Background: Antimicrobial resistance is a major public health concern and is primarily a result of systemic antimicrobial use. Most pediatric penile and inguinal/scrotal surgeries are defined as clean (class I) surgical wounds and, therefore, peri-procedural antibiotic prophylaxis is not recommended in uncomplicated cases. This study aims to better understand the national and individual hospital trends in antibiotic prophylaxis for ambulatory pediatric urologic surgeries at the lowest risk for iatrogenic infection. Methods: We queried the Pediatric Health Information System (PHIS) database for males (29 days to 18 years) undergoing outpatient penile (circumcision, lysis of adhesions, chordee, meatotomy) and/or “groin” (inguinal/scrotal) procedures (hernia repair, orchiopexy, orchiectomy) from 2016-2023. Periprocedural parenteral antibiotic use was abstracted. Patients undergoing penile or groin procedures for emergent conditions (i.e. incarcerated hernia, testicular torsion), utilizing a laparoscopic approach, or in combination with another procedure were excluded. Demographic and clinical characteristics were compared between procedures with “appropriate use” (no antibiotics) vs "overuse” (+antibiotic use) and a multivariable logistic regression model with generalized estimating equation approach to account for clustered data on hospitals was performed to identify factors associated with increased odds of inappropriate use. Secondary outcomes included post-operative ED visits, surgical site infections, allergic reactions, and Clostridium difficile infections. National trends in antibiotic prophylaxis use were compared by year and between hospitals that consistently reported data over the study period.
Results: 108,419 procedures (46% penile, 42% groin, 12% combination) were included. Median age at the time of surgery was 2 (IQR 0,7) years old. Overall, 14% (15,706/108,419) had peri-procedural antibiotic overuse. Groin procedures had higher rates of antibiotic overuse compared to penile procedures (19% vs 8%, p<0.001). Cefazolin was the most used antibiotic (95% of cases). On adjusted analysis, groin procedures (aOR 2.12), combined groin + penile procedures (aOR 2.43), older age (aOR 2.54), and urologist as proceduralist (aOR 1.52) were independently associated with greater odds of antibiotic overuse (Table). Rates of secondary outcomes were similar between groups. Rates of antibiotic overuse decreased from 2016 to 2023 (6.3% to 3.6% penile; 11.1% to 7.9% groin). There was significant variability in antibiotic prophylaxis between centers (range 0% to 32% groin; 0% to 16.7% penile over the study period, p<.001) (Figure). Conclusions: Despite the American Urological Association Best Practice Policy Statement on antimicrobial prophylaxis in 2008, the rate of peri-procedural antibiotic overuse remains significant (14%) for uncomplicated pediatric penile and groin procedures with significant variability in use between hospitals. Groin procedures, older patients, and a urologic proceduralist were associated with increased odds of antibiotic overuse. Continued education and interventions to improve antimicrobial stewardship are needed for pediatric urologists.
Table. Clinical factors and adjusted odds of antibiotic overuse
| Clinical factor | n (% total)n=108,417 total | Rate of antibiotic useo | Adjusted OR (95% CI) | p-value | |
| Procedure | Penile | 50176 (46.3) | 0.08 | referent | - |
| Groin | 45642 (42.1) | 0.19 | 2.12 (1.68,2.68) | <.001* | |
| Combined penile and groin | 12599 (11.6) | 0.21 | 2.43 (1.84,3.22) | <.001* | |
| Race | Non-Hispanic White | 56473 (52.1) | 0.15 | referent | - |
| Non-Hispanic Black | 17653 (16.3) | 0.12 | 1.0 (0.92,1.09) | 0.933 | |
| Hispanic | 16546 (15.3) | 0.16 | 1.03 (0.92,1.14) | 0.610 | |
| Asian | 4741 (4.4) | 0.15 | 0.98 (0.89,1.08) | 0.722 | |
| Other | 13004 (12) | 0.14 | 0.96 (0.9,1.04) | 0.310 | |
| Insurance | Government | 50552 (46.6) | 0.13 | referent | - |
| Private | 53369 (49.2) | 0.15 | 1.05 (0.97,1.13) | 0.254 | |
| Other | 4496 (4.1) | 0.17 | 1.09 (0.97,1.23) | 0.146 | |
| Setting | Rural | 11415 (12.3) | 0.17 | referent | - |
| Urban | 92995 (85.8) | 0.14 | 0.95 (0.88,1.01) | 0.119 | |
| Region | Midwest | 27024 (24.9) | 0.14 | referent | - |
| Northeast | 15437 (14.2) | 0.13 | 3.31 (0.43,25.16) | 0.248 | |
| South | 37151 (34.3) | 0.15 | 2.59 (0.66,10.19) | 0.172 | |
| West | 28805 (26.6) | 0.15 | 3.5 (0.79,15.51) | 0.099 | |
| Patient age | 0-9 years | 90176 (83.2) | 0.12 | referent | - |
| 10-18 years | 18241 (16.8) | 0.26 | 2.54 (1.98,3.26) | <.001* | |
| Proceduralist | Pediatric/general surgeon | 11436 (10.5) | 0.11 | referent | - |
| Urologist | 94530 (87.2) | 0.15 | 1.52 (1.03,2.26) | 0.035* | |
| *p-values <0.05 are considered significant oRate of antibiotic use calculated as number of cases with unnecessary antibiotic use/total number of casesAbbreviations: OR: odds ratio; CI: confidence interval | |||||
