Antimicrobial Prophylaxis Use and Outcomes for Children Undergoing Cholecystectomy.

Abstract

Importance: Consensus guidelines from the Infectious Disease Society of America recommend against antimicrobial prophylaxis in the operative management of uncomplicated cholelithiasis; however, these guidelines were derived entirely from the adult surgical population.

Objective: To compare surgical site infection (SSI) outcomes between children undergoing cholecystectomy who received prophylaxis and those who did not.

Design, setting, and participants: This was a cohort study using data from 141 hospitals participating in the National Surgical Quality Improvement Program-Pediatric. Patients younger than 18 years who underwent cholecystectomy for uncomplicated cholelithiasis from January 2021 to December 2022 were identified. Exclusion criteria included diagnoses of acute cholecystitis, pancreatitis, choledocholithiasis, hematologic disorders, and emergent procedures.

Exposure: Administration of prophylactic antibiotics before incision.

Main outcomes and measures: The main outcomes were 30-day postoperative SSI and readmission. Propensity score weighting on the likelihood of receiving prophylaxis was used to balance groups on case acuity, duration of surgery, hospital discharge diagnosis, and patient characteristics. The association between outcomes and the use of prophylaxis was estimated using logistic regression models, weighted by the inverse probability of treatment with a random effect by hospital to control for hospital-level clustering. A secondary analysis was performed exploring the association between broad-spectrum prophylaxis and outcomes.

Results: Of 2234 children who met criteria for inclusion (median age, 15.3 years; 19.7% male [399 of 2025]), 2025 (90.6%) received prophylaxis (utilization rates ranged from 0% to 100% among hospitals). Cefazolin was the most commonly used antibiotic (69.2% [1401 of 2025]), and 559 of 2025 patients (27.6%) received extended-spectrum prophylaxis (compared with cefazolin). In the propensity-weighted cohort, SSI rates were lower for children who received prophylaxis compared with those who did not (18.0 of 2016 [0.9%] vs 7.8 of 212 [3.7%]; adjusted odds ratio [AOR], 0.28; 95% CI, 0.11-0.70), and rates were similar between children receiving cefazolin and those receiving more extended-spectrum antibiotics in a secondary propensity-weighted analysis (13.9 of 1399 [1.0%] vs 2.9 of 558 [0.5%]; AOR, 0.54; 95% CI, 0.15-1.95).

Conclusions and relevance: The results of this study support prophylaxis use for children undergoing nonemergent cholecystectomy; however, use of extended-spectrum antibiotics was not associated with superior outcomes compared with cefazolin alone. Opportunities to optimize infection prevention or antimicrobial stewardship were identified in more than one-third of all children undergoing cholecystectomy.