and neonatal populations.

Surgical site infection after open and laparoscopic surgery in children: a systematic review and meta-analysis

Surgical site infections (SSIs) are the most common healthcare-associated infections in patients undergoing surgery. Various randomised control trials (RCTs) indicate that laparoscopic procedures can be associated with better outcomes compared to open procedures. However, how open versus laparoscopic approaches compare across various paediatric procedures with respect to SSI rate remains poorly defined. In this review, we examined RCTs that directly compare SSI rates after open versus laparoscopic operations for appendicitis, gastro-esophageal reflux, inguinal hernia, and pyloric stenosis. MEDLINE, Embase, and Web of Science were searched for RCTs comparing four types of open versus laparoscopic operations in children. The operations included appendectomy, fundoplication for gastro-esophageal reflux, inguinal hernia repair, or pyloromyotomy. 364 records were identified and screened, 54 full-text articles were assessed for eligibility, and 17 RCTs were included in the analysis. SSI rate was the primary outcome. Operative time and length of stay (LOS) were the secondary outcomes. A meta-analysis was conducted using RevMan 5.4 software. Laparoscopic appendectomy had a lower SSI rate than open appendectomy (odds ratio of 2.22 [1.19, 4.15] p = 0.01). Laparoscopic fundoplication for gastro-esophageal reflux, inguinal hernia repair, or pyloromyotomy for pyloric stenosis were not associated with lower SSI rate compared to open surgery. Operative time was shorter in open fundoplication (- 71.22 min [- 89.79,  - 52.65] p < 0.00001) than laparoscopic fundoplication. There was no significant difference in operative time of any of the other procedures. There was no significant difference in LOS between open and laparoscopic procedures for all types of operations analysed. Based on the findings of this review, it is recommended to utilise the laparoscopic approach over the open approach to reduce SSI risk in paediatric appendectomy.

Antibiotic Stewardship for the Neonatologist and Perinatologist

Antibiotic use is common in the neonatal intensive care unit. The density and heterogeneity of antibiotic prescribing suggests inappropriate and overuse of these agents. Potential antibiotic stewardship targets include sepsis, necrotizing enterocolitis, and perioperative prophylaxis. Diagnostic stewardship principles, including appropriately obtained cultures, may be leveraged to decrease unnecessary antibiotic prescribing. Strategies including guideline development, prospective audit and feedback, and formulary restriction have been successfully deployed in the neonatal intensive care unit to improve the quality of antibiotic prescribing. Implementation of antibiotic stewardship in the neonatal intensive care unit requires multidisciplinary collaboration between neonatologists, surgeons, infectious diseases specialists, pharmacists, and nurses.

Brief Overview and Updates on Infantile Hypertrophic Pyloric Stenosis: Focus on Perioperative Management

Infantile hypertrophic pyloric stenosis is the most common surgical cause of vomiting in infancy. After adequate resuscitation, surgical pyloromyotomy is the standard of care for infants with pyloric stenosis. This article provides a brief overview and updates on hypertrophic pyloric stenosis in infants, with a focus on the surgical approach as well as perioperative management of this pathology. The most controversial aspect of the management of infants with pyloric stenosis is post-pyloromyotomy feeding, as there is no clear consensus in the literature on the best regimen. More randomized controlled trials are needed to establish the optimal resuscitation protocol in the preoperative phase and the ideal feeding regimen in the postoperative phase for infants with hypertrophic pyloric stenosis. [Pediatr Ann. 2021;50:(3):e136-e141.].

Implementation of a Plan-Do-Study-Act framework to reduce unindicated surgical antimicrobial prophylaxis

PURPOSE

The goal of this study was to use a Plan-Do-Study-Act (PDSA) framework to reduce utilization of unindicated surgical antibiotic prophylaxis (SAP) for clean cases without foreign body implantation.

METHODS

This was a pre-post intervention study conducted at a single children's hospital comparing 6 months of retrospective preintervention data to 10 months of prospectively collected postintervention data. Interventions to reduce unindicated SAP included faculty meetings to review guidelines and establish consensus around inclusion criteria, publicizing guidelines with regular email reminders, and conducting ongoing compliance audits to root cause noncompliance. Early unanticipated noncompliant cases were associated with rotating trainees who prescribed SAP routinely without attending knowledge. A second PDSA cycle then included education-based emails targeting residents with mandatory feedback loop closure.

RESULTS

Preintervention, 40.4% (107/265) of patients received unindicated SAP. Postintervention, the rate of unindicated SAP decreased to 15.4% (6/39) after the first month and 6.2% (20/323) after 10 months, reflecting an 85% reduction across periods (p < 0.01). There was no difference in the rate of surgical site infections between the pre and postintervention cohorts (0.36% vs. 0.67%, p = 1.00).

CONCLUSIONS

Unindicated surgical antibiotic prophylaxis was significantly reduced by implementing a Plan-Do-Study-Act intervention targeting both faculty and trainees.

LEVEL OF EVIDENCE

Prospective comparative treatment study, level II.