Reduction of surgical site infections in pediatric patients with complicated appendicitis: Utilization of antibiotic stewardship principles and quality improvement methodology

Reducing Postoperative CT Imaging for Children With Complicated Appendicitis: A Pediatric Surgical Quality Collaborative Quality Improvement Project

BACKGROUND

Despite widespread initiatives to reduce ionizing radiation for appendicitis diagnosis, computed tomography (CT) scanning postoperatively remains common. The Pediatric Surgery Quality Collaborative (PSQC) aimed to identify differences between children's hospitals with high and low postoperative CT usage for complicated appendicitis.

METHODS

Using National Surgery Quality Improvement Program Pediatric data from PSQC children's hospitals, we compared postoperative CT imaging for complicated appendicitis (April 2020-March 2021). Key stakeholders from 11 hospitals (5 low CT utilization, 6 high CT utilization) participated in semi-structured interviews regarding postoperative imaging. Qualitative analysis of transcripts was performed deductively and inductively based on the Theoretical Domains Framework (TDF).

RESULTS

Five of twelve TDF domains were most prominent in influencing CT use: skills, beliefs about capabilities, intentions/goals, memory and decision processes, and environment. Children's hospitals with lower rates of postoperative CT use tended to: trust and educate the ultrasound technicians; believe US strengths outweigh weaknesses; image no sooner than 7 days postoperatively; have access to sufficient quality improvement resources; maintain trusting relationships between specialties; and prioritize radiation stewardship.

CONCLUSION

Hospitals at extremes of postoperative CT use for complicated appendicitis reveal strategies for improvement, which include imaging protocol development and adherence, quality improvement resource availability, interdisciplinary collaboration, and promoting radiation stewardship.

LEVEL OF EVIDENCE

Level V.

Standardization of Antibiotic Management and Reduction of Opioid Prescribing in Pediatric Complicated Appendicitis: A Quality Improvement Initiative

BACKGROUND

Appendicitis is one of the most common pediatric surgical procedures in the United States. However, wide variation remains in antibiotic prescribing and pain management across and within institutions. We aimed to minimize variation in antibiotic usage and decrease opioid prescribing at discharge for children with complicated appendicitis by implementation of a quality improvement (QI) initiative.

METHODS

On December 1st, 2021, a QI initiative standardizing postoperative care for complicated appendicitis was implemented across a tertiary pediatric healthcare system with two main surgical centers. QI initiative focused on antibiotic and pain management. An extensive literature search was performed and a total of 20 articles matching our patient population were critically appraised to determine the best evidence-based interventions to implement. Antibiotic regimen included: IV or PO ceftriaxone/metronidazole immediately post-operatively and transition to PO amoxicillin-clavulanic acid for completion of 7-day total course at discharge. Discharge pain control regimen included acetaminophen, ibuprofen, as needed gabapentin, and no opioid prescription. Guideline compliance were closely monitored for the first six months following implementation.

RESULTS

In the first 6-months post-implementation, compliance with use of ceftriaxone/metronidazole as initial post-operative antibiotics was 75.6 %. Transition to PO amoxicillin-clavulanic acid prior to discharge increased from 13.7 % pre-implementation to 73.7 % 6-months post-implementation (p < 0.001). Compliance with a 7-day course of antibiotics within the first 6-months post-implementation was 60 % across both sites. After QI intervention, overall opioid prescribing remained at 0 % at one surgical site and decreased from 17.6 % to 0 % at the second surgical site over the study timeframe (p < 0.001).

CONCLUSION

Antibiotic use can be standardized and opioid prescribing minimized in children with complicated appendicitis using QI principles. Continued monitoring of the complicated appendicitis guideline is needed to assess for further progress in the standardization of post-operative care.

STUDY TYPE

Quality improvement.

LEVEL OF EVIDENCE

Level III.

Intraoperative bacterial cultures fail to reliably predict the bacterial spectrum encountered during infectious complications after appendicitis

Acute appendicitis is a common surgical emergency. Complicated appendicitis usually warrants perioperative antibiotic treatment in order to prevent infectious complications. Whether routine microbiological testing benefits the individual patient is a topic of debate. The goal of our study was to assess perioperative antibiotic prescriptions as well as the benefit of microbiological testing during the appendectomy as a predictor for bacteria encountered in infectious complications. This is a retrospective analysis of 1218 consecutive patients that underwent appendectomy at a tertiary referral center between 2014 and 2021. The patient charts were systematically analyzed regarding intraoperative outcome, microbiologic results, and postoperative infectious complications. 1218 patients were included in this study of which 768 were uncomplicated appendicitis (UA) and 450 were complicated appendicitis (CA). Microbiological testing was performed in 39.2% of UA cases (33.6% of which grew bacteria) compared to 74.9% of CA cases (78.6% positive cultures). The strongest individual predictors for SSI were gangrenous and perforated appendicitis. A total of 58 surgical-site infections developed, of which 49 were intra-abdominal fluid collections or abscesses. Thirty-two patients had revision surgery or CT-guided drainage for SSI. In the cases where microbiological testing was done both during the appendectomy and the SSI, 13/18 showed different bacteria on culture testing. The infectious outcome was favorable in 98.3%. While microbiological testing offers insights into resistance patterns, it is of little benefit for the individual patient, given the low predictive value for bacteria found during SSI. Achieving source control combined with empiric antibiotic coverage leads to favorable outcomes independent of culture results.

Addressing pediatric surgical health inequities through quality improvement efforts

Concepts of healthcare quality and health equity should be inextricably linked but are often pursued separately. Quality improvement (QI) can serve as a powerful means to eliminate health inequities by adopting an equity-focused lens to diagnose and address baseline disparities among pediatric populations using targeted interventions. QI and pediatric surgery practitioners should integrate concepts of equity at every stage of formulating a QI project including conceptualization, planning, and execution. Early adaptation of an equity conscious perspective using QI methodology can prevent exacerbation of preexisting disparities while improving overall outcomes.

Noninvasive Detection of Bacterial Infection in Children Using Piezoelectric E-Nose

Currently, antibiotics are often prescribed to children without reason due to the inability to quickly establish the presence of a bacterial etiology of the disease. One way to obtain additional diagnostic information quickly is to study the volatile metabolome of biosamples using arrays of sensors. The goal of this work was to assess the possibility of using an array of chemical sensors with various sensitive coatings to determine the presence of a bacterial infection in children by analyzing the equilibrium gas phase (EGP) of urine samples. The EGP of 90 urine samples from children with and without a bacterial infection (urinary tract infection, soft tissue infection) was studied on the "MAG-8" device with seven piezoelectric sensors in a hospital. General urine analysis with sediment microscopy was performed using a Uriscan Pro analyzer and using an Olympus CX31 microscope. After surgical removal of the source of inflammation, the microbiological studies of the biomaterial were performed to determine the presence and type of the pathogen. The most informative output data of an array of sensors have been established for diagnosing bacterial pathology. Regression models were built to predict the presence of a bacterial infection in children with an error of no more than 15%. An indicator of infection is proposed to predict the presence of a bacterial infection in children with a high sensitivity of 96%.

Strategies for the implementation of clinical practice guidelines in public health: an overview of systematic reviews

Background

As a source of readily available evidence, rigorously synthesized and interpreted by expert clinicians and methodologists, clinical guidelines are part of an evidence-based practice toolkit, which, transformed into practice recommendations, have the potential to improve both the process of care and patient outcomes. In Brazil, the process of development and updating of the clinical guidelines for the Brazilian Unified Health System (Sistema Único de Saúde, SUS) is already well systematized by the Ministry of Health. However, the implementation process of those guidelines has not yet been discussed and well structured. Therefore, the first step of this project and the primary objective of this study was to summarize the evidence on the effectiveness of strategies used to promote clinical practice guideline implementation and dissemination.

Methods

This overview used systematic review methodology to locate and evaluate published systematic reviews regarding strategies for clinical practice guideline implementation and adhered to the PRISMA guidelines for systematic review (PRISMA).

Results

This overview identified 36 systematic reviews regarding 30 strategies targeting healthcare organizations, healthcare providers and patients to promote guideline implementation. The most reported interventions were educational materials, educational meetings, reminders, academic detailing and audit and feedback. Care pathways—single intervention, educational meeting—single intervention, organizational culture, and audit and feedback—both strategies implemented in combination with others—were strategies categorized as generally effective from the systematic reviews. In the meta-analyses, when used alone, organizational culture, educational intervention and reminders proved to be effective in promoting physicians' adherence to the guidelines. When used in conjunction with other strategies, organizational culture also proved to be effective. For patient-related outcomes, education intervention showed effective results for disease target results at a short and long term.

Conclusion

This overview provides a broad summary of the best evidence on guideline implementation. Even if the included literature highlights the various limitations related to the lack of standardization, the methodological quality of the studies, and especially the lack of conclusion about the superiority of one strategy over another, the summary of the results provided by this study provides information on strategies that have been most widely studied in the last few years and their effectiveness in the context in which they were applied. Therefore, this panorama can support strategy decision-making adequate for SUS and other health systems, seeking to positively impact on the appropriate use of guidelines, healthcare outcomes and the sustainability of the SUS.