Antimicrobial Prophylaxis Guideline for Lower Gastrointestinal Surgery in Children

1. Summary table of routine recommendations
2. Background information

1. Summary table of routine recommendations

*MRSA risk = previous MRSA infection or known colonisation.

*There needs to be an ongoing evaluation of the patient by the surgical team, any signs of wound inflammation or abdominal infection may justify continuation of antibiotics, may be changed to oral co-amoxiclav as indicated (30mg/kg every 8hours). Please discuss with Microbiology for individual cases as required.

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2. Background information

The continued presence of Meticillin-resistant Staphylococcus aureus (MRSA) in the Trust, ongoing problems with Clostridium difficile infection and the drive to reduce Health care associated infections have prompted a review of surgical prophylaxis in children.

The aim of antimicrobial prophylaxis when used in gastrointestinal surgery is a reduction in surgical site infection (SSI) or intrabdominal collections.

Colorectal Surgery

Antibiotics or not?
In a Cochrane systematic review (Nelson et al.⁽²⁾) of prophylactic antibiotic use in elective and emergency colorectal surgery, no trial was found that included children. A total of 182 randomised controlled trials, published between January 1980 and December 2007 (30,880 patients) were analysed. The authors claim the use of antibiotic prophylaxis for patients undergoing colorectal surgery is imperative⁽²⁾ 

Choice of antibiotic
Breckler et al.⁽¹⁾ carried out a nationwide survey in the United States to ascertain current practices of bowel preparation for elective colorectal surgery in children.  Four hundred and ninety-three surveys were administered, and 136 physicians responded (28%).⁽¹⁾ Intravenous antibiotics were used by 99% (n = 135) of the surgeons surveyed.⁽¹⁾ Cefoxitin was selected as the sole agent in 31% (n = 42).⁽¹⁾ Double- or triple-drug antibiotic prophylaxis was used by 22% of the respondents that included Ampicillin and an aminoglycoside (n = 8), ampicillin and an aminoglycoside plus either Clindamycin or Metronidazole (n = 17), or an aminoglycoside plus Clindamycin or Metronidazole (n = 5).⁽¹⁾ This demonstrates that there is no clear consensus on choice of optimal antibiotic.

It is well recognised that the required spectrum of coverage in colorectal surgery is determined by the flora found within the patient’s large bowel. This is a copious mixture of both anaerobic and aerobic species, rather than contaminants from the patient’s skin or the operating room.^(3,4) Nelson et al. conclude that antibiotic choices, which cover both anaerobic and aerobic bacteria, gave the best results.⁽²⁾ The efficacy of many different regimes is similar and it may be difficult to identify the most cost effective option. The current drive to reduce the rate of C. difficile infection has lead to a reduction in use of cephalosporins. An alternative would be Amoxicillin  , Gentamicin and Metronidazole which has compared favourably in clinical trials  Metronidazole is recommended to be given with a loading dose of 15mg followed thereafter by TDS dosing of 7.5 mg. Regimens for Gentamicin include TDS and OD protocols and these options are currently being compared within the trust.

Timing and Duration of therapy
The Cochrane systematic review of adult (Nelson et al.⁽²⁾) suggests that a single dose at induction is sufficient. and additional dosing may increase the risk of resistant organisms and C. difficile colitis.⁽²⁾ These data were however derived from adult patients. The SIGN trial also advocates single doses of an antibiotic with a sufficiently long half life to cover the duration of the operation but again is derived from adult studies and specifically highlights the need for further studies in paediatric subjects to help establish what would constitute an optimal prophylaxis regimen.

The duration of intravenous antibiotic prophylaxis after surgery varied among the respondents of the survey of Paediatric Surgical practice in the US reported by Breckler et al.⁽¹⁾ . This study demonstrated that 51% of surgeons continued antibiotics for 24 hours or less. whilst thirty-eight percent indicated that the duration of prophylaxis was 48 hours or greater.⁽¹⁾

To establish local consensus, 6 consultant paediatric surgeons in the Leeds Teaching Hospitals Trust who regularly undertake GI procedures were surveyed. All 6 surgeons state that they use Cefuroxime and Metronidazole as antibiotic prophylaxis for gastrointestinal procedures in children (not quite true - we’ve moved away from cef and met because of the trust wide concern re cephalosporins, but we’d be happy to move back if this remains a safe and effective option)..  However, in light of LTHT preference to avoid cephalosporins, we advocate the use of Amoxicillin  , Metronidazole and Gentamicin. Duration of prophylaxis remains undefined in paediatric setting, however, short duration upto 24hours would be preferred option to avoid any adverse effects and risk of bacterial resistance. This may need to be reviewed by the operating team depending on surgical findings. Once an infection has been identified, the antibiotic administration should be considered as therapeutic rather than prophylactic and clearly documented in clinical/operative notes.

Specific indications for recommending longer durations of prophylaxis include caecostomy button insertion and surgery for Anorectal Malformations and Hirschsprung Disease. Caecostomy insertion,  may be considered to be clean/contaminated and a prolonged course was considered necessary given the fact that a fistula is created that would potentially allow egress of faecal organisms into the peritoneal cavity and that the effects of this anatomical disruption are potentiated by the need to flush the button to maintain patency. Surgery for Hirschsprung Disease and for Anorectal Malformations can be considered “contaminated” and so fall outside the scope of recommendations by SIGN. The consequences of pelvic sepsis would be devastating and therefore the standard duration of prophylaxis may be up to 5 days.

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