Minimizing the Use of IV Antibiotic Prophylaxis after Pediatric Urologic Surgeries
Vivian W. Williams, MSN, RN, CPNP, Caroline Perlman, MHA, Julia B. Finkelstein, MD, MPH, FAAP.
Boston Children's Hospital, Boston, MA, USA.
BACKGROUND: Perioperative surgical antibiotic prophylaxis (AP) may decrease postoperative morbidity including surgical site infections (SSI), urinary tract infections (UTI), and bacteremia. AP may also contribute to the rising prevalence of antibiotic resistance, adverse drug reactions, and health care costs. Guidelines for AP are lacking, and prior literature has shown that peri- and post-operative AP is widely used by pediatric urologists with great variation in practices. At our children’s hospital, we found that postoperative intravenous (IV) AP utilization following common procedures, such as pyeloplasty and ureteral reimplant, was above the national benchmark. Therefore, we initiated a quality improvement effort aimed to reduce postoperative IV AP use.
METHODS: Pediatric urologists were briefed on postoperative IV AP utilization. Then, in collaboration with our institutional antibiotic stewardship and clinical informatics teams, IV AP were eliminated from our Urology postoperative order sets in the electronic medical record (EMR) on June 24th, 2022. The exception was the order set used following the complete primary repair of bladder exstrophy. For this study, IV AP utilization was abstracted for clean and clean-contaminated urologic surgeries occurring between January 2021 and January 2023. Since postoperative IV AP is not employed for ambulatory patients, day surgery cases were excluded from data collection. We evaluated baseline (January 2021-June 2022) and post-implementation (July 2022-January 2023) postoperative IV AP use. When postoperative IV AP was employed, the duration was categorized as less than or equal to 24 hours versus greater than 24 hours following surgery. As balancing measures, the rates of SSI and UTI were noted. These data are routinely tracked via institutional participation in the National Surgical Quality Improvement Program.
RESULTS: During the entire study period, 14 pediatric urologists performed 864 procedures that met inclusion criteria. The three most common surgeries were ureteral reimplant (n=260), pyeloplasty (n=120), and hypospadias repair (n=114). Baseline data showed that 69.1% (409/592) of pediatric urology cases received postoperative IV AP. The duration was greater than 24 hours following surgery in 22.0%, and the majority (90.0%) of these reflected clean-contaminated cases. After our EMR intervention, there was a significant decrease in the use of postoperative IV AP to 31.9% (from 69.1%, p<0.0001). No SSI occurred during the baseline or post-intervention time periods. There was also no significant difference in UTI rate during the study period (2.1% vs 1.5%, p=0.3450).
CONCLUSIONS: We successfully removed IV AP from most postoperative order sets, leading to a significant decrease in unnecessary antibiotic utilization after pediatric urologic surgery without a change in SSI or UTI rates. Essential to success was leveraging the EMR and key stakeholder buy-in. To achieve further reduction, we have begun to share data regarding AP utilization with faculty and trainees monthly. Ongoing monitoring and data analysis is crucial for evaluating the continued effectiveness of this intervention. In parallel, it is important to continue assessing for any change in SSI and UTI rates. The ultimate goal is to establish an evidence-based guideline for IV AP use after pediatric urologic surgery that balances antibiotic stewardship and SSI/UTI prevention.
Back to 2023 Abstracts