surgical antibiotic prophylaxis in pediatric surgery 827
inappropriately substituted with a newer one. In particular, ceftriaxone was used instead of cefazolin in 57% of cases and instead of cefoxitin in 76.8% of cases. Moreover, ampicillin- gentamicin combination was not used in hypospadias or epispadias repair, but it was replaced by ceftriaxone (44%). Broad-spectrum penicillins plus β-lactamase inhibitors (ampicillin plus sulbactam and amoxicillin plus clavulanic acid) were used instead of cefazolin or cefoxitin in 26.1% of cases. Prophylactic administration was inappropriately prolonged
in the great majority of cases, but the route of administration and dose of prophylactic antibiotics were appropriate in most circumstances. Adherence to timing was respected in <50% of the proce-
dures, and in >33% of cases, SAP was administered after incision, even as long as 24 hours after the start of the procedure. Appropriateness of SAP timing in surgical procedures with
indication for prophylaxis according to the various character- istics of each procedure is presented in Table 4. At univariate analysis, appropriate timing of SAP administration was significantly more likely in procedures performed in females, in older children/adolescents, in day surgeries, in elective surgeries, in clean surgical wounds, and in those undergoing
prosthesis implantation. Multivariate stepwise logistic regres- sion analysis results underscore those of the univariate analysis, except for weight, type of admission and surgical wound classification, which were removed from the model. However, appropriate timing of prophylaxis was more likely in patients who were admitted in general surgery wards and in those who underwent orthopedic surgeries than in those who underwent all other surgical procedures (Table 5). Although this was not a specific aim of our study, we reviewed the selected clinical records for development of an SSI, and none was detected.
discussion
Our study provides one of the few evaluations of the appro- priateness of SAP administration in pediatric surgery. The results clearly indicate that the overall nonadherence to correct SAP administration or nonadministration (27%) is char- acterized by both SAP overuse and underuse, with physicians being more prone to overuse (ie, providing SAP when it is not indicated, 35%) than to underuse (ie, neglecting SAP when it is indicated, 11%). This attitude demonstrates that physicians are more concerned about the risk of SSIs than the risks related to an excess or inappropriate use of antibiotics, such as the
table 2. Multiple Logistic Regression Analysis Results Examining Inappropriateness of SAP Administra- tion in Procedures Without SAP Indication
Variable
Gender Male
Female Age, y Weight, kg
Hospital with pediatric surgery ward Yes No
Ward of hospital stay General surgery
Surgical specialties
Type of admission Ordinary
Day surgery
Surgical procedure group Urological, gynecologic/obstetric Head and neckb
Surgical wound classification Clean
Other surgical disciplinesc
Clean contaminated or contaminated Surgical procedure duration, min
1.00a 2.25 1.01
OR SE 95% CI
Model 1. Inappropriate SAP Administration in Surgical Procedures Without SAP Indication (No. of Observations=680)
1.00a 0.35 1.04 1.02
1.00a 5.22
1.00a 3.38
1.00a 0.24
1.00a 2.72
0.11 0.04 0.01
3.00 1.56 0.07 1.17
0.78 0.01
0.18–0.65 0.95–1.13 1.00–1.04
1.70–16.1 1.36–8.36 0.13–0.43 1.17–6.32 Backward elimination
1.16–4.37 1.00–1.02
NOTE. SAP, surgical antibiotic prophylaxis; OR, odds ratio; SE, standard error; CI, confidence interval. aReference category. bIncluding ear, nose and throat (ENT), ophthalmic, and maxillofacial surgery. cIncluding tegument, orthopedic, and abdominal surgery.
.017 .010
.001 .394 .027
.004 .008 <.001 .020 P
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