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Original Investigation |

National Variability and Appropriateness of Surgical Antibiotic Prophylaxis in US Children’s Hospitals

Thomas J. Sandora, MD, MPH1; Monica Fung, MD2; Patrice Melvin, MPH3; Dionne A. Graham, PhD3; Shawn J. Rangel, MD, MSCE4
[+] Author Affiliations
1Division of Infectious Diseases, Department of Medicine, Boston Children’s Hospital, Boston, Massachusetts
2Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
3Center for Patient Safety and Quality Research, Boston Children’s Hospital, Boston, Massachusetts
4Department of Surgery, Boston Children’s Hospital, Boston, Massachusetts
JAMA Pediatr. 2016;170(6):570-576. doi:10.1001/jamapediatrics.2016.0019.
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Published online

Importance  Appropriate use of surgical antibiotic prophylaxis (AP) reduces surgical site infection rates, but prior data suggest variability in use patterns.

Objective  To assess national variability and appropriateness of AP in pediatric surgical patients.

Design, Setting, and Participants  Retrospective cohort study of 31 freestanding children’s hospitals in the United States using administrative data from 2010-2013. The study included 603 734 children younger than 18 years who underwent one of the 45 most commonly performed operations.

Exposures  Receipt of surgical AP.

Main Outcomes and Measures  Primary outcomes included procedure- and hospital-specific rates of AP use and appropriateness of use based on clinical guidelines and consensus statements. We also assessed rates of Clostridium difficile infection and potential allergic reactions (using epinephrine administration as a surrogate event) after AP receipt.

Results  Of the 603 734 eligible patients, the mean (SD) patient age was 4.8 (4.4) years and 384 571 (63.7%) were boys. For the 671 255 operations evaluated, AP was administered for 348 119 (52%) of procedures. Intrahospital variation in AP use by procedure ranged from 11.5% to 100% (median, 78.1%). Overall, AP use was considered appropriate for 64.6% of cases. Appropriate use of AP by hospital varied from 47.3% to 84.4% with large variability by procedure within each hospital. For procedures for which AP was indicated, the median rate of appropriate use by hospital was 93.8%; however, for procedures for which AP was not indicated, the median rate of appropriate use by hospital was 52.0%. The odds of C difficile infection and epinephrine administration were significantly higher among children who received AP (odds ratio, 3.34; 95% CI, 1.66-6.73 and odds ratio 1.97; 95% CI, 1.92-2.02; respectively).

Conclusions and Relevance  There is substantial national variability in the overall and appropriate use of AP for the most commonly performed operations in children both at a procedure and hospital level. A high proportion of AP use is inappropriate, potentially exposing many children to avoidable adverse events. Urgent attention should be directed to efforts to standardize the use of surgical AP in pediatrics.

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Figure 1.
Cohort Assembly
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Figure 2.
Interhospital Variation in Surgical Antibiotic Prophylaxis Among the 45 Most Commonly Performed Operations, 2010-2013

Open circles represent procedures for which prophylaxis was indicated; closed circles represent procedures for which prophylaxis was not indicated; and horizontal bars represent interquartile range by hospital. ORIF indicates open reduction internal fixation.

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Figure 3.
Interprocedural Variation in Appropriate Surgical Antibiotic Prophylaxis Among 31 Freestanding Children’s Hospitals, 2010-2013

Horizontal lines inside the box represent the median appropriate utilization rate; the borders of the box are the interquartile range (IQR); the plus sign represents the mean appropriate utilization rate; the whiskers are drawn to the most extreme points in the group that lie within the fences (the upper fence is defined as the third quartile plus 1.5 times the IQR, and the lower fence is defined as the first quartile minus 1.5 times the IQR); and circles outside the fences represent extreme outliers.

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Figure 4.
Interhospital Relationship Between Giving Prophylaxis When Indicated and Not Giving Prophylaxis When Not Indicated

Each circle represents 1 hospital with the size of the circle reflecting the volume of procedures; vertical and horizontal lines represent overall median rates.

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