Antibiotic Prophylaxis in Pediatric Cardiac Surgery: Where Are We and Where Do We Go? A Systematic Review

Abstract

Background: Prophylactic antibiotic therapy is given routinely in the peri-operative period to prevent surgical site infection. However, in pediatric cardiac surgery, an optimal schedule has not been defined. Pediatric recommendations follow the guidelines for adults, which might be improper because of the inherent challenges in pediatric research and the heterogeneity of the population. Implementation of an effective prophylaxis protocol is needed for children undergoing cardiac surgery, especially in view of worldwide antibiotic overuse and the development of drug resistance. In this review, we analyze the current knowledge supported by up-todate publications about antibiotic prophylaxis in pediatric cardiac surgery. Methods: The PubMed Ò database was searched for full-text journal articles describing peri-operative antibiotic prophylaxis in pediatric cardiac surgery published since 2000. Antibiotics used for standard prophylaxis with dosing schema, time of the first dose, additional dosage in extracorporeal circulation (ECC) priming, and prophylaxis duration were analyzed. Additionally, we looked for special clinical situations such as antibiotic prophylaxis in children with the sternum left open after surgery and patients with b-lactam allergy or preoperative methicillin-resistant Staphylococcus aureus (MRSA) colonization or those requiring extracorporeal membrane oxygenation (ECMO). Results: A total of 1,546 articles were evaluated, and we identified 20 for further analysis. On the basis of the current peri-operative antibiotic prophylaxis recommendations for cardiac surgery and the papers reviewed, we tried to propose a schedule for peri-operative antibiotic prophylaxis in pediatric cardiac surgery. Conclusions: There is a need for careful use and examination of the schedule proposed because the pharmacokinetics of antibiotics in pediatric patients with ECC is not fully understood. This should be evaluated further. Formulating uniform recommendations concerning peri-operative antibiotic prophylaxis is difficult.

Chlorhexidine bathing of the exposed circuits in extracorporeal membrane oxygenation: an uncontrolled before-and-after study

“…It is evident that acquired infection during ECMO leads to worse clinical outcomes [28]. Notwithstanding, individual infection prevention policies are adopted according to institutional preference [29,30]. Most of the represented strategies used CHG disinfection only for the cannula insertion sites [31].…”

Perioperative and long-term management of Fontan patients

“…Furthermore, antibiotic pharmacokinetics in paediatric patients undergoing cardiopulmonary bypass (CPB) is not fully known. 20 A suggested schedule has been proposed covering preoperative nasal swab screening and treatment of Staphylococcus aureus with Mupirocin, intraoperative prophylaxis with cefazolin with vancomycin added if MRSA colonisation is present, and continuation of antibiotics for 48 hours postoperatively (prolonged if delayed sternal closure or ECMO or VAD). However, more research is needed to determine and investigate an optimal protocol.…”

The Year in Review: Anesthesia for Congenital Heart Disease 2018

“…28 What is helpful with this cefuroxime study by Gertler and colleagues, 28 is that it supports findings from an earlier pharmacokinetic study in older children undergoing cardiovascular surgery in which a similar dosing strategy was found to be appropriate. 29 The review by Jaworski and colleagues 24 is helpful because it highlights the need for prospective randomized trials in children to help establish the correct dose and dosing schedule of antibiotics to assess the efficacy and safety of SAP in pediatric cardiac surgery. This comes at an important time as the United Kingdom's Sixth National Audit on Anesthesia, Surgery, and Life Threatening Allergic Reactions was published in May 2018.…”

“…There does not appear to be any randomized trials on the use of surgical antibiotic prophylaxis (SAP) in pediatric cardiac surgery. A recent systematic review of the literature by Jaworski and colleagues 24 identified 20 articles that described the use of perioperative SAP in pediatric cardiac surgery. The use of SAP is very variable.…”

“…For delayed sternal closure postsurgery there was also variability with only one study administering antibiotics until skin closure and removal of all drains. 24 Successful implementation of a standardized antibiotic prophylaxis regimen that can be maintained over time is difficult. One audit of practice found 20% of antibiotic use was inappropriate, 27% of patients failed to receive adequate intraoperative redosing, and 84% of patients had an inadequate postoperative antibiotic dosing schedule.…”