1
|
Pathan SR, Bhende VV, Sharma TS, Kumar A, Patel VA, Sharma KB, Pandya SB. Antibiotic Utilization and Prophylaxis in Paediatric Cardiac Surgery: A Retrospective Observational Study at a Rural Tertiary Care Hospital in India. Cureus 2023; 15:e45107. [PMID: 37842391 PMCID: PMC10569353 DOI: 10.7759/cureus.45107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2023] [Indexed: 10/17/2023] Open
Abstract
Introduction Antimicrobial prophylaxis, involving short antibiotic courses preceding surgical procedures, is recommended to minimize postoperative infections. Paediatric cardiac surgeries are classified as clean procedures, though infection challenges persist due to illness severity and extended ICU stays. Antimicrobial prophylaxis varies, ranging from single doses to extended administration until catheters are removed. Typically lasting 24 to 48 hours, it has proven infection-reduction benefits. Despite these practices, uncertainties surround the optimal nature, timing, and duration of administration. This concern is amplified by escalating antimicrobial resistance driven by antibiotic overuse. Vulnerable paediatric populations bear heightened consequences of irrational antimicrobial use, contributing to global resistance trends. Yet, a defined optimal prophylaxis schedule for paediatric cardiac surgery is lacking. Importing adult guidelines may be inadequate due to paediatric research complexities and population diversity. Developing effective prophylaxis protocols is crucial for children undergoing cardiac surgery, given global antibiotic overuse and evolving drug resistance. Establishing an optimal prophylactic strategy remains a challenge, necessitating further research for evidence-based protocols to mitigate infections in this vulnerable patient cohort. Methods This study investigates antibiotic use in paediatric cardiac surgery. A retrospective analysis of 100 patients from a rural Indian hospital (2017-2018) assesses antibiotic patterns, including type, dose, duration, and adherence to prophylaxis protocols. Results In the studied cohort of paediatric cardiac surgery patients, complete compliance (100%) with antibiotic prophylaxis was observed. However, deviations were identified: 30% received antibiotics prematurely, and 30% did not align with institutional protocol criteria. Concerning antibiotic selection, 87% followed hospital policy with the recommended cefoperazone and sulbactam combination plus amikacin, while 9% received piperacillin/tazobactam + amikacin due to sepsis. Irregular use (22%) based on clinical records occurred. Furthermore, 4% received piperacillin/tazobactam + teicoplanin, with one instance of inappropriate higher antibiotic use. Regarding prophylaxis duration, only 27% adhered to the appropriate timeline, with 40% exceeding 48 hours, indicating extended use. Upon discharge, a notable proportion (45 patients) received antibiotic prescriptions. Among them, 73% were prescribed rationally, while 27% exhibited irrational antibiotic use. Conclusion The findings of this study shed a significant light on the issue of antibiotic misuse within the context of paediatric cardiac surgery. It underscores the pressing need for more stringent measures to regulate and address this concerning trend. The study underscores the pivotal importance of adhering rigorously to established protocols and guidelines for antibiotic prophylaxis. This adherence not only holds the potential to elevate the overall quality of patient care but also plays a critical role in combating the escalating challenge of antibiotic resistance. Through a concerted effort to optimize antibiotic usage, we can simultaneously enhance patient outcomes and contribute to the ongoing fight against the emergence of antibiotic-resistant strains, thus preserving the efficacy of these vital medications for future generations.
Collapse
Affiliation(s)
- Sohilkhan R Pathan
- Clinical Research Services (CRS), Bhanubhai and Madhuben Patel Cardiac Centre, Bhaikaka University, Karamsad, IND
| | - Vishal V Bhende
- Pediatric Cardiac Surgery, Bhanubhai and Madhuben Patel Cardiac Centre, Bhaikaka University, Karamsad, IND
| | - Tanishq S Sharma
- Pediatric Cardiac Surgery, Bhanubhai and Madhuben Patel Cardiac Centre, Bhaikaka University, Karamsad, IND
| | - Amit Kumar
- Pediatric Cardiac Intensive Care, Bhanubhai and Madhuben Patel Cardiac Centre, Bhaikaka University, Karamsad, IND
| | - Vishal A Patel
- Clinical Research Services (CRS), Bhanubhai and Madhuben Patel Cardiac Centre, Bhaikaka University, Karamsad, IND
| | - Kruti B Sharma
- Clinical Research Services (CRS), Bhanubhai and Madhuben Patel Cardiac Centre, Bhaikaka University, Karamsad, IND
| | - Shivangi B Pandya
- Clinical Research Services (CRS), Bhanubhai and Madhuben Patel Cardiac Centre, Bhaikaka University, Karamsad, IND
| |
Collapse
|
2
|
Alpat S, Asam M. The use of protocolised care bundle to prevent paediatric cardiac surgical site infection in resource-limited setting. Cardiol Young 2023; 33:1307-1311. [PMID: 37518864 DOI: 10.1017/s1047951123001798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
OBJECTIVE Surgical site infection is an important concern due to its association with morbidity and mortality after paediatric cardiac surgery. The aim of this study was to present our approach and experience in the utilisation of a modified care bundle in a recently established paediatric cardiac surgical unit in the low-income region of Turkey. METHODS Between 2019 and 2021, we identified children who underwent cardiac surgical procedures and retrospectively collected relevant demographic data, disease characteristics, operational data, Risk Adjustment For Congenital Heart Surgery (RACHS-1) scores, and post-operative factors such as morbidities, mortality, critical care, and in-hospital stay lengths. Surgical site infections and late infections were scanned. RESULTS Ninety-six patients (49 males, 47 females) underwent a total of 127 surgical procedures during the study period. Overall adherence to the protocol was 94%, 100%, and 96% in the pre-operative, intra-operative, and post-operative periods, respectively. There was no reported surgical site infection, and no late infection was encountered throughout the follow-up period. CONCLUSIONS We conclude that a low rate of surgical site infection, or even a rate of nil, is attainable through the utilisation of locally standardised guidelines for its prevention.
Collapse
Affiliation(s)
- Safak Alpat
- Paediatric Cardiac Surgery, University of Health Sciences, Van Training and Research Hospital, Van, Turkey
| | - Mehmet Asam
- Paediatric Cardiac Surgery, University of Health Sciences, Van Training and Research Hospital, Van, Turkey
| |
Collapse
|
3
|
Glenn ET, Harman JR, Marietta J, Lake J, Bailly DK, Ou Z, Griffiths ER, Ware AL. Impact of a Surgical Wound Infection Prevention Bundle in Pediatric Cardiothoracic Surgery. Ann Thorac Surg 2023; 115:126-134. [PMID: 36126719 DOI: 10.1016/j.athoracsur.2022.08.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 07/26/2022] [Accepted: 08/29/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND The aim of this project was to decrease the incidence of surgical wound infection (SWI) to <1.5% in our pediatric cardiothoracic surgery patients using a prevention bundle and quality improvement process. METHODS An SWI prevention bundle addressing preoperative, intraoperative, and postoperative risks was implemented. The primary outcome was SWI based on Society of Thoracic Surgeons criteria (superficial, deep, or mediastinitis). Novel aspects of the bundle included standardization of surgical closure and wound coverage for 14 days with a negative pressure dressing or a silicone dressing. Data were collected from January 2017 to November 2021; bundle intervention began in December 2019. SWIs were tracked using a g-chart. Preintervention and postintervention cohorts were compared by standard descriptive statistics. There were no changes in SWI tracking methods during the study. RESULTS During the study, 1159 individuals underwent 1768 surgical interventions. Preintervention (n = 931) and postintervention (n = 837) groups were clinically similar, with fewer neonatal surgeries in the postintervention group. SWI decreased in all patients (preintervention period: 1 SWI per 22 surgeries; postintervention period: 1 SWI per 62.6 surgeries) and in neonates (preintervention period: 1 SWI per 12 surgeries; postintervention period: 1 SWI per 26.7 surgeries). Special cause variation was achieved in the entire cohort by March 2021 and in neonates by April 2021. Decreases in SWI occurred in superficial and deep wounds but not in mediastinitis. Annual rate of total SWIs decreased from 2.83% in 2019 to 1.15% in 2021. Intensive care unit and hospital length of stay did not change. CONCLUSIONS We demonstrated a reduction in SWI rates after implementing an SWI prevention bundle including standardized surgical closure and prolonged wound protection.
Collapse
Affiliation(s)
- Emilee T Glenn
- Heart Center, Intermountain Primary Children's Hospital, Salt Lake City, Utah.
| | - Jeremy R Harman
- Heart Center, Intermountain Primary Children's Hospital, Salt Lake City, Utah
| | - Jennifer Marietta
- Heart Center, Intermountain Primary Children's Hospital, Salt Lake City, Utah
| | - Jason Lake
- Division of Pediatric Infectious Disease, University of Utah, Salt Lake City, Utah
| | - David K Bailly
- Division of Pediatric Critical Care, University of Utah, Salt Lake City, Utah
| | - Zhining Ou
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Eric R Griffiths
- Division of Pediatric Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - Adam L Ware
- Division of Pediatric Cardiology, University of Utah, Salt Lake City, Utah
| |
Collapse
|
4
|
von Stumm M, Leps Y, Jochheim L, van Rüth V, Gottschalk U, Mueller G, Kozlik-Feldmann R, Hazekamp MG, Sachweh JS, Biermann D. Impact of delayed sternal closure on wound infections following neonatal and infant cardiac surgery. PLoS One 2022; 17:e0267985. [PMID: 35604953 PMCID: PMC9126390 DOI: 10.1371/journal.pone.0267985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 04/19/2022] [Indexed: 11/23/2022] Open
Abstract
Objectives Delayed sternal closure is a routine procedure to reduce hemodynamic and respiratory instability in pediatric patients following cardiac surgery, particularly in neonates and infants. In this setting, the possible links between sternal wound infection and delayed sternal closure are still a matter of debate. As a part of our routine, there was a low threshold for delayed sternal closure, so we reviewed our experience with sternal wound infections with a focus on potentially related perioperative risk factors, particularly delayed sternal closure. Methods We retrospectively identified 358 operated neonates (37%) and infants (mean age 3.6 months) in our local congenital heart disease database between January 2013 and June 2017. Potential risk factors for sternal wound infections, such as age, gender, complexity (based on Aristotle- and STS-EACTS mortality category), reoperation, use of cardiopulmonary bypass, extracorporeal membrane oxygenation, mortality and delayed sternal closure (163/358, 46%), were subjected to uni- and multivariate analysis. Results A total of 26/358 patients (7.3%) developed a superficial sternal wound infection. There were no deep sternal wound infections, no mediastinitis or sepsis. Applying univariate analysis, the prevalence of sternal wound infections was related to younger age, more complex surgery and delayed sternal closure. However, in multivariate analysis, sternal wound infection was only associated with delayed sternal closure (p = 0.013, odds ratio 8.6). Logistic regression revealed the prevalence of delayed sternal closure to be related to younger age, complexity, and the use of extracorporeal membrane oxygenation. Conclusion In patients younger than one year, sternal wound infections are clearly related to delayed sternal closure. However, in our cohort, all sternal wound infections were superficial and acceptable, considering the improved postoperative hemodynamic stability.
Collapse
Affiliation(s)
- Maria von Stumm
- Department of Congenital and Pediatric Heart Surgery, Children‘s Heart Clinic, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Yola Leps
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Luca Jochheim
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Victoria van Rüth
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Urda Gottschalk
- Department of Pediatric Cardiology, Children‘s Heart Clinic, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Goetz Mueller
- Department of Pediatric Cardiology, Children‘s Heart Clinic, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rainer Kozlik-Feldmann
- Department of Pediatric Cardiology, Children‘s Heart Clinic, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mark G. Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Joerg S. Sachweh
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Daniel Biermann
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technical University of Munich, Munich, Germany
- * E-mail:
| |
Collapse
|
5
|
Prendin A, Tabacco B, Fazio PC, De Barbieri I. Management of pediatric cardiac surgery wound: a literature review. ACTA BIO-MEDICA : ATENEI PARMENSIS 2021; 92:e2021203. [PMID: 34487083 PMCID: PMC8477079 DOI: 10.23750/abm.v92i4.11269] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 03/22/2021] [Indexed: 12/04/2022]
Abstract
Background: Sternal wound infection is a severe complication of cardiac surgery in the pediatric population (0-18 years old) that can lead to increased morbidity, mortality, and prolonged hospitalization. Health professionals have the ability to perform some interventions during the pre, intra and post-surgery to correctly manage sternal wounds, with the goal of preventing infections. Objectives: To identify and discuss current best practice in the prevention, incidence, and treatment of infections of the cardiac surgery site in the pediatric population. Methods: Between February 20th 2021 and February 28th 2021 we consulted the PubMed database adopting full text, 20 years, Humans, English, Child aged 0 to 18 years as criteria. Twenty articles out of sixty-six were considered relevant to this study. These were divided into four themes. Results: All studies highlight the lack of standard guidelines for managing pediatric patients undergoing cardiac surgery. Some centers developed protocols for managing antibiotic prophylaxis supported by measurable interventions; others implemented infection surveillance systems involving families taking care of patients after hospital discharge. Discussions: the identification of healthcare-associated infections in the pediatric population after cardiac surgery is useful in all peri-operative phases. The limited and restricted literature connected to single centers, with relatively small sample sizes, the use of a single database. Conclusion: There is a lack of standard guidelines. The prevention of site infection ought to the goal of reducing surgical site infections. Building a network between the multidisciplinary staff and the pediatric patient’s family improves the infection surveillance system, reducing the incidence of infections. (www.actabiomedica.it)
Collapse
|
6
|
de Andrade GV, de Souza NMG, Rocha ACF, Ribeiro SB, da Silva VM, Oliveira LAF. Surgical site infection prevention bundle for children submitted to cardiac surgery. Rev Esc Enferm USP 2021; 55:e20200470. [PMID: 34435612 DOI: 10.1590/1980-220x-reeusp-2020-0470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 04/22/2021] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To build and validate the content and appearance of a surgical site infection prevention bundle for children submitted to cardiac surgery. METHOD Methodological study in two phases: 1) Bundle construction from an integrative literature review from which interventions have been extracted to compose the instrument; 2) Bundle content and appearance validation by 24 judges. RESULTS The 24 found articles presented 17 interventions for surgical site infection prevention in this population. Out of them, seven intervention proposals have been chosen to compose the bundle and sent for assessment by judges. The final proposal includes all the seven items chosen in the construction phase and has achieved a content validity index over 0.8 in all items referring to content and appearance. CONCLUSION The content and appearance of the developed bundle proposes care for the prevention of surgical site infection throughout the perioperative period.
Collapse
|
7
|
Prendin A, Tabacco B, Fazio PC, Strini V, Brugnaro L, De Barbieri I. Survey on Sternal Wound Management in the Italian Pediatric Cardiac Intensive Care Units. Healthcare (Basel) 2021; 9:healthcare9070869. [PMID: 34356247 PMCID: PMC8308053 DOI: 10.3390/healthcare9070869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 07/06/2021] [Accepted: 07/07/2021] [Indexed: 11/16/2022] Open
Abstract
(1) Background: a review of the literature found a lack of standardized pediatric guidelines regarding wound management after cardiac surgery. (2) Objective: the aim of the study is to investigate the cardiac surgical wound management in Italian pediatric cardiac intensive care units. (3) Methods: we sent an online questionnaire to the 13 Italian pediatric cardiac intensive care units. (4) Results: ten pediatric cardiac intensive care units (77%) have a protocol for the management of the cardiac surgical wound. The staff members that mainly have the responsibility for the wound management after cardiac surgery are registered nurses and physicians together both in the pediatric cardiac intensive care units (69%), and when a patient is transferred to another ward (62%). Thirty-eight percent of the pediatric cardiac intensive care units have a protocol used to monitor wound infection, and the staff mostly uses a written shift report (54%) to monitor the infection. (5) Discussion: this is the first survey to investigate the management of the wound after cardiac surgery in Italian pediatric cardiac intensive care units. The small sample size and the fact that the centers involved are only Italian cardiac intensive care units are the limits of this study. (6) Conclusions: in the Italian pediatric cardiac intensive care units it emerged that there is a diversity in the treatments adopted and a lack of specific protocols in the management of the pediatric cardiac surgical wound.
Collapse
Affiliation(s)
- Angela Prendin
- Independent Researcher, 35100 Padua, Italy
- Correspondence:
| | | | - Paola Claudia Fazio
- Pediatric Intensive Care Unit, University-Hospital of Padua, 35100 Padua, Italy;
| | - Veronica Strini
- Clinical Research Unit, University-Hospital of Padua, 35100 Padua, Italy;
| | - Luca Brugnaro
- Training and Development Unit of the Health Professions, University-Hospital of Padua, 35100 Padua, Italy;
| | - Ilaria De Barbieri
- Nurse Coordinator Woman’s & Child’s Health Department, University-Hospital of Padua, 35100 Padua, Italy;
| |
Collapse
|
8
|
Affiliation(s)
- Thomas Bartman
- Division of Neonatology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - Richard J Brilli
- John F. Wolfe Endowed Chair in Medical Leadership and Pediatric Quality and Safety; Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| |
Collapse
|
9
|
Jha P, Woodward CS, Gardner H, Pietz C, Husain SA. A Quality Improvement Initiative to Reduce Surgical Site Infections in Patients Undergoing Delayed Sternal Closure After Pediatric Cardiac Surgery. Pediatr Cardiol 2020; 41:1402-1407. [PMID: 32556486 DOI: 10.1007/s00246-020-02396-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 06/12/2020] [Indexed: 11/30/2022]
Abstract
Sternal wound infections (SWI) in delayed sternal closure (DSC) patients are a healthcare burden after congenital heart surgery. There are no guidelines specific for pediatric DSC patients to prevent this costly complication. The hypothesis was that the modifications to a bundled approach for DSC patients would decrease the SWI rate. For this prospective cohort study, DSC patients were postoperatively admitted to a pediatric cardiac care unit from February 2017 to January 2018. Using a modified protocol for prevention of SWI, the infection rates pre- and post-modified protocol were compared. The primary outcome measure was SWI. Secondary outcome measures were compliance with modifications. Retrospective review of cases in pre-protocol modification era from January 1, 2014 to December 31, 2016 showed 377 pediatric cardiopulmonary bypass cases and 39 (10.4%) underwent DSC. During the post-protocol modification era, there were 129 cardiopulmonary bypass cases and 17 (13%) DSC cases. The SWI rate in DSC were 7.7% and 0% for pre-intervention and post-intervention, respectively (p = 0.52). The Bayesian confidence interval with Jeffreys prior gives a 95% confidence interval of 1.5% to 18.3% for pre-intervention and 0 to 13.5% for post-intervention. Compliance with the protocol bundle during the post protocol era was 93-100%. Although preliminary results are not statistically significant due to cohort size, the economic burden and increased LOS for each SWI is clinically significant. The early results of reduced infections for DSC patients using a modified bundle approach appear promising. Continued study and a multicenter project would be beneficial.
Collapse
Affiliation(s)
- Prashant Jha
- Division of Critical Care, Department of Pediatrics, Children's Hospital of Nevada, University Medical Center, 1800 W Charleston Blvd, Las Vegas, NV, 89128, USA.
- Department of Pediatrics, University of Nevada at Las Vegas, Las Vegas, NV, USA.
| | - Cathy S Woodward
- Pediatric Services, University Hospital - University Health System, 4502 Medical Dr, San Antonio, TX, 78229, USA
- Division of Pediatric Critical Care, Department of Pediatrics, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Heather Gardner
- Pediatric Services, University Hospital - University Health System, 4502 Medical Dr, San Antonio, TX, 78229, USA
- Division of Pediatric Critical Care, Department of Pediatrics, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Clinton Pietz
- Pediatric Services, University Hospital - University Health System, 4502 Medical Dr, San Antonio, TX, 78229, USA
- Division of Pediatric Critical Care, Department of Pediatrics, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - S Adil Husain
- Division of Pediatric Cardiothoracic Surgery, The University of Utah's School of Medicine, Salt Lake City, UT, USA
| |
Collapse
|
10
|
Abstract
OBJECTIVES Although open chest management optimizes hemodynamics after cardiac surgery, it increases postoperative infections and leads to increased mortality. Despite the importance of antibiotic prophylaxis during open chest management, no specific recommendations exist. We aimed to compare the occurrence rates of bloodstream infection and surgical site infection between the different prophylactic antibiotic regimens for open chest management after pediatric cardiac surgery. DESIGN Retrospective, single-center, observational study. SETTING PICU at a tertiary children's hospital. PATIENTS Consecutive patients younger than or equal to 18 years old with open chest management after cardiac surgery followed by delayed sternal closure, between January 2012 and June 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We compared the composite occurrence rate of postoperative bloodstream infection and surgical site infection within 30 days after cardiac surgery between three prophylactic antibiotic regimens: 1) cefazolin, 2) cefazolin + vancomycin, and 3) vancomycin + meropenem. In 63 pediatric cardiac surgeries with open chest management, 17 bloodstream infections, and 12 surgical site infections were identified postoperatively. The composite occurrence rates of bloodstream infection and surgical site infection were 10 of 15 (67%), 10 of 19 (53%), and nine of 29 (31%) in the cefazolin, cefazolin + vancomycin, and vancomycin + meropenem regimens, respectively (p = 0.07). After adjusting for age, open chest management duration, extracorporeal membrane oxygenation use, and nasal methicillin-resistant Staphylococcus aureus colonization in multivariable analysis, there was no significant difference between the cefazolin and the cefazolin + vancomycin regimens (p = 0.19), while the vancomycin + meropenem regimen had a lower occurrence rate of bloodstream infection and surgical site infection than the cefazolin regimen (odds ratio, 0.0885; 95% CI, 0.0176-0.446; p = 0.003). CONCLUSIONS In this study, a lower occurrence rate of postoperative bloodstream infection and surgical site infection was observed among patients with broad-spectrum antibiotic regimen after pediatric cardiac surgery with open chest management. Further studies, ideally randomized controlled studies investigating the efficacy of broad-spectrum antibiotics and their complications, are warranted before routine implementation of broad-spectrum prophylactic antibiotic regimen.
Collapse
|
11
|
Silvetti S, Landoni G, Castagnola E, Nuri H, Pomé G, Moscatelli A. Antibiotic Management for Delayed Sternal Closure Following Pediatric Cardiac Surgery: A Systematic Review of Recent Literature. J Cardiothorac Vasc Anesth 2019; 34:1333-1340. [PMID: 31420313 DOI: 10.1053/j.jvca.2019.07.134] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 07/02/2019] [Accepted: 07/16/2019] [Indexed: 12/21/2022]
Abstract
Delayed sternal closure after pediatric cardiac surgery is a management option for the treatment of patients with severely impaired heart function. The optimal antimicrobial treatment strategy for this condition is unknown. The aim of this systematic review was to evaluate the current antibiotic administration attitudes in pediatric cardiac surgery patients needing an open chest in terms of infection with a focus on surgical site infection rate. The authors performed a systematic review and meta-analysis of all articles, which described the antibiotic administration strategy and surgical site infection rate in pediatric patients with an open chest after cardiac surgery. The authors performed a subgroup analysis on "standard" versus "non-standard" (defined as any antimicrobial drugs different from the adult guidelines recommendations) therapy for one-proportion meta-analysis with a random effect model. The authors identified 12 studies published from January 1, 2000 to July 1, 2019 including a total of 2,203 patients requiring an open chest after cardiac surgery, 350 of whom (15.9%) developed infections and 182 (8.3%) developed a surgical site infection. The surgical site infection rate in patients with "non-standard" strategy was higher than in patients with "standard" strategy: 8.8% (140 reported infections/1,582 patients) versus 6.8% (42 reported infections/621 patients), p = 0.001. The "standard" antibiotic management proposed by guidelines for adult cardiac surgery patients could be used an acceptable strategy to treat pediatric patients with an open chest after cardiac surgery.
Collapse
Affiliation(s)
- Simona Silvetti
- Neonatal and Pediatric Intensive Care Unit, Department of Surgery and Critical Care, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, University Vita-Salute San Raffaele, Milano, Italy.
| | - Elio Castagnola
- Infectious Disease Unit, Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Halkawt Nuri
- Cardiac Surgery Unit, Department of Surgery and Critical Care, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Giuseppe Pomé
- Cardiac Surgery Unit, Department of Surgery and Critical Care, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Andrea Moscatelli
- Neonatal and Pediatric Intensive Care Unit, Department of Surgery and Critical Care, IRCCS Istituto Giannina Gaslini, Genova, Italy
| |
Collapse
|
12
|
Jaworski R, Kansy A, Dzierzanowska-Fangrat K, Maruszewski B. Antibiotic Prophylaxis in Pediatric Cardiac Surgery: Where Are We and Where Do We Go? A Systematic Review. Surg Infect (Larchmt) 2019; 20:253-260. [DOI: 10.1089/sur.2018.272] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Radoslaw Jaworski
- Department of Pediatric Cardiothoracic Surgery, Children's Memorial Health Institute, Warsaw, Poland
| | - Andrzej Kansy
- Department of Pediatric Cardiothoracic Surgery, Children's Memorial Health Institute, Warsaw, Poland
| | | | - Bohdan Maruszewski
- Department of Pediatric Cardiothoracic Surgery, Children's Memorial Health Institute, Warsaw, Poland
| |
Collapse
|
13
|
Abstract
BACKGROUND Perioperative infections have significant consequences for children with congenital heart disease (CHD), which can manifest as acute or chronic infection followed by poor growth and progressive cardiac failure. The consequences include delayed or higher-risk surgery, and increased postoperative morbidity and mortality. METHODS A systematic search for studies evaluating the burden and interventions to reduce perioperative infections in children with CHD was undertaken using PubMed. RESULTS Limited studies conducted in low- to middle-income countries demonstrated the large burden of perioperative infections among children with CHD. Most studies focussed on infections after surgery. Few studies evaluated strategies to prevent preoperative infection or the impact of infection on decision-making around the timing of surgery. Children with CHD have multiple risk factors for infections including delayed presentation, inadequate treatment of cardiac failure, and poor nutrition. CONCLUSIONS The burden of perioperative infections is high among children with CHD, and studies evaluating the effectiveness of interventions to reduce these infections are lacking. As good nutrition, early corrective surgery, and measures to reduce nosocomial infection are likely to play a role, practical steps can be taken to make surgery safer.
Collapse
|