ORIGINAL ARTICLE
Antibiotic Prophylaxis to Prevent Surgical Site Infections in Children: A Prospective Cohort Study Amir Khoshbin, MD, MSc,∗ Jeannette P. So, MSc,† Ilyas S. Aleem, MD,‡ Derek Stephens, MSc,§ Anne G. Matlow, MD, MSc, FRCSC,¶ and James G. Wright, MD, MPH, FRCSC∗ †§; for The SickKids Surgical Site Infection Task Force
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. Keywords: antibiotic prophylaxis, guideline compliance, pediatric surgery, quality improvement, surgical site infection (Ann Surg 2015;262:397–402)
S
urgical-site infections (SSIs) result in prolonged hospitalization, increased morbidity, and mortality.1,2 In the United States, the cost of preventable SSIs has been approximated to be $345 million annually.3 Strategies to reduce SSIs have focused on patient optimization, infection surveillance programs, postoperative care, and operative factors such as antibiotic prophylaxis (AP).4,5 Although the benefits of AP within 1 hour before surgical incision have been well documented to reduce SSIs in adults,6,7 most prior studies in children have shown no benefit,8–15 leading to uncertainty about the benefits of antibiotics in children and adolescents, and widely variables rates of administration.16 However, previous studies in children have had small sample sizes, lacked comprehensive evidence-based AP guidelines, utilized nonvalidated definitions of SSI or not evaluated patients with surgical implants for the appropriate duration. The use of AP, or the alternative strategy of giving antibiotics to all children to prevent SSI, needs to be weighed against potential risks, including side effects, toxicity, cost, and increased emergence of antimicrobial resistance.17 The goal of this prospective cohort study was to determine the association between AP and subsequent SSIs in pediatric surgical patients.
METHODS Study Location Patients undergoing both urgent and scheduled surgical procedures at The Hospital for Sick Children from April 1, 2009, to December 31, 2010, were evaluated. The Hospital for Sick Children is a 278-bed pediatric hospital in Toronto, Ontario, Canada. Institutional ethics approval was obtained before study initiation and data collection.
Inclusion and Exclusion From the ∗ Division of Orthopedic Surgery, University of Toronto, Toronto, Ontario, Canada; †Department of Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada; ‡Division of Orthopedic Surgery, McMaster University, Hamilton, Ontario, Canada; §Child Health Evaluative Services, The Hospital for Sick Children, Toronto, Ontario, Canada; and ¶Center for Patient Safety, University of Toronto, Toronto, Ontario, Canada. Members of The SickKids Surgical Site Infection Task Force include the following: Zoran Bojic, MHSc, PMP, CLA, ASQ-CMQOE; Rita Damignani, MSc, BScPT; Annie Fecteau, MDCM, FRCP(C); Igor Luginbuehl, MD; Anne G. Matlow, MD, MSc, FRCPC; Jean Paul Paraiso, MSc; Lisa Pendergast, RN; Debi Senger, CHIM; Jeannette P. So, MSc; Laurie Streitenberger, RN, BSc, CIC; Kathryn Timberlake, PharmD; and James G. Wright, MD, MPH, FRCSC. Disclosure: Supported by the Robert B. Salter Chair of Surgical Research (to J.G.W.). Supported by Pfizer(to K.T.). The authors declare no conflicts. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.annalsofsurgery.com). Reprints: James G. Wright, MD, MPH, FRCSC, The Hospital for Sick Children, 555 University Avenue, Black Wing, Room 1254, Toronto, ON M5G 1X8, Canada. E-mail: [email protected]. C 2014 Wolters Kluwer Health, Inc. All rights reserved. Copyright ISSN: 0003-4932/14/26202-0397 DOI: 10.1097/SLA.0000000000000938
Annals of Surgery r Volume 262, Number 2, August 2015
All patients undergoing any elective or nonelective surgical procedure (performed by a total of 53 staff surgeons) in the following seven surgical disciplines were eligible for the study: cardiovascular surgery, general surgery, neurosurgery, orthopedic surgery, otolaryngology, plastic surgery, and urology. Patients with documented or suspected pre-existing infection, including patients with otitis media, cholesteatoma, perforated appendix, abscess, sepsis, draining pus, or fistula, were excluded. Procedures that involved the oral cavity, isolated endoscopies (including foreign body removal), organ retrieval, or central venous line removal were also excluded.
Antibiotic Prophylaxis Guideline A surgical AP guideline was defined from prior evidencebased guidelines,18,19 including from The American Academy of Pediatrics,20 Centers for Disease Control and Prevention (CDC),4 American Society of Health-System Pharmacists,21 Infectious Diseases Society of America,22 Surgical Infection Society,23 and Surgical Infection Prevention Guideline Writers Workgroup (see the Appendix, Supplemental Digital Content 1 available at http://links.lww.com/SLA/A826, which shows full guideline).24 www.annalsofsurgery.com | 397
Copyright © 2014 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Annals of Surgery r Volume 262, Number 2, August 2015
Khoshbin et al
Doses appropriate for children and neonates, and alternatives in circumstances of allergy, were provided.25 Operating room nurses documented the administration of AP and the timing of administration relative to surgical incision. The nursing staff could not sign off on the electronic operating room logs until AP documentation was completed. Each wound was classified as follows: “dirty” wounds were considered operative fields with “gross contamination or spillage into the operative field,” whereas “clean-contaminated” wounds were those that “involved the surgical transection of a nonsterile mucocutaneous surface.”26 All other procedures were considered to be “clean.”26 In addition, the following variables were collected for patients at the time of surgery: sex, age (years), weight (kilograms), American Society of Anesthesiologists physical status (categorized as either I-II or III-V), duration of procedure (hours, as per operating room log), admission status (categorized as inpatient or outpatient), and the surgical discipline of the primary surgeon. American Society of Anesthesiologists physical status was dichotomized as I-II indicative of healthy patients or patients with mild disease, and III-IV for patients with severe disease that may or may not be life-threatening. Patients were “inpatients” if their admission was more than 24 hours before the planned surgical procedure or their postoperative admission was more than 24 hours. “Outpatients” were patients who were admitted 24 hours or earlier, before the planned surgical procedure, and whose postoperative admission was 24 hours or less.
Surgical Site Infections Although direct examination of surgical wounds was the traditional approach to detecting SSIs,4 at The Hospital for Sick Children, this type of surveillance was available only for cardiovascular surgical procedures, neurosurgeries, and spine instrumentations. Therefore, SSIs in our study were identified using patients’ medical records. Health records coders extracted data from patients’ charts and assigned diagnostic and procedural codes using the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, the Canadian Classification of Health Interventions, and the 3M-Codefinder software for all inpatient, day surgery, and emergency encounters. Coders were specifically trained to use the CDC/National Healthcare Safety Network (NHSN) SSI criteria: an infection (superficial, deep, or organ space) occurring within 30 days of a surgical procedure, except as recommended for patients with surgical implants, an infection occurring within 1 year.4 For patients without implants, an infection that occurred more than 30 days after the surgical procedure was not classified as an SSI. The coding quality analyst flagged charts with surgical infection diagnoses for review with infection control, to confirm presence of SSI. Any amendments were recoded accordingly.
Indication and Compliance Antibiotic prophylaxis and compliance were categorized as (1) complete compliance: antibiotics, when indicated, given 60 minutes or less, before surgical incision (deemed “on-time”), (2) partial compliance: antibiotics given when indicated but not 60 minutes or less before incision (deemed “late”), or (3) noncompliant: antibiotics not given when indicated (deemed “not given”). For complete compliance, AP must have been given before inflation of a tourniquet (if used), otherwise noncompliance was noted. For patients with allergies or previous colonization with methicillinresistant Staphylococcus aureus, if vancomycin was used, administration of the AP must have been 120 minutes or less before surgical incision (see the Appendix, Supplemental Digital Content 1 available at http://links.lww.com/SLA/A826, which shows full guideline).20,24 398 | www.annalsofsurgery.com
Statistical Analysis Continuous variables were analyzed by independent Student’s t tests and categorical variables were analyzed by chi-square tests. An alpha value of less than .05 (2-tailed) was considered significant for all comparisons. The primary outcome for this study was whether an SSI occurred after a surgical procedure (binary outcome). Multiple logistic regressions assessed the relationship of SSI and AP compliance, adjusting for patient factors (age, sex, American Society of Anesthesiologists physical status, and wound classification) and surgical factors (admission status, surgical discipline, and surgical duration). Mean differences with 95% confidence intervals (Newcombe-Wilson hybrid score) for SSI rates and adjusted relative risks were estimated for patients on the basis of the aforementioned variables. All variables and categorization of variables were consistent for all comparisons and regression analyses performed. Missing values were not imputed and patients with missing variables were excluded from the analyses. Statistical analyses were performed by an independent biostatistician with SAS Version 9.3 for Windows (SAS Institute, Cary, NC).
RESULTS Of 10 556 patients who underwent surgery during the 21-month study period, 9465 (89.7%) met the inclusion criteria and were enrolled (Fig. 1). The mean patient age was 6.8 ± 5.7 years, with 61.0% (N = 5770) being males. The majority of patients had general surgery procedures (n = 1928; 20.4%). Patients who received AP differed from those not given AP, with respect to sex, American Society of Anesthesiologists physical status, wound classification, admission status, surgical discipline, and surgical duration (Tables 1 and 2). Data were unavailable for some patients, which included American Society of Anesthesiologists physical status (n = 368 [3.9%] total; n = 4 [1.9%] with SSIs vs n = 364 [3.9%] without SSIs), wound classification (n = 135 [1.4%] total; n = 1 [0.5%] with SSI vs n = 134 [1.4%] without SSIs) and admission status (n = 44 [0.5%] total; n = 0 [0%] with SSI vs n = 44 [0.5%] without SSIs). Of the 9465 included patients, AP was indicated for 56.1% (n = 5309) and not indicated for 43.9% (n = 4156). A total of 216 SSIs were detected (SSI rate: 2.3%; 95% confidence interval: 2.0%– 2.6%). Of the 216 patients with SSIs, 54 (25.0%) had a surgical implant inserted during their procedure. Of 5309 (56.1%) patients, for whom antibiotics were indicated according to the guideline, the 3901 (73.5%) patients with complete compliance had an infection rate of 3.0%, compared with the 1408 (26.5%) noncompliant patients with an infection rate of 4.3% (unadjusted, mean difference: 1.3%; 95% confidence interval: 0.2%–2.6%; P = 0.02). Of 4156 (43.9%) patients, for whom antibiotics were not indicated, the 895 (21.5%) patients who received antibiotics due to noncompliance with the guideline had an infection rate of 1.7% compared with an infection rate of 0.7% in the 3261 (78.5%) patients who did not receive antibiotics (unadjusted, mean difference: 1.0%; 95% confidence interval: 0.3%–2.1%; P = 0.005). Of all factors, patients with a clean wound (adjusted relative risk: 0.6; 95% confidence interval: 0.4–0.9; P = 0.009) had a lower risk of developing an SSI. Being an inpatient (adjusted relative risk: 2.9; 95% confidence interval: 1.4–5.7; P = .004), longer surgical duration (adjusted relative risk: 1.0; 95% confidence interval: 1.0–1.0; P < .001) or certain surgical disciplines (cardiovascular, general surgery, neurosurgery, and orthopedics) were associated with increased risk of developing an SSI (Table 3). With complete AP compliance, the adjusted relative risk of SSI was 0.7 times that of partial or noncompliance (95% confidence interval: 0.5–0.9; P = 0.02). In procedures where antibiotics were not indicated, the risk of developing an SSI was unchanged by whether C 2014 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2014 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Annals of Surgery r Volume 262, Number 2, August 2015
Pediatric Surgical Infection Prevention
Total Number of Paents N=9465
Anbiocs Indicated N=5309 (56.1%)
Anbiocs Given N=4320 (81.4%)
FIGURE 1. Surgical site infection rates by antibiotic prophylaxis indication and compliance.
Anbiocs Not Indicated N=4156 (43.9%)
Anbiocs Not Given N=989 (18.6%)
Anbiocs Given N=895 (21.5%)
Anbiocs Not Given N= 3261 (78.5%)
Within
Antibiotic Prophylaxis to Prevent Surgical Site Infections in Children: A Prospective Cohort Study Amir Khoshbin, MD, MSc,∗ Jeannette P. So, MSc,† Ilyas S. Aleem, MD,‡ Derek Stephens, MSc,§ Anne G. Matlow, MD, MSc, FRCSC,¶ and James G. Wright, MD, MPH, FRCSC∗ †§; for The SickKids Surgical Site Infection Task Force
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. Keywords: antibiotic prophylaxis, guideline compliance, pediatric surgery, quality improvement, surgical site infection (Ann Surg 2015;262:397–402)
S
urgical-site infections (SSIs) result in prolonged hospitalization, increased morbidity, and mortality.1,2 In the United States, the cost of preventable SSIs has been approximated to be $345 million annually.3 Strategies to reduce SSIs have focused on patient optimization, infection surveillance programs, postoperative care, and operative factors such as antibiotic prophylaxis (AP).4,5 Although the benefits of AP within 1 hour before surgical incision have been well documented to reduce SSIs in adults,6,7 most prior studies in children have shown no benefit,8–15 leading to uncertainty about the benefits of antibiotics in children and adolescents, and widely variables rates of administration.16 However, previous studies in children have had small sample sizes, lacked comprehensive evidence-based AP guidelines, utilized nonvalidated definitions of SSI or not evaluated patients with surgical implants for the appropriate duration. The use of AP, or the alternative strategy of giving antibiotics to all children to prevent SSI, needs to be weighed against potential risks, including side effects, toxicity, cost, and increased emergence of antimicrobial resistance.17 The goal of this prospective cohort study was to determine the association between AP and subsequent SSIs in pediatric surgical patients.
METHODS Study Location Patients undergoing both urgent and scheduled surgical procedures at The Hospital for Sick Children from April 1, 2009, to December 31, 2010, were evaluated. The Hospital for Sick Children is a 278-bed pediatric hospital in Toronto, Ontario, Canada. Institutional ethics approval was obtained before study initiation and data collection.
Inclusion and Exclusion From the ∗ Division of Orthopedic Surgery, University of Toronto, Toronto, Ontario, Canada; †Department of Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada; ‡Division of Orthopedic Surgery, McMaster University, Hamilton, Ontario, Canada; §Child Health Evaluative Services, The Hospital for Sick Children, Toronto, Ontario, Canada; and ¶Center for Patient Safety, University of Toronto, Toronto, Ontario, Canada. Members of The SickKids Surgical Site Infection Task Force include the following: Zoran Bojic, MHSc, PMP, CLA, ASQ-CMQOE; Rita Damignani, MSc, BScPT; Annie Fecteau, MDCM, FRCP(C); Igor Luginbuehl, MD; Anne G. Matlow, MD, MSc, FRCPC; Jean Paul Paraiso, MSc; Lisa Pendergast, RN; Debi Senger, CHIM; Jeannette P. So, MSc; Laurie Streitenberger, RN, BSc, CIC; Kathryn Timberlake, PharmD; and James G. Wright, MD, MPH, FRCSC. Disclosure: Supported by the Robert B. Salter Chair of Surgical Research (to J.G.W.). Supported by Pfizer(to K.T.). The authors declare no conflicts. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.annalsofsurgery.com). Reprints: James G. Wright, MD, MPH, FRCSC, The Hospital for Sick Children, 555 University Avenue, Black Wing, Room 1254, Toronto, ON M5G 1X8, Canada. E-mail: [email protected]. C 2014 Wolters Kluwer Health, Inc. All rights reserved. Copyright ISSN: 0003-4932/14/26202-0397 DOI: 10.1097/SLA.0000000000000938
Annals of Surgery r Volume 262, Number 2, August 2015
All patients undergoing any elective or nonelective surgical procedure (performed by a total of 53 staff surgeons) in the following seven surgical disciplines were eligible for the study: cardiovascular surgery, general surgery, neurosurgery, orthopedic surgery, otolaryngology, plastic surgery, and urology. Patients with documented or suspected pre-existing infection, including patients with otitis media, cholesteatoma, perforated appendix, abscess, sepsis, draining pus, or fistula, were excluded. Procedures that involved the oral cavity, isolated endoscopies (including foreign body removal), organ retrieval, or central venous line removal were also excluded.
Antibiotic Prophylaxis Guideline A surgical AP guideline was defined from prior evidencebased guidelines,18,19 including from The American Academy of Pediatrics,20 Centers for Disease Control and Prevention (CDC),4 American Society of Health-System Pharmacists,21 Infectious Diseases Society of America,22 Surgical Infection Society,23 and Surgical Infection Prevention Guideline Writers Workgroup (see the Appendix, Supplemental Digital Content 1 available at http://links.lww.com/SLA/A826, which shows full guideline).24 www.annalsofsurgery.com | 397
Copyright © 2014 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Annals of Surgery r Volume 262, Number 2, August 2015
Khoshbin et al
Doses appropriate for children and neonates, and alternatives in circumstances of allergy, were provided.25 Operating room nurses documented the administration of AP and the timing of administration relative to surgical incision. The nursing staff could not sign off on the electronic operating room logs until AP documentation was completed. Each wound was classified as follows: “dirty” wounds were considered operative fields with “gross contamination or spillage into the operative field,” whereas “clean-contaminated” wounds were those that “involved the surgical transection of a nonsterile mucocutaneous surface.”26 All other procedures were considered to be “clean.”26 In addition, the following variables were collected for patients at the time of surgery: sex, age (years), weight (kilograms), American Society of Anesthesiologists physical status (categorized as either I-II or III-V), duration of procedure (hours, as per operating room log), admission status (categorized as inpatient or outpatient), and the surgical discipline of the primary surgeon. American Society of Anesthesiologists physical status was dichotomized as I-II indicative of healthy patients or patients with mild disease, and III-IV for patients with severe disease that may or may not be life-threatening. Patients were “inpatients” if their admission was more than 24 hours before the planned surgical procedure or their postoperative admission was more than 24 hours. “Outpatients” were patients who were admitted 24 hours or earlier, before the planned surgical procedure, and whose postoperative admission was 24 hours or less.
Surgical Site Infections Although direct examination of surgical wounds was the traditional approach to detecting SSIs,4 at The Hospital for Sick Children, this type of surveillance was available only for cardiovascular surgical procedures, neurosurgeries, and spine instrumentations. Therefore, SSIs in our study were identified using patients’ medical records. Health records coders extracted data from patients’ charts and assigned diagnostic and procedural codes using the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, the Canadian Classification of Health Interventions, and the 3M-Codefinder software for all inpatient, day surgery, and emergency encounters. Coders were specifically trained to use the CDC/National Healthcare Safety Network (NHSN) SSI criteria: an infection (superficial, deep, or organ space) occurring within 30 days of a surgical procedure, except as recommended for patients with surgical implants, an infection occurring within 1 year.4 For patients without implants, an infection that occurred more than 30 days after the surgical procedure was not classified as an SSI. The coding quality analyst flagged charts with surgical infection diagnoses for review with infection control, to confirm presence of SSI. Any amendments were recoded accordingly.
Indication and Compliance Antibiotic prophylaxis and compliance were categorized as (1) complete compliance: antibiotics, when indicated, given 60 minutes or less, before surgical incision (deemed “on-time”), (2) partial compliance: antibiotics given when indicated but not 60 minutes or less before incision (deemed “late”), or (3) noncompliant: antibiotics not given when indicated (deemed “not given”). For complete compliance, AP must have been given before inflation of a tourniquet (if used), otherwise noncompliance was noted. For patients with allergies or previous colonization with methicillinresistant Staphylococcus aureus, if vancomycin was used, administration of the AP must have been 120 minutes or less before surgical incision (see the Appendix, Supplemental Digital Content 1 available at http://links.lww.com/SLA/A826, which shows full guideline).20,24 398 | www.annalsofsurgery.com
Statistical Analysis Continuous variables were analyzed by independent Student’s t tests and categorical variables were analyzed by chi-square tests. An alpha value of less than .05 (2-tailed) was considered significant for all comparisons. The primary outcome for this study was whether an SSI occurred after a surgical procedure (binary outcome). Multiple logistic regressions assessed the relationship of SSI and AP compliance, adjusting for patient factors (age, sex, American Society of Anesthesiologists physical status, and wound classification) and surgical factors (admission status, surgical discipline, and surgical duration). Mean differences with 95% confidence intervals (Newcombe-Wilson hybrid score) for SSI rates and adjusted relative risks were estimated for patients on the basis of the aforementioned variables. All variables and categorization of variables were consistent for all comparisons and regression analyses performed. Missing values were not imputed and patients with missing variables were excluded from the analyses. Statistical analyses were performed by an independent biostatistician with SAS Version 9.3 for Windows (SAS Institute, Cary, NC).
RESULTS Of 10 556 patients who underwent surgery during the 21-month study period, 9465 (89.7%) met the inclusion criteria and were enrolled (Fig. 1). The mean patient age was 6.8 ± 5.7 years, with 61.0% (N = 5770) being males. The majority of patients had general surgery procedures (n = 1928; 20.4%). Patients who received AP differed from those not given AP, with respect to sex, American Society of Anesthesiologists physical status, wound classification, admission status, surgical discipline, and surgical duration (Tables 1 and 2). Data were unavailable for some patients, which included American Society of Anesthesiologists physical status (n = 368 [3.9%] total; n = 4 [1.9%] with SSIs vs n = 364 [3.9%] without SSIs), wound classification (n = 135 [1.4%] total; n = 1 [0.5%] with SSI vs n = 134 [1.4%] without SSIs) and admission status (n = 44 [0.5%] total; n = 0 [0%] with SSI vs n = 44 [0.5%] without SSIs). Of the 9465 included patients, AP was indicated for 56.1% (n = 5309) and not indicated for 43.9% (n = 4156). A total of 216 SSIs were detected (SSI rate: 2.3%; 95% confidence interval: 2.0%– 2.6%). Of the 216 patients with SSIs, 54 (25.0%) had a surgical implant inserted during their procedure. Of 5309 (56.1%) patients, for whom antibiotics were indicated according to the guideline, the 3901 (73.5%) patients with complete compliance had an infection rate of 3.0%, compared with the 1408 (26.5%) noncompliant patients with an infection rate of 4.3% (unadjusted, mean difference: 1.3%; 95% confidence interval: 0.2%–2.6%; P = 0.02). Of 4156 (43.9%) patients, for whom antibiotics were not indicated, the 895 (21.5%) patients who received antibiotics due to noncompliance with the guideline had an infection rate of 1.7% compared with an infection rate of 0.7% in the 3261 (78.5%) patients who did not receive antibiotics (unadjusted, mean difference: 1.0%; 95% confidence interval: 0.3%–2.1%; P = 0.005). Of all factors, patients with a clean wound (adjusted relative risk: 0.6; 95% confidence interval: 0.4–0.9; P = 0.009) had a lower risk of developing an SSI. Being an inpatient (adjusted relative risk: 2.9; 95% confidence interval: 1.4–5.7; P = .004), longer surgical duration (adjusted relative risk: 1.0; 95% confidence interval: 1.0–1.0; P < .001) or certain surgical disciplines (cardiovascular, general surgery, neurosurgery, and orthopedics) were associated with increased risk of developing an SSI (Table 3). With complete AP compliance, the adjusted relative risk of SSI was 0.7 times that of partial or noncompliance (95% confidence interval: 0.5–0.9; P = 0.02). In procedures where antibiotics were not indicated, the risk of developing an SSI was unchanged by whether C 2014 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2014 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Annals of Surgery r Volume 262, Number 2, August 2015
Pediatric Surgical Infection Prevention
Total Number of Paents N=9465
Anbiocs Indicated N=5309 (56.1%)
Anbiocs Given N=4320 (81.4%)
FIGURE 1. Surgical site infection rates by antibiotic prophylaxis indication and compliance.
Anbiocs Not Indicated N=4156 (43.9%)
Anbiocs Not Given N=989 (18.6%)
Anbiocs Given N=895 (21.5%)
Anbiocs Not Given N= 3261 (78.5%)
Within
![[Surgical site infections: antibiotic prophylaxis in surgery].](/assets/img/hold.png)
