medwireNews: Prophylactic antibiotics reduce the risk for surgical site infection (SSI) and hospital readmission among children undergoing nonemergent cholecystectomy, a retrospective study concludes.
After balancing the data using weighting based on patient demographic characteristics, SSI rates 30 days after surgery were lower for 2016 children who received prophylaxis than for the 212 who did not, at 0.9% and 3.7%, respectively, and a significant odds ratio of 0.28 in favor of prophylaxis.
Prophylaxis also significantly reduced the likelihood of hospital readmission in the propensity-weighted group, with rates of 1.5% and 4.4% for the prophylaxis and no prophylaxis treatment groups, respectively, and a significant odds ratio of 0.33.
However, extended-spectrum antibiotics provided no more benefit than cefazolin in terms of SSI rates and the result was echoed for readmission rates.
“The results of this analysis have practice-changing implications for more than one-third of all children undergoing nonemergent cholecystectomy, aiming to optimize both SSI prevention and antimicrobial stewardship,” write Shawn Rangel (Boston Children’s Hospital, Harvard Medical School, Massachusetts, USA) and colleagues in JAMA Pediatrics.
Established guidelines advising against prophylaxis use in patients undergoing cholecystectomy for uncomplicated cholelithiasis are derived entirely from adult studies, and the majority of children receive prophylactic antibiotics despite a prior “paucity of evidence” in the pediatric population, the researchers say.
To shed light on this issue, Rangel and colleagues collected outcome data from the American College of Surgeons National Surgical Quality Improvement Program–Pediatric between 2021 and 2022 for participants younger than 18 years old who underwent cholecystectomy for uncomplicated cholelithiasis. This was defined as patients lacking a concurrent diagnosis of acute cholecystitis, pancreatitis, or choledocholithiasis.
The participants were a median of 15 years old, 81% were girls, and 42% were White. Among the 2234 children with data available for the study, 91.0% received prophylaxis, with 61% of 141 hospitals using it in all cases and 1.4% of hospitals never using it.
The researchers found that the most common antibiotics used for prophylaxis were cefazolin, cefoxitin, clindamycin, cefotetan, piperacillin-tazobactam, and cefazolin plus metronidazole, with corresponding rates of 69.2%, 20.2%, 2.7%, 2.0%, 1.7%, and 1.7%.
Overall, 27.6% of the participants received antibiotics with extended-spectrum coverage to treat a wider range of gram-positive, gram-negative, or anaerobic organisms compared with the broad-spectrum agent cefazolin. This prophylaxis included monotherapy with ampicillin-sulbactam, cefoxitin, or piperacillin-tazobactam, and dual-therapy with cefazolin or metronidazole and a second agent.
Secondary analysis of the propensity-weighted cohort did not find a significant benefit with regard to SSI at 30 days with the use of extended-spectrum antibiotics versus cefazolin (0.5 vs 1.0%) or for readmission (1.4 vs 1.6%).
The authors acknowledge limitations to the study, including its retrospective design and the potential for confounding by the perception of more advanced disease, but note that the results challenge established guidelines recommending against prophylaxis use in these children.
They recognize that several randomized trials and meta-analyses conducted in adults have also supported the use of prophylaxis, “leading us to consider that the effect of prophylaxis may be influenced by differences among studies in the definition of study cohorts, exposures, and outcomes,” they say.
The authors conclude: “Unplanned visits to emergency departments or outpatient clinics may require time away from work or school for both patients and caregivers and impose additional demands on the health care system.”
“Use of a single dose of a first-generation cephalosporin before surgery would therefore appear reasonable for preventing SSIs in this cohort of children.”
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