Procedure-level Misutilization of Antimicrobial Prophylaxis in Pediatric Surgery: Implications for Improved Stewardship and More Effective Infection Prevention
Katherine He, MD, MS1, Marie Iwaniuk, PhD2, Michael J. Goretsky, MD3, Robert A. Cina, MD4, Jacqueline M. Saito, MD, MSCI5, Bruce Hall, MD, PhD, MBA2,5, Catherine Grant, BSN, RN2, Mark E. Cohen, PhD2, Jason Newland, MD, MEd6, Clifford Y. Ko, MD, MS, MSHS2, Shawn J. Rangel, MD, MSCE1
1Department of Surgery, Boston Children's Hospital, Boston, MA; 2American College of Surgeons, Chicago, IL; 3Department of Surgery, Children's Hospital of the King's Daughters, Norfolk, VA; 4Department of Surgery, The Medical University of South Carolina, Charlestown, SC; 5Department of Surgery, Washington University St. Louis School of Medicine and BJC Healthcare, St. Louis, MO; 6Department of Pediatrics, Washington University St. Louis School of Medicine, St. Louis, MO
Background: The study objective was to quantify the burden of procedure-level antibiotic prophylaxis misutilization to identify high-priority targets for stewardship and surgical site infection prevention.
Methods: Multicenter cohort study of elective pediatric surgeries at 90 NSQIP-Pediatric hospitals (6/2019-6/2020). Procedure-level misutilization burden was derived by multiplying rates from NSQIP-Pediatric data by case volume data from the Pediatric Health Information System database. The contribution of each procedure to the overall misutilization burden from all procedures was used to identify high-priority procedures.
Results: N=11689. Overutilization was associated with inappropriately broad-spectrum agents (14.0%), unindicated utilization (12.6%) and postoperative prophylaxis >24 hours (8.4%) (table 1). Procedures associated with the greatest burden of unindicated utilization included cholecystectomy, ovarian procedures, and orchidopexy (93% of cases). Underutilization was associated with administration after incision (6.2%), omission when indicated (4.4%) and use of inappropriately narrow spectrum agents (4.1%) (table 2). Procedures associated with the greatest relative burden of inappropriately narrow spectrum agents included gastrostomy, colorectal, and small bowel procedures (92% of cases).
Conclusion: A small number of procedures account for a disproportionate burden of antibiotic misutilization in pediatric surgery. Multiple high-priority opportunities were identified for both improved stewardship and infection prevention, often within the same procedure groups.
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