Association Between Antibiotic Redosing Before Incision and Risk of Incisional Site Infection in Children With Appendicitis

Abstract

Objective: To evaluate whether redosing antibiotics within an hour of incision is associated with a reduction in incisional surgical site infection (iSSI) in children with appendicitis. Background: Existing data remain conflicting as to whether children with appendicitis receiving antibiotics at diagnosis benefit from antibiotic redosing before incision.Methods: This was a multicenter retrospective cohort study using data from the Pediatric National Surgical Quality Improvement Program augmented with antibiotic utilization and operative report data obtained though supplemental chart review. Children undergoing appendectomy at 14 hospitals participating in the Eastern Pediatric Surgery Network from July 2016 to June 2020 who received antibiotics upon diagnosis of appendicitis between 1 and 6 hours before incision were included. Multivariable logistic regression was used to compare odds of iSSI in those who were and were not redosed with antibiotics within 1 hour of incision, adjusting for patient demographics, disease severity, antibiotic agents, and hospital-level clustering of events. Results: A total of 3533 children from 14 hospitals were included. Overall, 46.5% were redosed (hospital range: 1.8%-94.4%, P < 0.001) and iSSI rates were similar between groups [redosed: 1.2% vs non-redosed: 1.3%; odds ratio (OR) 0.84, (95%,CI, 0.39-1.83)]. In subgroup analyses, redosing was associated with lower iSSI rates when cefoxitin was used as the initial antibiotic (redosed: 1.0% vs nonredosed: 2.5%; OR: 0.38, (95% CI, 0.17-0.84)], but no benefit was found with other antibiotic regimens, longer periods between initial antibiotic administration and incision, or with increased disease severity. Conclusions: Redosing of antibiotics within 1 hour of incision in children who received their initial dose within 6 hours of incision was not associated with reduction in risk of incisional site infection unless cefoxitin was used as the initial antibiotic.

Implemented Interventions in Preventing Surgical Site Infection in Pediatric Appendicitis Patients: A Scoping Review

“…Antibiotics were administered at different points in time during the patient’s care in the hospital and at discharge. Cramm et al found no significant difference in the SSI rates after redosing cefoxitin, ceftriaxone combined with metronidazole, and piperacillin-tazobactam within one hour of the appendectomy procedure 22 . None of the patients had wound infection or intra-abdominal abscess with or without administration of ornidazole, penicillin plus tobramycin, and piperacillin prophylactically, as reported by Kizilcan et al 23 .…”

Postoperative Antibiotics, Outcomes, and Resource Use in Children With Gangrenous Appendicitis

“…A logistic regression model was used to calculate propensity scores for each patient, using patient age at appendectomy, high severity intraoperative disease (defined as presence of gangrene), and clinical severity (for which PLOS served as a proxy) as covariates. 9 After propensity scores were calculated, children were matched 1:1 across groups using a greedy matching algorithm. Mixed-effects logistic regression was then used in the matched cohorts to estimate the association between use of any postoperative antibiotics and outcomes, adjusting for hospital-level clustering.…”

“…10 The present study represents a more robust and generalizable analysis due to its multicenter design, relatively large sample size, and use of previously validated intraoperative criteria for nonperforated appendicitis with GSE findings. 9 Furthermore, the validity of this analysis is strengthened by the use of propensity matching to balance measures of disease severity between treatment groups. Finally, inclusion of a complementary hospital-level analysis provides further insight into the lack of clinical effectiveness of postoperative antibiotic use over a wide range of practice variation as it pertains to both use and duration as separate measures.…”

“…The presence of GSE findings was established through a standardized, keyword-based review of operative report text for each case, which has previously been validated and shown to have high interrater reliability. 9 Children with missing data for exposures or outcomes were excluded. Race and ethnicity were not reported as part of this analysis because these data were not reliably reported in NSQIP-Pediatric (41% of the cohort was categorized as unknown) and are unlikely to be important predictors of a patient's response to antibiotics.…”

“…In a multicenter study including 6133 children with nonperforated appendicitis, the presence of GSE findings was associated with increased length of stay and higher rates of SSI and hospital revisits compared with cases where GSE findings were absent. 9 Whether this increase in SSI rates and resource use can be mitigated by postoperative continuation of antibiotics remains uncertain, with available data limited to small, single-center experiences using heterogenous definitions for both exposures and outcomes. [10][11][12] With these considerations, the goal of this analysis was to evaluate whether use of postoperative antibiotics was associated with improved outcomes in children with nonperforated appendicitis with GSE findings from 16 children's hospitals, collectively representing a wide range of patient populations and practice environments.…”