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

Abstract

ImportanceUse 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.ObjectiveTo evaluate whether use of postoperative surgical prophylaxis is correlated with SSI rates in children undergoing nonemergent surgery.Design, Setting, and ParticipantsThis 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.ExposuresContinuation of antimicrobial prophylaxis beyond time of incision closure.Main Outcomes and MeasuresThirty-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.ResultsForty 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 RelevanceUse 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.

Surgical Site Infections After Pediatric Liver Transplantation—Impact of a Change in Perioperative Prophylactic Antibiotic Protocol

“…A recently published multicenter study across Europe found great heterogeneity regarding the duration of PAP, with a range from single dose PAP to 10 days [19]. In one study, standardization of perioperative antibiotic regimen in pediatric liver transplantation, gram‐negative broad‐spectrum antibiotic treatment for >48 h declined from 77% to 44% after implementation without an increase in infectious complications [31]. Our study found that prolonged PAP duration did not substantially reduce SSIs.…”

“…Results from adult trials cannot be extrapolated directly due to differing risk factors and physiological characteristics [30]. Furthermore, studies from nonimmunocompromised children that failed to identify benefit from PAP [31,32] cannot be directly transferred to children in the postoperative phase after LTx, which is characterized by high levels of immunosuppressants, often prolonged ventilation, use of vasopressors and sometimes associated wound healing disorders in the early postoperative phase. Prospective randomized controlled trials are warranted to identify optimal prevention bundles against SSIs at all stages and reduce antimicrobial exposure as well as reoperations.…”

Preventing Surgical Site Infections in the Era of Escalating Antibiotic Resistance and Antibiotic Stewardship

“…A sufficient body of evidence now exists to broadly question the value of postoperative antibiotic prophylaxis in uncomplicated surgical procedures . For breast surgery, pediatric surgery, liver resection, cardiac surgery, pacemaker implantation, oromaxillofacial surgery, sarcoma resection, orthopedic surgery, and spine surgery, studies have shown no difference in SSI frequency when omitting or reducing the duration of postoperative antibiotic prophylaxis. In contrast, postoperative antibiotic durations longer than 24 hours have repeatedly been shown to be associated with increases in Clostridioides difficile infection, acute kidney injury, and antibiotic-resistant infection .…”