Thomas J Sandora1, Monica Fung2, Patrice Melvin3, Dionne A Graham3, Shawn J Rangel4. 1. Division of Infectious Diseases, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts. 2. Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts. 3. Center for Patient Safety and Quality Research, Boston Children's Hospital, Boston, Massachusetts. 4. Department of Surgery, Boston Children's Hospital, Boston, Massachusetts.
Abstract
IMPORTANCE: Appropriate use of surgical antibiotic prophylaxis (AP) reduces surgical site infection rates, but prior data suggest variability in use patterns. OBJECTIVE: To assess national variability and appropriateness of AP in pediatric surgical patients. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of 31 freestanding children's hospitals in the United States using administrative data from 2010-2013. The study included 603 734 children younger than 18 years who underwent one of the 45 most commonly performed operations. EXPOSURES: Receipt of surgical AP. MAIN OUTCOMES AND MEASURES: Primary outcomes included procedure- and hospital-specific rates of AP use and appropriateness of use based on clinical guidelines and consensus statements. We also assessed rates of Clostridium difficile infection and potential allergic reactions (using epinephrine administration as a surrogate event) after AP receipt. RESULTS: Of the 603 734 eligible patients, the mean (SD) patient age was 4.8 (4.4) years and 384 571 (63.7%) were boys. For the 671 255 operations evaluated, AP was administered for 348 119 (52%) of procedures. Intrahospital variation in AP use by procedure ranged from 11.5% to 100% (median, 78.1%). Overall, AP use was considered appropriate for 64.6% of cases. Appropriate use of AP by hospital varied from 47.3% to 84.4% with large variability by procedure within each hospital. For procedures for which AP was indicated, the median rate of appropriate use by hospital was 93.8%; however, for procedures for which AP was not indicated, the median rate of appropriate use by hospital was 52.0%. The odds of C difficile infection and epinephrine administration were significantly higher among children who received AP (odds ratio, 3.34; 95% CI, 1.66-6.73 and odds ratio 1.97; 95% CI, 1.92-2.02; respectively). CONCLUSIONS AND RELEVANCE: There is substantial national variability in the overall and appropriate use of AP for the most commonly performed operations in children both at a procedure and hospital level. A high proportion of AP use is inappropriate, potentially exposing many children to avoidable adverse events. Urgent attention should be directed to efforts to standardize the use of surgical AP in pediatrics.
IMPORTANCE: Appropriate use of surgical antibiotic prophylaxis (AP) reduces surgical site infection rates, but prior data suggest variability in use patterns. OBJECTIVE: To assess national variability and appropriateness of AP in pediatric surgical patients. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of 31 freestanding children's hospitals in the United States using administrative data from 2010-2013. The study included 603 734 children younger than 18 years who underwent one of the 45 most commonly performed operations. EXPOSURES: Receipt of surgical AP. MAIN OUTCOMES AND MEASURES: Primary outcomes included procedure- and hospital-specific rates of AP use and appropriateness of use based on clinical guidelines and consensus statements. We also assessed rates of Clostridium difficileinfection and potential allergic reactions (using epinephrine administration as a surrogate event) after AP receipt. RESULTS: Of the 603 734 eligible patients, the mean (SD) patient age was 4.8 (4.4) years and 384 571 (63.7%) were boys. For the 671 255 operations evaluated, AP was administered for 348 119 (52%) of procedures. Intrahospital variation in AP use by procedure ranged from 11.5% to 100% (median, 78.1%). Overall, AP use was considered appropriate for 64.6% of cases. Appropriate use of AP by hospital varied from 47.3% to 84.4% with large variability by procedure within each hospital. For procedures for which AP was indicated, the median rate of appropriate use by hospital was 93.8%; however, for procedures for which AP was not indicated, the median rate of appropriate use by hospital was 52.0%. The odds of C difficile infection and epinephrine administration were significantly higher among children who received AP (odds ratio, 3.34; 95% CI, 1.66-6.73 and odds ratio 1.97; 95% CI, 1.92-2.02; respectively). CONCLUSIONS AND RELEVANCE: There is substantial national variability in the overall and appropriate use of AP for the most commonly performed operations in children both at a procedure and hospital level. A high proportion of AP use is inappropriate, potentially exposing many children to avoidable adverse events. Urgent attention should be directed to efforts to standardize the use of surgical AP in pediatrics.
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