O1096: Procedure-level Misutilization of Antimicrobial Prophylaxis in Pediatric Surgery: Implications for Improved Stewardship and More Effective Infection Prevention

Background: The objective of this study was to quantify the burden of antibiotic prophylaxis misutilization at the procedure-level as a strategy to identify high-priority targets for both stewardship efforts and more effective surgical site infection prevention.

Methods: This was a multicenter cohort study of children undergoing non-emergent general surgical procedures at 90 hospitals participating in the National Surgical Quality Improvement Program (NSQIP) Pediatric Surgical Antibiotic Prophylaxis Pilot Collaborative between June 2019 and June 2020. Prophylaxis utilization data were collected at all hospitals and measures of misutilization were developed from procedure-based consensus guidelines. Measures of overutilization included use of overly broad-spectrum agents or “double coverage”, continuation of prophylaxis more than 24 hours after incision closure, and unindicated use of prophylaxis in clean procedures without implants. Measures of underutilization included prophylaxis administered after incision, omission of antibiotics in clean-contaminated cases, and use of agents with inappropriately narrow spectrum of coverage. Estimates of procedure-level misutilization burden were derived by multiplying misutilization rates calculated from NSQIP-Pediatric data by case volume data obtained from the Pediatric Health Information System database. The relative contribution of each procedure to the overall burden of misutilization from all procedures was used as a framework to identify high-priority procedures for each measure.

Results: 11689 patients were included. Overutilization of prophylaxis was most commonly associated with inappropriately broad-spectrum agents (14.0%), followed by unindicated utilization (12.6%) and continuation of prophylaxis more than 24 hours after incision closure (8.4%) (table 1). Procedures associated with the greatest relative burden of overutilization included small bowel procedures, hepatobiliary procedures, and gastrostomy for use of inappropriately broad-spectrum prophylaxis (78% of cases); cholecystectomy, ovarian procedures, and orchidopexy for unindicated utilization (93% of cases); and colorectal procedures, small bowel procedures, and pectus repair for inappropriately prolonged duration >24 hours (71% of cases). Underutilization of prophylaxis was most commonly associated with administration after incision (6.2%), followed by omission when indicated (4.4%) and use of inappropriately narrow spectrum agents (4.1%) (table 2). Procedures associated with the greatest relative burden of underutilization included gastrostomy, small bowel procedures and colorectal procedures for administration after incision (48% of cases); gastrostomy, reflux procedures, and small bowel procedures for omission of prophylaxis when indicated (55% of cases); and colorectal procedures, gastrostomy, and small bowel procedures for use of inappropriately narrow spectrum agents (92% of cases).

Conclusion: A relatively small number of procedures account for a disproportionate burden of antibiotic misutilization in pediatric surgery. Although overutilization of prophylaxis was relatively more common than underutilization, multiple high-priority opportunities were identified for both improved stewardship and infection prevention, often within the same procedure groups.