Neonatal Antibiotic Prophylaxis and Surgical Site Infection Adam C. Alder, MD MSCS Ryan Walk, MD UTSW and Children s Health Dallas, TX
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1 Neonatal Antibiotic Prophylaxis and Surgical Site Infection Adam C. Alder, MD MSCS Ryan Walk, MD UTSW and Children s Health Dallas, TX
2 Nothing to disclose Disclosures
3 Objectives Review the current challenges with SSI in neonates Review successes and failures at Children s Health Discuss future directions
4 Background Surgical Site Infections 0.82 Common complication Significant morbidity and mortality NSQIP Pediatric 1% to 4% of Pediatric Operations Up to 6% of Neonatal Operations
5 Background
6 Antibiotic Prophylaxis Reduce the burden of microorganisms Minimize wound contamination Reduce the incidence of SSI
7 Antibiotic Prophylaxis Decreased antibiotic exposure Limited antibiotic resistance Reduced cost Lower rates of clostridium difficile Improved infection rates
8 Review of Local Data Total patients in NSQIP Cohort 40 Patients 5 Excluded: Gastroschisis/Omphalocele 11 Pyloromyotomy (Lap and Open) 7 Gastrostomy Tubes 4 Necrotizing Enterocolitis 3 Ladd s Procedures 10 Miscellaneous Abdominal Choledochal cyst, Atresias, Etc. Wound Complications 22.9% Wound Infection 3 Incisional Superficial (Antibiotics) 4 Incisional Deep (Open Wound, Antibiotics) 1 Deep/Organ Space (Reoperation)
9 Surgical Prophylaxis? 17/35 (49%) Appropriate Abx 11 pyloromyotomies receiving Ancef 18/35 (51%) Inappropriate Abx 5 inadequate or no coverage 2 Failure to re-dose intraoperatively Others: inappropriate antibiotic selection 18 Inappropriate Antibiotic Administration 7 Wound Infections (39%) Class 2/3 Procedures (Including Gtube) 17 Inappropriate Antibiotics 6 Appropriate Antibiotics 4 Gastrostomy Tubes (Single dose Ancef OK) 2 (12.5%) Non-GTube patients appropriate 6 Wound Infections (26%) 37.5% Excluding Gastrostomy Placements
10 Quality Improvement Plan
11 Stakeholders Simple, Quick and Easy Surgeon, Neonatologist, Anesthesiologist Antibiotic Committee ID, Surgery, Pharmacy Education program
12 Proposed Prophylaxis Regimen Administration within 60min of incision Duration Colorectal Procedures: 48 hours Necrotizing Enterocolitis: Treatment course Kasai Procedure Peri-operative regimen Followed by standard cholangitis prophylaxis All others Single dose, or not > 24hr New ACS/SIS guidelines do not support > 1 dose
13 Proposed Prophylaxis Regimen Colorectal Procedures Cefazolin (30mg/kg) + Metronidazole (15 mg/kg) Necrotizing Enterocolitis Zosyn (75-100mg/kg) +/- Vancomycin (15mg/kg) All Cases, PCN Allergy Clindamycin (10mg/kg; Re-dose at 6hours) - PLUS - Gentamicin (2.5mg/kg; No Re-dose) All Cases, Hx of MRSA (in addition to other abx) Vancomycin (15mg/kg)
14 Simplified Regimen Ancef for Everything Allergic to Ancef? Clindamycin and Gentamycin Poop? Add Flagyl! Fancy Liver Surgeon? Rocephin and Flagyl Vanc kills MRSA
15 Follow-up Data All Neonatal Operations 2/23 5/23 27 Cases; 24 Neonates 2 Ladd s 7 Gastrostomy Tubes 7 NEC 0 Pyloromyotomies 11 Miscellaneous Abdominal/Thoracic
16 Pre Pre-Intervention: 48.6% Post-Intervention: 55.6% p = Abx Appropriate (%) Post
17 Pre Pre-Intervention: 22.9% Post-Intervention: 14.8% p = Infection (%) Post
18 Post Intervention Details Pre-intervention Group 17 Patients Appropriate : 1 infection (6%) 18 Patients Inappropriate: 7 infections (39%) p = Post-intervention Group 15 Patients Appropriate : 0 infections 12 Patients Inappropriate : 4 infections (33%) p = 0.028
19 Post Intervention Details 1 not given / 1 given late (no infxn) 1 prolonged duration (no infection) 1 Incorrect dosing interval (no infxn) 1 inadequate duration (+ infection) 1 Incorrect antibiotics (+ infection) 3 failures to re-dose intra-operatively No infection 4 failures to re-dose prior to incision 2 Infections
20 Future Directions EPIC Best-Practice Advisory Once patient scheduled for OR Automatic alert regarding antibiotic prophylaxis Triggers when provider enters chart If no antibiotic ordered within 24hrs of surgery
21 Future Directions Anticipated Work-flow Surgery team communicates procedure to NICU and desired antibiotics NICU Team orders antibiotics to bedside with pre-op orders and standard order set Antibiotics delivered from NICU Pharmacy Available to anesthesia on induction Post-op antibiotic regimen automatically continued based on procedure
22 Actual Stakeholders Surgeon Attending/Fellow/Resident team/app team Neonatologist Attending/Fellow/APP Nursing NICU Nurse Manager/Education Leader/Bedside Nurse Pharmacy NICU Pharmacy/OR Pharmacy IT VP Informatics/Data Team/OR Environment/NICU Environment/Orderset Team/EPIC Quality Surgeon Champion/SCR/Quality reviewers Antibiotic Stewardship Attending ID, Antibiotic Pharmacy
23 Summary Neonates are a high risk group Little data and benchmarking Complex environment Huge possibilities!
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