An evaluation of antimicrobial prophylaxis in paediatric surgery and its financial implication

Assessment of Surgical Antibiotic Prophylaxis Compliance in Pediatrics: A Pre-post Quasi-experimental Study

OBJECTIVE

Data from rigorous evaluations of the impact of interventions on improving surgical antibiotic prophylaxis (SAP) compliance in pediatrics are lacking. Our objective was to assess the impact of a multifaceted intervention on improving pediatric SAP compliance in a hospital without an ongoing antimicrobial stewardship program.

STUDY DESIGN

A multidisciplinary team at the Montreal Children's Hospital performed a series of interventions designed to improve pediatric SAP compliance in June 2015. A retrospective, quasi-experimental study was performed to assess SAP compliance before and following the interventions. Our study included patients under 18 years old undergoing surgery between April and September in 2013 (preintervention) and in 2016 (postintervention). A 10-week washout period was included to rigorously assess the persistence of compliance without ongoing interventions. SAP, when indicated, was qualified as noncompliant, partially compliant (adequate agent and timing) or totally compliant (adequate agent, dose, timing, readministration, duration).

RESULTS

A total of 982 surgical cases requiring SAP were included in our primary analysis. The composite partial and total compliance increased from 51.4% to 55.8% [adjusted odds ratio 1.3; 95% confidence interval: 1.0-1.8; P = 0.06]. Although improvements in correct dose and readministration were significant, there was no significant improvement in correct timing, agent selection or duration.

CONCLUSION

Our study demonstrated that overall SAP compliance did not significantly improve following a washout period, illustrating the importance of ongoing surveillance and feedback from an antimicrobial stewardship program. Our strict approach in evaluating the timing criterion may also explain the lack of a significant impact on SAP compliance.

Adherence to surgical antibiotic prophylaxis guidelines in children: A cohort study

AIMS

Surgical antimicrobial prophylaxis (SAP) is an important measure to reduce post-operative infections. Guidelines exist, but their efficacy and performance in children is poorly understood compared with adults. To review adherence to SAP guidelines, this study assesses risk factors for non-adherence and rate of early post-surgical infections.

METHODS

A retrospective cohort study of paediatric surgical cases (0-<18 years) at a tertiary children's hospital was performed. Patient characteristics, surgical factors and antimicrobial details were evaluated against hospital guidelines for overall adherence and domains of: antimicrobial choice, dose, re-dosing, timing and duration. Multiple regression analysis was used to determine risk factors for non-adherence. Hospital records were reviewed for post-operative infections at 7 and 30 days.

RESULTS

Among 326 cases, overall guideline adherence was 39.6% but varied by domain and surgical subspecialty. Incorrect wound classification was associated with overall non-adherence on multivariate regression (odds ratio (OR): 2.59; P < 0.001). Incorrect antimicrobial choice was more likely in children with penicillin hypersensitivity (OR 138.34, P = 0.004) and incorrect dosing more likely in adolescent patients (OR 4.33; P = 0.004). Presence of invasive devices was associated with prolonged duration of antimicrobials (OR 2.92, P = 0.016). Only two post-operative infections were documented by 30 days, but data were insufficient to exclude mild infections managed in the community.

CONCLUSIONS

SAP was suboptimal in children, with areas for improvement including better guidance on wound classification, allergy management and care for adolescent patients. Documented infections were rare, but mild infections were unable to be excluded due to limited post-discharge information.

Surgical antimicrobial prophylaxis and its dose appropriateness among paediatric patients in a Nigerian teaching hospital

Surgical antimicrobial prophylaxis (SAP) prevents incision site infection. We assessed SAP compliance with existing international guidelines, evaluated the appropriateness of the antimicrobial doses, and determined the risk factors for antimicrobial under-dosing. A retrospective chart review was performed for patients who under-went surgery and administered antimicrobial prophylaxis. Compliance with SAP guidelines was evaluated. Antimicrobial doses were categorized as under-, normal-, or over-dose. Of the 303 surgical patients, 97.7% received SAP and complete compliance was achieved in 5.6%. Of the 550 antimicrobial prescriptions, metronidazole (42.7%) and cefuroxime (34.7%) were the most prescribed. Over- (31.5%), under- (44.5%), and normal- dosing (24.0%) were recorded, respectively. None of the factors evaluated predicted the risk of antimicrobial under-dosing. Full compliance with international SAP guidelines was poor in our study. Correct timing, re-dosing, and duration of antimicrobial use were the most violated. Most antimicrobials were under-dosed, suggesting a need for national and institutional SAP guidelines.

Appropriateness of Surgical Antibiotic Prophylaxis in Pediatric Patients in Italy

OBJECTIVES

Appropriate use of surgical antibiotic prophylaxis (SAP) reduces intraoperative wound contamination in pediatric surgery, thus minimizing the risk of surgical site infection (SSIs). Conversely, inappropriate use of SAP exposes patients to the risk of antibiotic side effects and contributes to the emergence of antimicrobial resistance. Our aims were to describe SAP administration and to analyze factors associated with nonadherence in pediatric patients.

DESIGN

Descriptive study.

SETTING

Overall, 955 pediatric patients underwent 1,038 surgical procedures.

METHODS

We assessed adherence to SAP international guidelines for surgical procedures performed on children aged <18 years in 2015 in 4 randomly selected hospitals in Calabria (Italy). The clinical records of these patients were retrospectively reviewed.

RESULTS

Appropriate SAP administration or nonadministration pertained to 754 surgical procedures (72.6%). Surgical antibiotic prophylaxis was administered in 88.5% of 358 procedures with an SAP indication. Adherence to guidelines for appropriate drug choice were followed in 5.7% of cases, for route of administration in 76.7% of cases, for timing in 48.6% of cases, for duration in 14.5% of cases, and for dose in 91.5% of cases, and for all components in only 5 cases (1.6%). Among 680 procedures without SAP indication, 35.7% case patients received antibiotics. Inappropriate administration of antibiotics in procedures without SAP indication was associated with surgical specialty wards (P=.008), ordinary admission (P<.001), head and neck surgical procedures (P=.020), clean surgery (P=.017), and surgical duration (P=.010).

CONCLUSIONS

Discrepancies between SAP guidelines and actual practice behavior more frequently indicate excessive use of antibiotics than underuse. Increased awareness of SAP guidelines is required.

Infect Control Hosp Epidemiol 2017;38:823–831

Prescription of antibiotics in Riga and Vilnius tertiary children's hospitals

Objectives

The aim of this study was to compare the use of antibiotics among hospitalised children in Riga (Latvia) and in Vilnius (Lithuania) at two tertiary paediatric centres.

Methods

A point prevalence survey (PPS) was conducted using validated and standardised Antibiotic Resistance and Prescribing in European Children (ARPEC) project methodology during November 2012. All inpatients less than 18 years old were included in the study. All data were recorded for patients with active antimicrobial prescriptions at 8 am on the day of the survey. Data were entered into the ARPEC-webPPS programme and were validated online for accuracy.

Results

The proportion of patients receiving antimicrobial therapy was statistically different: 128 (37.0%) patients in Riga and 83 (26.3%) in Vilnius. The most common age group in Riga and Vilnius was 1-5 years. The most commonly used antibiotic classes for the treatment and prophylaxis of infection were third-generation cephalosporins (38; 25.5% prescriptions) in Riga and second-generation cephalosporins (16; 19.8%) in Vilnius. Parenteral use of antimicrobials was higher in Riga than in Vilnius: 111 (74.5%) prescriptions to paediatric patients in Riga and 45 (55.6%) prescriptions in Vilnius.

Conclusions

The PPS identified differences in antibiotic use in both hospitals and problem areas for improvement: high use of third-generation cephalosporins for paediatric patients (in Riga) and predominant use of parenteral antibiotics. Further collaboration between both centres is needed because sharing audit data and antimicrobial stewardship initiatives may encourage further changes in practice at both institutions.

[Assessment of antibiotic use and impact of an intervention intended to modify the prescribing behavior in surgical prophylaxis in 6hospitals in the metropolitan area of Monterrey, Mexico]

BACKGROUND

Improper use of antibiotics increases antimicrobial resistance.

OBJECTIVE

Evaluate the use of antibiotics and the impact of an intervention designed to improve antibiotic prescription for surgical prophylaxis in 6 hospitals of Monterrey, Mexico.

MATERIAL AND METHODS

Design: A prospective multicenter survey and a pretest-postest experimental study. Phase 1: Survey to evaluate the use of antibiotics through an especially designed guide. Phase 2: Intervention designed to improve antibiotic prescription for surgical prophylaxis by the medical staff by using printed, audiovisual and electronic messages. Phase 3: Survey to evaluate the impact of the intervention.

ANALYSIS

Frequencies, percentages, medians, ranges and X² test.

RESULTS

Phase 1: We evaluated 358 surgical patients, 274 prophylactic antibiotic regimens. A total of 96% of antibiotics regimens began with inappropriate timing (290/302), 82.8% were inappropriate regimens (274/331), 77.7% were in inappropriate dosage (230/296), 86% of inadequate length (241/280), and in 17.4% restricted antibiotics were used (52/299). Phase 2: 9 sessions including 189 physicians (14 department chairs, 58 general practitioners and 117 residents). Phase 3: We evaluated 303 surgical patients, 218 prophylactic antibiotics regimens. Inappropriate treatment commencement was reduced to 84.1% (180/214) (P<0.001), inappropriate regimens to 75.3% (162/215) (P=0.03), inappropriate dosages to 51.2% (110/215) (P<0.001), and use of restricted antibiotics to 8.3% (18/215) (P=0.003).

CONCLUSIONS

Inappropriate use of prophylactic antibiotics in surgery is a frequent problem in Monterrey. The intervention improved the antibiotic prescription for surgical prophylaxis by reducing inappropriate treatment commencement, regimens, dosages, and overuse of restricted antibiotics. It is necessary to strengthen strategies to improve the prescription of antibiotics in surgical prophylaxis.

Clinical practice audit concerning antimicrobial prophylaxis in paediatric neurosurgery: results from a German paediatric oncology unit

BACKGROUND

Perioperative antimicrobial prophylaxis (PAP) has been identified as an important target for internal audits, concerning the judicious use of antibiotics. Paediatric oncology patients with brain tumours face an increased risk of surgical site infection (SSI) after neurosurgery and receive routine PAP in this setting.

PATIENTS AND METHODS

All patients younger than 18 years admitted to the paediatric oncology centre (POC) with a neurosurgical intervention. Systematic audit of routine clinical data is divided in two groups: retrospective (Jan 01, 2012-March 31, 2014) and prospective (April 01, 2014-March 31, 2015) referring to an internal PAP guideline, invented in Jan. 2014). Surveillance of SSI up to 30 days after the operation with standard criteria (Centres for Disease Control and Prevention, USA).

RESULTS

In total, 53 neurosurgical operations were analysed in 33 paediatric oncology patients. Twelve patients received more than one operation. The detailed analysis of PAP revealed prophylactic cefuroxim doses about 30 mg/kg instead of 50 mg/kg and no repeated dosing in operations lasting longer than 4 h. In addition, Cefotaxim, which is not indicated as PAP in neurosurgery, was used instead of Cefuroxim (or Ampicillin-Sulbactam) in 23 % of all cases in the retrospective and 18 % of all cases in the prospective audit. PAP for more than 3 doses (>24 h) was administered in 66 % in the retrospective group and in 60 % in the prospective group (p = n.s.). In both groups, no SSI was detected.

DISCUSSION

This first comprehensive audit of PAP in paediatric oncology patients undergoing neurosurgery outlines significant opportunities to improve clinical practice in terms of correct dosing, the correct choice of the antibiotic, a correct timing schedule and a shorter duration of PAP. In addition, our results illustrate in detail the challenges in clinical practice when an evidence-based approach to improve a standard workflow has to be implemented.

Antibiotic Prophylaxis to Prevent Surgical Site Infections in Children: A Prospective Cohort Study

OBJECTIVE

To investigate the association between antibiotic prophylaxis (AP) and surgical-site infection in pediatric patients.

BACKGROUND

Surgical-site infections (SSIs) are a major cause of postoperative morbidity and mortality. Despite numerous studies in adults, benefit of AP in preventing SSIs in children is uncertain.

METHODS

Patients aged 0 to 21 years who underwent surgical procedures at a pediatric acute care hospital from April 1, 2009, to December 31, 2010, were assessed. Antibiotic prophylaxis indication and administration according to an evidence-based guideline were recorded. Complete compliance was defined as AP given, when indicated, within 60 minutes before incision. Surgical-site infections were identified using the Centers for Disease Control and Prevention criteria and documented in the medical records using the International Classification of Diseases, Tenth Revision. Multiple logistic regressions adjusting for age, sex, American Society of Anesthesiologists status, wound classification, admission status, surgical discipline, and surgical duration evaluated association of AP compliance and SSI.

RESULTS

Of 5309 patients for whom antibiotics were indicated, 3901 (73.5%) with complete compliance had an infection rate of 3.0%, whereas 1408 (26.5%) who were not compliant had an infection rate of 4.3% (adjusted relative risk: 0.7; 95% confidence interval: 0.5-0.9; P = 0.02). Of 4156 patients for whom antibiotics were not indicated, the 895 (21.5%) who received antibiotics had an infection rate of 1.7% compared with 0.7% in the 3261 (78.5%) who did not receive antibiotics (adjusted relative risk: 1.6; 95% confidence interval: 0.8-3.1; P = 0.18).

CONCLUSIONS

In pediatric surgery, complete compliance with AP was associated with 30% decreased risk of SSI.

Economic evaluation of appropriate duration of antibiotic prophylaxis for prevention of neurosurgical infections in a middle-income country

BACKGROUND

Preoperative antibiotic prophylaxis is one of the preventive measures for surgical site infections (SSIs). Very little data about the cost effectiveness of the appropriate duration of antibiotic prophylaxis in low- and middle-income countries are available. We aim to assess the cost effectiveness of the use of antibiotic prophylaxis for <24 hours to prevent neurosurgical infections in a middle-income country, Turkey.

METHODS

A 1-year prospective study was performed between June 2012 and June 2013. During this study period patients were followed-up on for the development of SSI by means of hospital and postdischarge surveillance. Patients included in the study group received appropriate duration of antibiotic prophylaxis (<24 hours), and the duration of prophylaxis was longer in the control group. The antibiotic costs per patient, including prophylaxis and treatment, were calculated.

RESULTS

A total of 822 operations consisting of craniotomy (n = 558), spinal fusion (n = 220), and ventricular shunt (n = 44) were included in the study. The study group included 488 (59.4%) patients who underwent operations with appropriate duration (<24 hours) of antibiotic prophylaxis. Prophylactic antibiotic cost per patient was significantly lower in the study group ($3.35 and $20.41, respectively). The SSI rates did not differ between the 2 groups: 3.5% (17/488) in the study group and 3.6 (12/822) in the control group (P > .05).

CONCLUSION

This cost-analysis study demonstrates that prolonged antibiotic prophylaxis correlates with increased burden of cost, but it is not preventive for SSI.

Antimicrobial usage among hospitalized children in Latvia: a neonatal and pediatric antimicrobial point prevalence survey

BACKGROUND AND OBJECTIVE

The point prevalence survey was conducted as part of the Antibiotic Resistance and Prescribing in European Children (ARPEC) Project. The study aimed at analyzing pediatric and neonatal antimicrobial prescribing patterns in Latvian hospitals, to identify targets for quality improvement.

MATERIALS AND METHODS

A one day cross-sectional point prevalence survey on antibiotic use in hospitalized children was conducted in November 2012 in 10 Latvian hospitals, using a previously validated and standardized method. The survey included all inpatient pediatric and neonatal beds and identified all children receiving an antimicrobial treatment on the day of survey.

RESULTS

Overall 549 patients were included in the study; 167 (39%) patients admitted to pediatric wards and 25 (21%) patients admitted to neonatal wards received at least one antimicrobial. Pediatric top three antibiotic groups were third-generation cephalosporins (55 prescriptions, 28%), extended spectrum penicillins (n=32, 16%) and first-generation cephalosporins (n=26, 13%). Eleven pediatric patients (85%) received surgical prophylaxis more than 1 day; 143 pediatric patients (86%) received antibiotics intravenously. Lower respiratory tract infections were the most common indications for antibiotic use both in pediatric (n=60, 35.9%) and neonatal patients (n=9, 36%). The most used antibiotics for neonatal patients were benzylpenicillin (n=12, 32%), and gentamicin (n=9, 24%).

CONCLUSIONS

We identified a few problematic areas, which need improvement: the high use of third-generation cephalosporins for pediatric patients, prolonged surgical prophylaxis, predominant use of parenteral antibiotics and an urgent need for local antibiotic guidelines.

Intrapartum-related neonatal encephalopathy incidence and impairment at regional and global levels for 2010 with trends from 1990

BACKGROUND

Intrapartum hypoxic events ("birth asphyxia") may result in stillbirth, neonatal or postneonatal mortality, and impairment. Systematic morbidity estimates for the burden of impairment outcomes are currently limited. Neonatal encephalopathy (NE) following an intrapartum hypoxic event is a strong predictor of long-term impairment.

METHODS

Linear regression modeling was conducted on data identified through systematic reviews to estimate NE incidence and time trends for 184 countries. Meta-analyses were undertaken to estimate the risk of NE by sex of the newborn, neonatal case fatality rate, and impairment risk. A compartmental model estimated postneonatal survivors of NE, depending on access to care, and then the proportion of survivors with impairment. Separate modeling for the Global Burden of Disease 2010 (GBD2010) study estimated disability adjusted life years (DALYs), years of life with disability (YLDs), and years of life lost (YLLs) attributed to intrapartum-related events.

RESULTS

In 2010, 1.15 million babies (uncertainty range: 0.89-1.60 million; 8.5 cases per 1,000 live births) were estimated to have developed NE associated with intrapartum events, with 96% born in low- and middle-income countries, as compared with 1.60 million in 1990 (11.7 cases per 1,000 live births). An estimated 287,000 (181,000-440,000) neonates with NE died in 2010; 233,000 (163,000-342,000) survived with moderate or severe neurodevelopmental impairment; and 181,000 (82,000-319,000) had mild impairment. In GBD2010, intrapartum-related conditions comprised 50.2 million DALYs (2.4% of total) and 6.1 million YLDs.

CONCLUSION

Intrapartum-related conditions are a large global burden, mostly due to high mortality in low-income countries. Universal coverage of obstetric care and neonatal resuscitation would prevent most of these deaths and disabilities. Rates of impairment are highest in middle-income countries where neonatal intensive care was more recently introduced, but quality may be poor. In settings without neonatal intensive care, the impairment rate is low due to high mortality, which is relevant for the scale-up of basic neonatal resuscitation.

Timing of surgical antibiotic prophylaxis administration: complexities of analysis

Background

The timing of prophylactic antibiotic administration is a patient safety outcome that is recurrently tracked and reported. The interpretation of these data has important implications for patient safety practices. However, diverse data collection methods and approaches to analysis impede knowledge building in this field. This paper makes explicit several challenges to quantifying the timing of prophylactic antibiotics that we encountered during a recent study and offers a suggested protocol for resolving these challenges.

Challenges

Two clear challenges manifested during the data extraction process: the actual classification of antibiotic timing, and the additional complication of multiple antibiotic regimens with different timing classifications in a single case. A formalized protocol was developed for dealing with incomplete, ambiguous and unclear documentation. A hierarchical coding system was implemented for managing cases with multiple antibiotic regimens.

Interpretation

Researchers who are tracking prophylactic antibiotic timing as an outcome measure should be aware that documentation of antibiotic timing in the patient chart is frequently incomplete and unclear, and these inconsistencies should be accounted for in analyses. We have developed a systematic method for dealing with specific problematic patterns encountered in the data. We propose that the general adoption of a systematic approach to analysis of this type of data will allow for cross-study comparisons and ensure that interpretation of results is on the basis of timing practices rather than documentation practices.