Shawn J. Rangel

Importance: Postoperative antimicrobial prophylaxis (PAP) is frequently used following pectus excavatum repair and accounts for the highest relative burden of potentially avoidable postoperative antibiotic days among pediatric general surgical procedures.Objective: To evaluate the association of postoperative antibiotic prophylaxis with postoperative rates of surgical site infections, reoperation, and readmission in children undergoing pectus excavatum repair who did and did not receive postoperative antibiotic prophylaxis.Design, Setting, and Participants: This cohort study included children aged younger than 18 years undergoing pectus excavatum repair from January 2021 to December 2023 at 141 hospitals participating in the National Surgical Quality Improvement Program–Pediatric.Exposures: Continuation of prophylactic antibiotics after incision closure.Main Outcomes and Measures: Primary outcomes included 30-day postoperative rates of surgical site infections (SSIs), reoperation, and readmission. Propensity score matching was used to balance groups (without PAP or with PAP) on patient and operative characteristics plausibly associated with PAP use and outcomes. Mixed-effects models were used to compare outcomes between matched groups, with a random effect used to account for hospital clustering. A complementary hospital-level analysis was used to explore the correlation between rates of PAP use and observed to expected (O/E) rate ratios for each outcome after adjusting for differences in patient and procedural characteristics among hospitals.Results: A total of 3552 patients were included (median [IQR] age, 15.4 [14.5-16.4] years; 3099 males [87.3%]). Postoperative prophylaxis was used in 1949 patients (54.9%) for a median (IQR) duration of 21.6 (14.6-24.0) hours. In the matched cohort of 3168 patients, outcomes were similar in children receiving PAP compared with those who did not, with 26 of 1584 (1.6%) of children who received PAP developing an SSI compared with 29 of 1584 (1.8%) of children who did not receive PAP (odds ratio [OR], 0.90; 95% CI, 0.50-1.61). For children requiring reoperation, 25 of 1584 (1.6%) received PAP compared with 27 of 1584 (1.7%) who did not (OR, 0.98; 95% CI, 0.52-1.83). For readmission, 41 of 1584 (2.6%) children received PAP compared with 57 of 1584 (3.6%) who did not (OR, 0.81; 95% CI, 0.48-1.34). In the hospital-level analysis, no correlation was found between rates of postoperative prophylaxis use and O/E rate ratios for SSIs (Spearman ρ, −0.07; P = .43), reoperation (Spearman ρ, −0.01; P = .93), or readmission (Spearman ρ, −0.03; P = .65).Conclusions and Relevance: In this cohort study of 3552 pediatric patients undergoing pectus excavatum repair, postoperative antibiotic use was not associated with improved outcomes, challenging the routine use of postoperative prophylaxis in the operative management of this condition.

Objective: To compare outcomes in infants undergoing pyloromyotomy who did and did not receive antimicrobial prophylaxis. Summary Background Data: Variation exists among pediatric surgeons in the perceived utility and use of prophylactic antibiotics for infants undergoing pyloromyotomy. Methods: We conducted a multicenter study of infants undergoing pyloromyotomy at 148 hospitals participating in NSQIP-Pediatric from January 2021 to December 2023. Outcomes were compared using patient-level propensity-matched mixed-effects models, adjusting for hospital clustering. A complementary hospital-level analysis assessed the correlation between institutional prophylaxis rates and observed-to-expected (O/E) surgical site infection (SSI) rate ratios. Results: 6093 infants were included, of which 46.6% received prophylaxis. In the propensity-matched analysis, outcomes were similar for SSI (no prophylaxis: 38/2591 [1.6%] vs. prophylaxis: 28/2591 [1.1%], aOR 0.61; 95% CI, 0.37–1.01) and higher rates of prophylaxis use were not correlated with lower SSI O/E rate ratios in the hospital-level analysis (Spearman ρ = 0.11; P = 0.13). In propensity-matched subgroup analyses stratified by operative approach, no benefit was observed in the use of prophylaxis in infants undergoing laparoscopic pyloromyotomy (prophylaxis: 24/2288 [1.1%] vs. no prophylaxis: 25/2288 [1.1%]; aOR, 0.96; 95% CI, 0.55–1.69); however, a significant reduction in SSI rates was observed with open repair (prophylaxis: 6/311 [1.9%] vs. no prophylaxis: 16/311 [5.1%]; aOR 0.36; 95% CI, 0.14–0.93). Conclusions: Routine prophylaxis use does not reduce SSI rates in infants undergoing laparoscopic pyloromyotomy; however, a significant reduction in SSI was observed in infants undergoing open repair, suggesting selective prophylaxis is indicated in this higher-risk cohort.

Importance: Consensus guidelines from the Infectious Disease Society of America recommend against antimicrobial prophylaxis in the operative management of uncomplicated cholelithiasis; however, these guidelines were derived entirely from the adult surgical population.Objective: To compare surgical site infection (SSI) outcomes between children undergoing cholecystectomy who received prophylaxis and those who did not.Design, Setting, and Participants: This was a cohort study using data from 141 hospitals participating in the National Surgical Quality Improvement Program–Pediatric. Patients younger than 18 years who underwent cholecystectomy for uncomplicated cholelithiasis from January 2021 to December 2022 were identified. Exclusion criteria included diagnoses of acute cholecystitis, pancreatitis, choledocholithiasis, hematologic disorders, and emergent procedures.Exposure: Administration of prophylactic antibiotics before incision.Main Outcomes and Measures: The main outcomes were 30-day postoperative SSI and readmission. Propensity score weighting on the likelihood of receiving prophylaxis was used to balance groups on case acuity, duration of surgery, hospital discharge diagnosis, and patient characteristics. The association between outcomes and the use of prophylaxis was estimated using logistic regression models, weighted by the inverse probability of treatment with a random effect by hospital to control for hospital-level clustering. A secondary analysis was performed exploring the association between broad-spectrum prophylaxis and outcomes.Results: Of 2234 children who met criteria for inclusion (median age, 15.3 years; 19.7% male [399 of 2025]), 2025 (90.6%) received prophylaxis (utilization rates ranged from 0% to 100% among hospitals). Cefazolin was the most commonly used antibiotic (69.2% [1401 of 2025]), and 559 of 2025 patients (27.6%) received extended-spectrum prophylaxis (compared with cefazolin). In the propensity-weighted cohort, SSI rates were lower for children who received prophylaxis compared with those who did not (18.0 of 2016 [0.9%] vs 7.8 of 212 [3.7%]; adjusted odds ratio [AOR], 0.28; 95% CI, 0.11-0.70), and rates were similar between children receiving cefazolin and those receiving more extended-spectrum antibiotics in a secondary propensity-weighted analysis (13.9 of 1399 [1.0%] vs 2.9 of 558 [0.5%]; AOR, 0.54; 95% CI, 0.15-1.95).Conclusions and Relevance: The results of this study support prophylaxis use for children undergoing nonemergent cholecystectomy; however, use of extended-spectrum antibiotics was not associated with superior outcomes compared with cefazolin alone. Opportunities to optimize infection prevention or antimicrobial stewardship were identified in more than one-third of all children undergoing cholecystectomy.

In Reply We read with interest (and admittedly with some degree of expectation) the astute commentary submitted by Hall and colleagues in response to our