824 infection control & hospital epidemiology july 2017, vol. 38, no. 7
hospitals in Calabria (Italy), had undergone elective or urgent surgical procedures, were not on antibiotic therapy, and did not have any infection at the time of surgery. Clinical records of these patientswere retrospectively reviewed
by trained medical residents in public health at the University “Magna Græcia” of Catanzaro, and data were retrieved on a standardized electronic report form. Demographic data included gender, nationality, and age. Clinical data included weight in kilograms, presence of risk factors and comorbidities, prior antibiotic allergies, ward of hospital stay, type of admission categorized as ordinary hospitalization or day surgery, admission and discharge dates, and diagnosis. Data related to surgical pro- cedures included date, surgical procedure groups, type of surgery (elective or urgent), surgical wound classification,18 American Society of Anesthesiologists physical status (ASA score), duration of surgical procedure in minutes, time of anesthesia induction and of surgical incision, length of hospital stay at time of surgery, and implantation of prosthesis. For patients receiving antibiotics, details of SAP, such as antibiotic agents and classes, place and route of administration, time of first dose, duration, dose, and number of postoperative doses were also recorded. SAP indication was defined according to international
guidelines. In particular, appropriateness of SAP, whenever it was indicated, was assessed based on the Scottish inter- collegiate guidelines,14 supplemented by the Italian national guidelines.13 For each surgical procedure, the following items were evaluated: drug choice, route, timing, duration, and doses administered. SAP was deemed appropriate if all these parameters were in accordance with the guidelines. Prophylactic drug choice was categorized as optimal if the
antibiotic regimen was concordant with the guidelines. The term “adequate” referred to regimens that were effective for prophylaxis but were not appropriate according to guidelines, including agents with a spectrumof activity comparable to that recommended by the guidelines. Inadequate regimens included those deemed an unsuitable choice for SAP. Route of administration was categorized as appropriate or
not appropriate according to the guidelines. Timing of SAP was considered appropriate if the antibiotic was administered within 1 hour prior to surgical incision; in all other cases, it was considered inappropriate. SAP duration was considered appropriate if it was administered for <24 hours after surgery. SAP dose was considered appropriate if the antibiotic dose required for prophylaxis was the same as that for the therapy of infection, based on the body weight.14 Otherwise, it was considered inappropriate, and the SAP dose was categorized as either excessive or inadequate. Approval from the Institutional Ethics Committee of “Mater
Domini” Hospital of Catanzaro, Italy, was obtained on February 2, 2016.
Statistical Analysis
Univariate analysis and multivariate stepwise logistic regression analysis were performed. Univariate analysis was performed
using χ2 test for all categorical variables, and Student t test was used for independent samples to compare all continuous variables. Independent variables for which P was ≤0.25 in univariate analysis were included in the multivariate models. The significance level for variables entering the logistic regres- sion models was set at 0.2 and for removal from the model at 0.4. A 2-sided P value ≤.05 was considered statistically significant. In themultivariate logistic regressionmodels, the outcomes of
interest were the inappropriate SAP administration in proce- dures without SAP indication (Model 1) and the appropriate timing of SAP administration in procedures with SAP indication (Model 2). The following independent variables were included if they met the aforementioned criteria: gender (male=0; female=1), age (continuous, in years), weight (continuous, in kilograms), hospital with pediatric surgery ward (no=0; yes=1), ward of hospital stay (general surgery=0; surgical specialties=1), type of admission (ordinary=0; day surgery =1), surgical procedure group (urological, gynecologic/obste- tric=0; head and neck=1; tegument=2; orthopedic=3; abdominal=4), type of surgery (elective=0; urgent=1), night- time procedures (no=0; yes=1), surgical wound classification (clean=0; clean contaminated, contaminated or dirty con- taminated=1), ASA score (<3=0; ≥3=1), surgical procedure duration (continuous, in minutes), and implantation of prosthesis (no=0; yes=1). The results of the multivariate models, adjusted for hospitals, are expressed as odds ratio (OR) with 95% confidence interval (95% CI) and P values. Statistical analyses were performed using Stata Statistical software, version 14.0.19
results
In this study, 955 pediatric patients who underwent surgery were eligible, and their charts were reviewed. These patients underwent a total of 1,038 surgical procedures: 876 underwent 1 procedure, 75 underwent 2 procedures, and 4 underwent 3 procedures. The main characteristics of included patients and related procedures are reported in Table 1. Among the most frequent procedures were excisions of skin lesions (11.8%), inguinal and crural hernia repairs (11.7%), circumcisions
(11.4%), orchiopexies (9.9%), open reductions and internal fixations of bone fractures (5.6%), appendectomies (5.4%), and adenoidectomies and/or tonsillectomies (4.1%). Figure 1 shows the distribution of procedures according to
SAP correct adherence. SAP was administered with 317 of the procedures for which it was indicated (88.5%) and with 243 of those in which it was not indicated (35.7%). Overall, correct SAP administration or nonadministration was identified for 754 (72.6%) procedures. The inappropriate administration of SAP when it was not indicated significantly increased in relation to the following factors: with age; for surgical specialties; for hospitals without a pediatric surgery ward; for ordinary and urgent admissions; for nighttime procedures; in abdominal procedures, and in
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