American Academy of Pediatrics – Committee on Infectious Diseases and the Pediatric Infectious Diseases Society

View all recommendations from this society

November 12, 2018

Don’t use a broad spectrum antimicrobial agent for perioperative prophylaxis or continue prophylaxis after the incision is closed for uncomplicated clean and clean-contaminated procedures.

When indicated, the timely administration of perioperative antibiotics can reduce post-operative infections when narrow spectrum antibiotics (eg, cefazolin) are given before surgery. Perioperative prophylaxis should not be continued after the incision is closed for uncomplicated clean and clean-contaminated procedures (ie respiratory, gastrointestinal, or genitourinary sites are breached but without infection or inflammation. Clean contaminated procedure is when you cross the respiratory, GI, or urogenital tract without gross contamination.) Broad spectrum antibiotics and longer durations of therapy have not been shown to be more beneficial and these practices contribute to the development of antimicrobial resistance and the emergence of pathogenic organisms (eg, Clostridium difficile). Both the dose and timing of perioperative antibiotic administration are important for optimal effect. Many studies show poor adherence to published guidelines on use of perioperative antibiotics, which emphasizes the need for ongoing quality improvement approaches in this area.

This list from the American Academy of Pediatrics is developed with judicious use of antimicrobials in mind, however, when a patient has suddenly and inexplicably become severely ill, the short-term, empiric use of broad-spectrum antibiotics is warranted, and should be left to the discretion of the medical team.

How The List Was Created

The American Academy of Pediatrics Committee on Infectious Diseases’ Subcommittee on Antimicrobial Resistance and Stewardship identified the need to promote the judicious use of antibiotics in the inpatient setting at their strategic planning session held in October 2015. A workgroup of pediatric experts was formed with representatives from the Academy’s Committee on Infectious Diseases, Committee on Fetus and Newborn, Section on Infectious Diseases, and external partners from the Pediatric Infectious Diseases Society. A modified Delphi process was used to create the list for Choosing Wisely. Experts from the workgroup were asked to create an initial list of what practices may be included– 15 practices for inpatient antimicrobial stewardship were identified through email and conference calls.

The workgroup reviewed and ranked via survey which practices within the list of 15 were the most important to include. The survey also asked for any additional suggestions for inpatient AS practices that were not included on the list. This survey was then simultaneously sent to the Antimicrobial Resistance Stewardship workgroup, as well as, internally, to the following Executive Committees: 1. Committee on Hospital Care, 2. Committee on Fetus and Newborn, 3. Committee on Pediatric Emergency Medicine, Section on Critical Care, Section on Emergency Medicine, Section on Infectious Diseases, and Section on Neonatal-Perinatal Medicine and externally to the Pediatric Infectious Diseases Society Executive Committee and their antimicrobial stewardship workgroup. The list was edited based on the feedback received and narrowed down to a new top ten list. The workgroup reviewed the list and voted on their top five based on the following criteria: 1. Feasibility, 2. Supported by Evidence, 3. Not Duplicative, 4. Free from Harm, and 5. Truly Necessary. The list was peer reviewed by relevant expert Committee, Council and Section leadership. The AAP Executive Committee approved this publication of the list.

AAP’s disclosure and conflict of interest policy can be found at www.aap.org.

Sources

Berrios-Torres S, Umscheid C, Bratzler D, et al. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg. doi:10.1001/ jamasurg.2017.0904.

Bratzler DW, Dellinger P, Olsen KM et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013:70:195-283.

European Centre for Disease Prevention and Control. Systematic review and evidence-based guidance on perioperative antibiotic prophylaxis. Stockholm: ECDC: 2013. Doi 10.2900/85936.

TSteinberg JP, Braun BI, Hellinger WC et al. Timing of antimicrobial prophylaxis and the risk of surgical site infections: results from the Trial to Reduce Antimicrobial Prophylaxis Errors. Ann Surg. 2009;250: 10-6. doi: 10.1097/SLA.0b013e3181ad5fca.

Ranji Sr, Shetty K, Posley KA et al. Prevention of Healthcare-Associated Infections. Vol 6 of: Shojania KG, McDonald KM, Wachter RM, Owens DK, editors. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies. Technical Review 9 (Prepared by the Stanford University-UCSF Evidence-based Practice Center under Contract No. 290 02-0017). AHRQ Publication No. 04(07)-0051-6. Rockville, MD: Agency for Healthcare Research and Quality. January 2007.