Antibiotic prophylaxis in pediatric surgery: when more is not better-or safer

Antibiotic resistance is a major public health concern. While surgical antibiotic prophylaxis (SAP) reduces surgical site infections (SSIs), inappropriate use may cause harm. This study evaluates the impact of SAP appropriateness and compares beta-lactam versus non-beta-lactam antibiotic use in pediatric surgery.

A retrospective cohort analysis was conducted using ACS NSQIP Pediatric data (2021-2023). Exclusions included preexisting infections, malignancy, immunodeficiencies, and emergent surgeries. SAP appropriateness was classified according to NSQIP guidelines. Logistic regression assessed association between SAP categories and postoperative infections, presented as odds ratios (ORs) and 95% confidence intervals (CIs).

Of 189,111 patients, 87.5% received SAP, 10.2% were overtreated, and 3.9% undertreated. SSIs occurred in 1.9%. Compared to appropriate use, undertreatment was associated with higher odds of SSI (OR: 1.4; 95% CI: 1.2-1.7), sepsis (1.6; 1.1-2.2), C. difficile colitis (2.5; 1.2-5.5), and UTI (1.8; 1.2-2.5). Overtreatment was linked to lower odds of UTI (0.7; 0.5-0.8). Non-beta-lactam antibiotics had higher odds of pneumonia (1.4; 1.0-2.0; p = 0.047) compared to beta-lactam antibiotics.

Appropriate SAP is crucial in minimizing postoperative infections. These results underscore the importance of antibiotic selection among pediatric surgical patients.