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ORIGINAL ARTICLE Table of Contents   
Year : 2021  |  Volume : 18  |  Issue : 1  |  Page : 28-32
Outcome of restricted antibiotic policy in a tertiary-level paediatric surgical unit


Department of Paediatric Surgery, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India

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Date of Submission27-Aug-2020
Date of Decision25-Oct-2020
Date of Acceptance24-Nov-2020
Date of Web Publication16-Feb-2021
 

   Abstract 


Purpose: The purpose was to evaluate the effect of a more restrictive antibiotic policy on infective complications, mainly surgical-site infection (SSI) in clean and clean contaminated surgeries in children. Materials and Methods: The study included children who underwent clean or clean contaminated surgeries over a period of 18 months with a no-antibiotic or single dose of pre-operative antibiotic protocol, respectively. These were compared to historical controls in previous 18 months where the antibiotic policy was to continue the course for 3–5 days. The outcome looked for was presence of SSI or infection related to the operated organ. Results: A total of 933 (study group) patients were compared to 676 historic controls (control group). In the study group, 661 of 933 were clean surgeries and 272 were clean contaminated surgeries. In the study group, 490 of the 676 were clean surgeries and 186 were clean contaminated surgeries. Clean contaminated surgeries included urological surgeries, gastrointestinal tract surgeries and neurosurgeries, whereas clean surgeries were typically day-care surgeries. Comparing the infective outcomes in each type of surgery, there was no statistical difference between cases or controls in either subgroup. Conclusion: Antibiotic prophylaxis (AP) is not required for clean surgeries. For clean contaminated surgeries, just one dose of pre-operative AP is effective in preventing SSI.

Keywords: Clean contaminated wound, clean wound, restrictive antibiotic policy, surgical antibiotic prophylaxis surgical-site infection

How to cite this article:
Basavaraju M, Alladi A, Vepakomma D. Outcome of restricted antibiotic policy in a tertiary-level paediatric surgical unit. Afr J Paediatr Surg 2021;18:28-32

How to cite this URL:
Basavaraju M, Alladi A, Vepakomma D. Outcome of restricted antibiotic policy in a tertiary-level paediatric surgical unit. Afr J Paediatr Surg [serial online] 2021 [cited 2022 Jul 3];18:28-32. Available from: https://www.afrjpaedsurg.org/text.asp?2021/18/1/28/309569



   Introduction Top


The WHO's first global report on antibiotic resistance, 2014, reveals serious, worldwide threat to public health and that without urgent action the world is headed for a post-antibiotic era, in which common infections can once again kill.[1] The 2014 WHO's South-East Asia Region data reveal that antibiotic resistance is a burgeoning problem in this region, which is home to a quarter of the world's population. The report's results show high levels of  Escherichia More Details coli and Klebsiella pneumonia resistance to third-generation cephalosporins. In some parts of the region, more than one-quarter of Staphylococcus aureus infections are reported to be methicillin-resistant S. aureus.[2]

Surgeons also have an important role in combating drug resistance. There are well-established guidelines by the Centers for Disease Control and Prevention (CDC),[3] Scottish Intercollegiate Guidelines Network, Joint Commission on Accreditation of Healthcare Organizations, National Health Service and others about the timing and dosing of antibiotic prophylaxis (AP) to prevent surgical-site infection (SSI). Despite this, there is considerable evidence that antibiotics are used excessively and inappropriately for the prevention of SSI.[4],[5],[6],[7],[8],[9]

There are a number of studies in adults about the AP and SSI[10] but few in children.[11],[12],[13],[14],[15] Antibiotic protocols vary between institutes, and adherence to guidelines is variable. Development of antimicrobial resistance is directly proportional to the volume of antimicrobials consumed.[16] Therefore, regulation and restriction are essential to reduce the development of antimicrobial resistance.

Aim

The study aim was to evaluate the effect of a more restrictive antibiotic policy on infective complications, mainly SSI in clean and clean contaminated surgeries in children.


   Materials and Methods Top


The study included 933 children aged between 0 and 18 years who had clean and clean contaminated surgeries over a period of 18 months with a no-antibiotic or single dose of pre-operative antibiotic protocol, respectively, as per CDC guidelines.[3] These were compared to historical controls in previous 18 months where there was no fixed protocol and the antibiotic policy was to continue the course for 3–5 days as per surgeon's choice. The outcome looked for was presence of SSI or infection related to the operated organ. These were compared to historical controls from the same unit in the preceding 18 months where antibiotics were given for an extensive period of time of 3–5 days. Contaminated and dirty wounds requiring therapeutic antibiotics were excluded. In addition, patients in whom antibiotics were continued for other reasons such as sepsis were excluded.

Control group – pre-protocol period

Clean surgeries received one dose of prophylactic antibiotic (cefotaxime) and clean contaminated surgeries received antibiotics (cefotaxime and metronidazole/amikacin) for variable periods of time (3–5 days) depending on surgeon preference and type of surgery.

Study group – protocol period

Clean surgeries did not receive any antibiotic and clean contaminated procedures received only prophylactic dose of antibiotic which were cefotaxime and amikacin for genitourinary surgeries, cefotaxime and metronidazole for gastrointestinal (GI) surgeries and ceftriaxone for central nervous system surgeries just before induction. One more dose of antibiotic was given if duration of surgery is >t ½ of the drug.

Data were obtained from inpatient case sheets, outpatient follow-up and department morbidity and mortality registers.

Parameters compared were SSI, other infections specific to organ operated and any other systemic infections. The follow-up period was defined as 30 days from initial operation and SSI was defined as per CDC criteria. Data were evaluated by Chi-square and Fisher's exact test. Routine microbiological investigation of causative organism was not included as part of the study.


   Results Top


A total of 933 patients in the study group were compared to 676 historic controls where random antibiotic protocols had been used. Both were subdivided into clean and clean contaminated surgeries. A total of 490 of the 676 controls (72.5%) were clean surgeries and 186 (27.5%) were clean contaminated surgeries. In the study group, 661 of the 933 (70.8%) surgeries were clean and 272 (29.2%) were clean contaminated surgeries. Clean contaminated surgeries included elective opening of respiratory, GI, genitourinary and neurosurgical tracts with minimal spillage, whereas clean surgeries included circumcision, hernia, orchidopexy, pyloromyotomy and splenectomy where respiratory, alimentary and genitourinary tracts were not entered. Data are provided in [Table 1] and [Table 2] and results are summarised in [Table 3].
Table 1: Clean cases: Comparing surgical-site infection in the control and study groups

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Table 2: Clean contaminated cases: Comparing surgical-site infection in gastrointestinal, central nervous system and urology surgeries in the control and study groups

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Table 3: Comparative summary of results of the study and control groups for clean and clean contaminated cases

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Our SSI in the control group for clean and clean contaminated cases was 0.82% and 3.23% and study group was 1.06% and 2.57%, respectively. There was definitely no advantage in giving prophylaxis to clean cases as per our results (0.82% vs. 1.06%, P = 0.77). In addition, for clean contaminated cases, one dose of prophylactic antibiotic was effective in preventing SSI compared to multidosing (3.23% vs. 2.57%, P = 0.68).

The difference in the proportion of SSI for clean cases in the control group as compared to the study group was between −0.0113 and 0.0146 (95% confidence). The difference in the proportion of SSI for clean contaminated cases in the study group as compared to the control group was between −0.0251 and 0.0452. The 95% confidence interval included 0. Fisher's exact test and Chi-square test were used to compare the SSI in the two groups. The difference in the proportion of SSI was not statistically different in both groups.


   Discussion Top


SSI rates as per the traditional wound classification system by CDC are reported to be <2% for clean cases and 4%–10% for clean contaminated cases,[17] and the corresponding National Nosocomial Infections Surveillance System hospitals' reported data were 2.1% and 3.3%, respectively.[18]

We did not demonstrate a significant change in SSI rates in clean cases (1.48%) versus clean contaminated cases (1.29%) [Table 3].

Our results showed no advantage in giving any prophylaxis to clean cases with similar rates of SSI in those who received pre-operative antibiotics compared with those that did not (0.82% vs. 1.06%, P = 0.77). This was similar to a study by Horwitz et al.[11] who showed similar rates of SSI in clean cases that received pre operative antibiotics compared with those that did not (3.9% vs. 2.4%, P = 0.34). A prospective cohort study by Koshbin et al. on 5309 patients showed that 43.9% of the patient population who received AP, when not indicated by the guideline, had no reduction of SSIs.[19] This finding is important because giving antibiotics to all children would pose potential side effects and risks. Thus, the guideline obviated the need for antibiotics in approximately 45% of procedures. Our study also showed similar results, in that, clean cases did not require antibiotics and hence it was avoided in 70.9% (661/933) of our cases.

A study by Bracho-Blanchet et al.[13] of single- versus multi-dose prophylaxis in children showed significant decrease in SSI rates in single- or short-course prophylaxis compared to multi-dose (1.2% vs. 10.9%). Our study showed that there was no added benefit in giving multi-dose antibiotics to clean contaminated cases.

Early catarrhal appendicitis was treated as clean contaminated surgery and none had any SSI.

Newborns who underwent colostomy for anorectal malformation and children undergoing colostomy closure were considered as clean contaminated surgery because bowel was opened under controlled condition without spillage.

A prospective, randomised clinical study by Feza et al. compared the results of 1-day versus 7-day administration of the same prophylactic antibiotics to children undergoing colostomy closure and found no difference in the rate of infectious complications.[20] In our study, colostomy closure patients had bowel preparation but no oral AP. SSI in colostomy closure patients was 5% and 7% in the control and study groups, respectively, and not statistically significant [Table 2].

A study by Tofft et al. found that in patients with single-stage posterior sagittal anorectoplasty (PSARP), there was no difference in the risk of wound dehiscence irrespective of the duration of the antibiotic used (<1 day vs. >1 day).[21] In our study, 28 cases of PSARP for anorectal malformation also received only one dose of prophylactic antibiotics versus 18 cases receiving multidose, and there was no significant difference in SSI on comparison [Table 2].

Pyeloplasty and urethroplasty were included as clean contaminated surgeries. In the control group, antibiotics for both the above-mentioned surgeries were continued for 5 days and 7–10 days, respectively. None of the pyeloplasty or urethroplasty patients had SSI.

In the study group, only one pre-operative dose of antibiotic was administered, and none of the urethroplasty children developed SSI and 1/21 (4.7%) of the pyeloplasty children developed SSI. This was not statistically significant. In a review about the influence of perioperative factors on primary severe hypospadias repair by Castagnetti and El-Ghoneimi, post-operative AP did not have any impact on surgical complications.[22] A recent study by Baillargeon et al. does not support the routine use of prolonged antibiotics in hypospadias repair.[23]

There is insufficient evidence and bias regarding the role of empirical prophylactic antibiotics in all patients for as long as catheter is indwelling.[24] In our study, urethroplasties, pyeloplasties and PSARP cases had catheter in situ in the post-operative period ranging from 5 to 10 days. Symptomatic urinary tract infection was documented in 3.4% versus 2.3% cases in the control and study groups. We found that catheter was not an indication for continuing antibiotic.

Many studies, which used only perioperative antibiotics for neurosurgical procedures, have reported an incidence of SSI as low as 0.8% to as high as 5%–7%.[25] In our study, we included ventriculoperitoneal shunt and myelomeningocele (MMC) repairs as clean contaminated surgeries. Cases of ruptured MMC and those with post-operative cerebrospinal fluid leak were excluded. In the control group, antibiotics were given for 5 days and 7.1% (1/14) developed infection, whereas in the study group, only 4% (1/25) developed wound infection which again was not significant [Table 2].

Pyloromyotomy is considered a clean surgery and prophylaxis is not indicated in adults. However, a study by Ladd et al. suggested that it may benefit paediatric patients.[26] Our study did not show any statistically significant difference in SSI in the study and control groups [Table 1].

Research has shown that surgical techniques, skin preparation and method of wound closure are significant factors that can influence the incidence of subsequent infection. AP has also had a positive impact but mostly for contaminated wounds. Many other factors such as ASA classification, duration of surgery and contamination at the time of surgery have been identified as having an effect on the potential for infection. We should consider these factors before, during and after surgery. AP is an adjunct to, not a substitute for, good surgical technique.

Our results showed that restricting antibiotic use and adhering to guidelines does not increase the SSI rates.

Reviewing Indian literature also revealed that in a majority of cases, surgical prophylaxis was inappropriate in terms of choice of antimicrobial agent, timing of administration and duration of prescription.[27],[28]

SSI risk classification systems such as those from Nosocomial Infection Control and the CDC are extrapolated from adult studies. In adults, SSI risk is influenced by the underlying comorbidities, whereas in children, that procedure-specific factors and markers of acute physiologic status strongly predict SSI risk.[11],[12] Therefore, some paediatric surgeons may not consider adult AP guidelines to be relevant for their patients.

Therefore, meta-analyses and larger cohort studies are definitely required to establish antibiotic guidelines in paediatric surgical patients, especially infants and newborns. However, formulation of guidelines alone is incapable of changing the practice. Every institute must take strict measures to reinforce these guidelines in order to combat drug resistance.


   Conclusion Top


AP is not required for clean surgeries. For clean contaminated surgeries, just one dose of pre-operative AP is effective in preventing SSI. Appropriate AP should be an integral component of an effective policy for the control of healthcare-associated infection.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Available from: http://www.who.int/world-health-day/2011. [Last accessed on 2020 Aug 26].  Back to cited text no. 1
    
2.
Available from: http://www.who.int/mediacentre/news/releases/2014. [Last accessed on 2020 Aug 26].  Back to cited text no. 2
    
3.
Available from: http://www.cdc.gov/hicpac/pdf/SSIguidelines.pdf. [Last accessed on 2020 Aug 26].  Back to cited text no. 3
    
4.
Sumiyama Y, Kusachi S, Yoshida Y, Arima Y, Tanaka H, Nakamura Y, et al. Questionnaire on perioperative antibiotic therapy in 2003: Postoperative prophylaxis. Surg Today 2006;36:107-13.  Back to cited text no. 4
    
5.
Gul YA, Hong LC, Prasannan S. Appropriate antibiotic administration in elective surgical procedures: Still missing the message. Asian J Surg 2005;28:104-8.  Back to cited text no. 5
    
6.
Andrajati R, Vlcek J, Kolar M, Pípalová R. Survey of surgical antimicrobial prophylaxis in Czech Republic. Pharm World Sci 2005;27:436-41.  Back to cited text no. 6
    
7.
Castella A, Charrier L, Di Legami V, Pastorino F, Farina EC, Argentero PA, et al. Surgical site infection surveillance: Analysis of adherence to recommendations for routine infection control practices. Infect Control Hosp Epidemiol 2006;27:835-40.  Back to cited text no. 7
    
8.
Gagliotti C, Ravaglia F, Resi D, Moro ML. Quality of local guidelines for surgical antimicrobial prophylaxis. J Hosp Infect 2004;56:67-70.  Back to cited text no. 8
    
9.
Rangel SJ, Fung M, Graham DA, Ma L, Nelson CP, Sandora TJ. Recent trends in the use of antibiotic prophylaxis in pediatric surgery. J Pediatr Surg 2011;46:366-71.  Back to cited text no. 9
    
10.
Manniën J, van Kasteren ME, Nagelkerke NJ, Gyssens IC, Kullberg BJ, Wille JC, et al. Effect of optimized antibiotic prophylaxis on the incidence of surgical site infection. Infect Control Hosp Epidemiol 2006;27:1340-6.  Back to cited text no. 10
    
11.
Horwitz JR, Chwals WJ, Doski JJ, Suescun EA, Cheu HW, Lally KP. Pediatric wound infections: A prospective multicenter study. Ann Surg 1998;227:553-8.  Back to cited text no. 11
    
12.
Casanova JF, Herruzo R, Diez J. Risk factors for surgical site infection in children. Infect Control Hosp Epidemiol 2006;27:709-15.  Back to cited text no. 12
    
13.
Bracho-Blanchet E, Porras-Hernández J, Dávila-Pérez R, Coria-Lorenzo J, Gómez-Inestrosa A, Nieto-Zermeño J. Comparison between two antibiotic schemes in relation to surgical site infection in children: A randomized clinical trial. Cir Cir 2009;77:279-85.  Back to cited text no. 13
    
14.
Bucher B, Guth R, Elward A, Hamilton N, Dillon P, Warner B, et al. Factors and outcomes of surgical site infection in children. J Am Coll Surg 2011;212:1033-8.  Back to cited text no. 14
    
15.
Varik K, Kirsimägi Ü, Värimäe EA, Eller M, Lõivukene R, Kübarsepp V. Incidence and risk factors of surgical wound infection in children: A prospective study. Scand J Surg 2010;99:162-6.  Back to cited text no. 15
    
16.
Austin DJ, Kristinsson KG, Anderson RM. The relationship between the volume of antimicrobial consumption in human communities and the frequency of resistance. Proc Natl Acad Sci U S A 1999;96:1152-6.  Back to cited text no. 16
    
17.
Pear S. Patient risk factors and best practice for SSI prevention. Manag Infect Control 2007;3:56-64.  Back to cited text no. 17
    
18.
Culver D, Horan T, Gaynes R, Martone WJ, Jarvis WR, Emori TG, et al. Surgical wound infection rates by wound class, operative procedure, and patient risk index. Am J Med 1991;91:152-7S  Back to cited text no. 18
    
19.
Khoshbin A, Jeannette P, Aleem IS, Stephens D, Matlow AG, Wright JG, et al. Antibiotic Prophylaxis to Prevent Surgical Site Infections in Children: A Prospective Cohort Study. Ann Surg 2015;262:397-402.  Back to cited text no. 19
    
20.
Feza M, Akgiir F, Tanyel C, Biiyiikpamukqu N, Hiqsrnmez A. Prophylactic antibiotics for colostomy closure in children: Short versus long course. Pediatric Surg Int 1992;7:279-81.  Back to cited text no. 20
    
21.
Tofft L, Salö M, Arnbjörnsson E, Stenström P. Wound dehiscence after posterior sagittal anorectoplasty in children with anorectal malformations. Biomed Res Int 2018;2018:2930783.  Back to cited text no. 21
    
22.
Castagnetti M, El-Ghoneimi A. The influence of perioperative factors on primary severe hypospadias repair. Nat Rev Urol 2011;8:198-206.  Back to cited text no. 22
    
23.
Baillargeon E, Duan K, Brezezinski A, Jednak R, El-Sherbiny M. The role of preoperative prophylactic antibiotics in hypospadias repair. Can Urol Assoc J 2014;8:236-40.  Back to cited text no. 23
    
24.
Glaser AP, Rosoklija I, Johnson EK, Yerkes EB. Prophylactic antibiotic use in pediatric patients undergoing urinary tract catheterization: A survey of members of the Society for Pediatric Urology. BMC Urol 2017;17:76.  Back to cited text no. 24
    
25.
McClelland S 3rd, Hall WA. Postoperative central nervous system infection: Incidence and associated factors in 2111 neurosurgical procedures. Clin Infect Dis 2007;45:55-9.  Back to cited text no. 25
    
26.
Ladd AP, Nemeth SA, Kirincich AN, Scherer LR 3rd, Engum SA, Rescorla FJ, et al. Supraumbilical pyloromyotomy: A unique indication for antimicrobial prophylaxis. J Pediatr Surg 2005;40:974-7.  Back to cited text no. 26
    
27.
Rehan HS, Kakkar AK, Goel S. Surgical antibiotic prophylaxis in a tertiary care teaching hospital in India. Int J Infect Control 2010;6:34-9.  Back to cited text no. 27
    
28.
Khan SA, Rao PG, Rao A, Rodrigues G. Survey and evaluation of antibiotic prophylaxis usage in surgery wards of tertiary level institution before and after the implementation of clinical guidelines. Indian J Surg 2006;68:150-6.  Back to cited text no. 28
    

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Correspondence Address:
Dr. Anand Alladi
Department of Paediatric Surgery, Bangalore Medical College and Research Institute, Super Speciality Hospital, Victoria Hospital Campus, Fort, Bengaluru - 560 002, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ajps.AJPS_127_20

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