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BACKGROUND:
Post-operative surgical site infections (SSI) are a source of potentially preventable perioperative morbidity. The use of perioperative antibiotics in adult patients is governed by the Surgical Care Improvement Project (SCIP). However, no such SCIP guidelines exist for pediatric perioperative antibiotics in part due to the limited amount of data regarding SSI in this patient population. This study prospectively evaluates the role of perioperative antibiotics in SSI in a cohort of patients undergoing genitourinary procedures.
METHODS:
A prospective quality assurance database on SSI was maintained for consecutive patients undergoing open (non-endoscopic) pediatric urologic surgical procedures performed by three pediatric urologists. IRB-approval was obtained to review this database over a 3 year period from 2011 to 2014. Only patients with 30 day follow up were included in the study. The primary outcome was the incidence of SSI in patients; subsequently stratified by peri-operative antibiotic usage. Peri-operative antibiotic usage during this time was dependent on the practice pattern of the individual surgeon. SSI were confirmed by a physician and required antibiotic therapy. The rate of SSI reported is site specific, as a number of patients had multiple site procedures. Only patients with wound class (WC) 1 (clean) and 2 (clean-contaminated) were included.
RESULTS:
1185 patients with 1313 surgical sites were available for review during the 3 year time period. Of these, 1020 patients with 1133 surgical sites had adequate follow up for inclusion into the study. The overall SSI rate was 0.9% (10 occurences); in WC1 and WC2 surgical procedures overall SSI rate was 0.4%, and 1.9% respectively.
Only superficial skin infections (3) were noted in WC1 operations, and of those operations, 271 out of 847 patients (32%) received peri-operative antibiotics. The SSI rate was identical, 0.4%, in patients receiving antibiotics, and 0.4% in patients not receiving antibiotics.
WC2 operations included low risk procedures, such as urethromeatoplasty. These patients (146) did not receive peri-operative antibiotics and did not have any infections.
Higher risk WC2 operations, such as pyeloplasty, hypospadias, and ureteral reimplantation, had an overall SSI rate of 3.4%. Peri-operative antibiotics were used in all 203 high risk WC2 operations. The superficial skin infection rate was 1.5%, deep/organ site infection rate was 0.5%, and UTI rate was 1.5%.
The most common antibiotic used for peri-operative prophylaxis was cefazolin (92.6%) followed by ampicillin (2.5%) and gentamycin (2.9%).
CONCLUSIONS:
WC1 operations showed no difference in rates of infection in patients receiving or not receiving peri-operative antibiotics; no discernible benefit is noted from the use of peri-operative antibiotics. Similarly, low risk WC2 operations did not have any infections, and likely do not need peri-procedural antibiotics. In contrast, high risk WC2 operations had an overall infection rate of 3.4% even with the use of peri-operative antibiotics. This suggests that pediatric urologic surgical procedures with significant violation of the genitourinary system are the most likely to benefit from peri-operative antibiotics due to the increased incidence of SSI. Further guidelines for antibiotic use in pediatric urology should focus primarily on high risk WC2 surgical procedures.