Decreasing surgical site infections in pediatric stoma closures
Hira Ahmad1, Andrew B Nordin2, Devin R Halleran1
1Center of Colorectal and Pelvic Reconstruction, Nationwide Children's Hospital, Columbus, OH.
Insights
Implementing a gastrointestinal (GI) bundle and optimizing preoperative antibiotics significantly reduced surgical site infections (SSIs) in pediatric patients undergoing GI surgery. Targeted antibiotic selection based on wound pathogens further decreased SSI rates, improving patient outcomes.
Area of Science:
- Surgical Quality Improvement
- Infectious Disease Prevention
- Pediatric Surgery
Background:
- Gastrointestinal (GI) surgery is a major source of surgical site infections (SSIs) in children, leading to increased morbidity.
- Previous implementation of a GI bundle successfully reduced SSI rates, length of stay, and hospital charges.
- Further reduction of SSIs was hypothesized by optimizing preoperative antibiotic selection for stoma closures.
Purpose of the Study:
- To evaluate the impact of targeted preoperative antibiotic selection on SSI rates in pediatric patients undergoing GI stoma takedown procedures.
- To determine if modifying antibiotic choice based on identified wound pathogens can further decrease SSI rates after initial bundle implementation.
Main Methods:
- A retrospective cohort study was conducted to analyze SSI rates before and after changes in antibiotic protocols.
- Preoperative antibiotic protocols were adjusted from cefoxitin to ampicillin-sulbactam based on analysis of prevalent pathogens, including enterococcus, in wound infections.
- Data on SSI rates, causative organisms, and antibiotic sensitivities were collected and analyzed over distinct study periods.
Main Results:
- The baseline SSI rate for stoma takedown patients was 21.4%.
- Following the implementation of a GI bundle, the SSI rate decreased significantly to 7.9% (p=0.03).
- Further modification of preoperative antibiotics led to a substantial reduction in SSI rates to 2.2% (p=0.039).
Conclusions:
- A comprehensive GI bundle is effective in reducing SSIs in pediatric GI surgery.
- Tailoring preoperative antibiotic choices to specific, prevalent wound infection pathogens can further enhance SSI reduction.
- Institution-specific analysis of wound infections and subsequent antibiotic regimen modification is recommended for optimizing SSI prevention strategies.
Introduction:
Gastrointestinal (GI) operations represent a significant proportion of the surgical site infection (SSI) burden in pediatric patients, resulting in significant morbidity. We have previously demonstrated that a GI bundle decreases SSI rates, length of stay (LOS), and hospital charges. Following this success, we hypothesized that by targeting the preoperative antibiotics for stoma closures based on organisms found in infected wounds, we could further decrease SSI rates.
Methods:
As part of a broad quality improvement effort to reduce SSI rates, we reviewed the responsible pathogens and their sensitivities as well as the preoperative antibiotic used, and found that 15% of wound infections were caused by enterococcus. Based on this information, starting in April 2017, we changed the prior preoperative antibiotic cefoxitin to ampicillin-sulbactam, which more accurately targeted the prevalent pathogens from April 2017 to October 2018.
Results:
The baseline SSI rate for all stoma takedown patients was 21.4% (25 of 119). After bundle implementation, this decreased to 7.9% (17 of 221; p = 0.03) over a period of 2.5 years. Then, after changing the preoperative antibiotics, our rate of SSI decreased further to 2.2% (1 of 44; p = 0.039) over a period of 1.5 years.
Conclusion:
Significant reduction of SSI in GI surgery can be accomplished with several prevention strategies (our GI bundle). Then a change of the preoperative antibiotic choice, chosen based on causative wound infection organisms, may further decrease SSI rates. We recommend an institution specific analysis of wound infections and modification of preoperative antibiotics if the responsible organisms are resistant to the original antibiotic choice.
Type Of Study:
Retrospective cohort study.
Level Of Evidence:
Level III.
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