Postoperative Antimicrobial Prophylaxis Use and Outcomes in Pectus Excavatum Repair

Postoperative antimicrobial prophylaxis (PAP) is frequently used following pectus excavatum repair and accounts for the highest relative burden of potentially avoidable postoperative antibiotic days among pediatric general surgical procedures.

To evaluate the association of postoperative antibiotic prophylaxis with postoperative rates of surgical site infections, reoperation, and readmission in children undergoing pectus excavatum repair who did and did not receive postoperative antibiotic prophylaxis.

This cohort study included children aged younger than 18 years undergoing pectus excavatum repair from January 2021 to December 2023 at 141 hospitals participating in the National Surgical Quality Improvement Program-Pediatric.

Continuation of prophylactic antibiotics after incision closure.

Primary outcomes included 30-day postoperative rates of surgical site infections (SSIs), reoperation, and readmission. Propensity score matching was used to balance groups (without PAP or with PAP) on patient and operative characteristics plausibly associated with PAP use and outcomes. Mixed-effects models were used to compare outcomes between matched groups, with a random effect used to account for hospital clustering. A complementary hospital-level analysis was used to explore the correlation between rates of PAP use and observed to expected (O/E) rate ratios for each outcome after adjusting for differences in patient and procedural characteristics among hospitals.

A total of 3552 patients were included (median [IQR] age, 15.4 [14.5-16.4] years; 3099 males [87.3%]). Postoperative prophylaxis was used in 1949 patients (54.9%) for a median (IQR) duration of 21.6 (14.6-24.0) hours. In the matched cohort of 3168 patients, outcomes were similar in children receiving PAP compared with those who did not, with 26 of 1584 (1.6%) of children who received PAP developing an SSI compared with 29 of 1584 (1.8%) of children who did not receive PAP (odds ratio [OR], 0.90; 95% CI, 0.50-1.61). For children requiring reoperation, 25 of 1584 (1.6%) received PAP compared with 27 of 1584 (1.7%) who did not (OR, 0.98; 95% CI, 0.52-1.83). For readmission, 41 of 1584 (2.6%) children received PAP compared with 57 of 1584 (3.6%) who did not (OR, 0.81; 95% CI, 0.48-1.34). In the hospital-level analysis, no correlation was found between rates of postoperative prophylaxis use and O/E rate ratios for SSIs (Spearman ρ, -0.07; P = .43), reoperation (Spearman ρ, -0.01; P = .93), or readmission (Spearman ρ, -0.03; P = .65).

In this cohort study of 3552 pediatric patients undergoing pectus excavatum repair, postoperative antibiotic use was not associated with improved outcomes, challenging the routine use of postoperative prophylaxis in the operative management of this condition.