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Perioperative Prophylaxis in Pediatric Solid Organ Transplantation: A Baseline Stewardship Audit Using Routine
Charles B Foster1, Kaitlyn Rivard2, Venkatraman A Arakoni3
1Section of Pediatric Infectious Diseases, Cleveland Clinic Children's, Cleveland, Ohio, USA.
Insights
Antibiotic prophylaxis timing and initial regimens in pediatric transplants were mostly successful. However, extended antibiotic use post-transplant, especially in abdominal cases, needs improvement for better antimicrobial stewardship.
Area of Science:
- Pediatric Solid Organ Transplantation
- Antimicrobial Stewardship
- Quality Improvement
Background:
- Perioperative antibacterial prophylaxis protocols vary significantly across pediatric solid organ transplant centers.
- Standardizing protocols is crucial for establishing baseline stewardship measures and guiding future quality improvement initiatives.
Purpose of the Study:
- To evaluate adherence to institutional perioperative antibacterial prophylaxis protocols in pediatric solid organ transplantation.
- To identify areas for improvement in antimicrobial stewardship and quality-of-care.
Main Methods:
- Retrospective analysis of 164 pediatric transplants (2010-2021).
- Assessment of on-time dosing, regimen selection, targeted add-on agents (MRSA, VRE), anaerobic coverage, Gram-negative broadening, and discontinuation timing.
- Utilized anesthesia and medication data to evaluate protocol concordance and exposure patterns.
Main Results:
- High adherence to on-time dosing (95.7%) and initial recommended regimens (87.2%).
- Suboptimal discontinuation rates (61.0%), particularly in intestinal and multivisceral transplants.
- Increased use and duration of MRSA-directed add-ons in abdominal transplants; protocol-linked antibiotic continuation beyond target windows observed in 8.6% of therapy days.
Conclusions:
- Pediatric transplant antibiotic prophylaxis demonstrates strong initial timing and regimen selection.
- Antibiotic continuation beyond protocol cutoffs in abdominal transplantation is a key area for prospective review and improvement.
- Routine electronic data can generate reproducible measures and organ-specific targets for stewardship and quality improvement.
Background:
Perioperative antibacterial prophylaxis in pediatric solid organ transplantation varies by center in regimen, add-on agents, and stop dates. We used institutional protocols as a unified reference standard to establish baseline stewardship measures and targets for future quality-improvement work.
Methods:
We retrospectively evaluated 164 pediatric transplants from 2010 to 2021. Using anesthesia timing and medication-administration data, we assessed on-time dosing, regimen selection, MRSA- and VRE-directed add-on agents, double anaerobic coverage, Gram-negative broadening during the protocol window, and discontinuation at organ-specific stop targets. We also used transplant-day anchoring and protocol-defined windows to describe whether primary-admission broad-spectrum exposure represented protocol-linked prophylaxis or later exposure. The audit measured protocol concordance and exposure patterns, not the appropriateness of deviations.
Results:
Prophylaxis was given on time in 95.7% of procedures. Overall, 87.2% received the recommended initial regimen, 7.3% the protocol-defined beta-lactam allergy regimen, and 4.3% another broad Gram-negative regimen. Only 61.0% stopped the main regimen by the intended cutoff; stop performance was best in kidney transplantation and poorest in intestinal and multivisceral transplantation. MRSA-directed add-ons clustered in intestinal and multivisceral procedures and often extended beyond the intended duration. A secondary descriptive analysis identified contiguous protocol-linked continuation beyond the intended window in 8.6% of primary-admission broad-spectrum days of therapy.
Conclusions:
Timing and initial regimen selection were strong. The main baseline process measure requiring prospective review was continuation of protocol-linked antibiotics beyond cutoffs in abdominal transplantation. This audit shows how routine electronic data can be used to create reproducible measures and organ-specific targets for future stewardship and quality-improvement studies.
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