Antimicrobial prophylaxis Guideline for Pyloromyotomy Surgery in Children

Summary table of routine recommendations

*MRSA risk = previous MRSA infection or known colonisation.

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.

Pyloromyotomy

Antibiotic guidelines for pyloromyotomy note differences in practice. Mullassery et al. ⁽¹⁾ carried out a survey of 94 members of the British Association of Paediatric Surgeons. They found that prophylactic antibiotics were used by 70% of the surgeons exclusively performing umbilical pyloromyotomy. Six surgeons using other operative techniques (RUQ or laparoscopy) also found this policy beneficial. However, more than 50% of pediatric surgeons responding to the study questionnaire do not routinely prescribe antibiotics. A survey of consultant paediatric surgeons currently performing this procedure in the Leeds Teaching Hospitals Trust was performed. All six responded. Three of 6 surgeons (50%) stated that they use a single dose of flucloxacillin as prophylaxis against infection following pyloromyotomy. The remaining three surgeons do not use antibiotic prophylaxis.

A literature review was performed. Ladd et al. ⁽²⁾ studied all patients who underwent pyloromyotomy at a tertiary paediatric hospital over a 6-year period. Baseline wound infection rate was determined through review of patients with right upper quadrant incisions (group 1). A nonrandomized comparison was performed between patients with a supraumbilical approach (group 2) and those undergoing supraumbilical incisions after prophylactic antibiotic administration (group 3). Antimicrobial prophylaxis consisted of a first-generation cephalosporin (25 mg/kg) administered at the time of incision. The rate of infection in group 1 was 2.3% (6/257). With introduction of the supraumbilical approach, there was a statistically significant increase in the wound infection rate to 7.0%. The use of prophylactic antibiotics with a supraumbilical approach in group 3 obtained a rate of wound infection equivalent to that of group 1 of 2.3%. This is a decrease of 67% in the rate of wound infection. Ladd et al. conclude that the use of a supraumbilical incision in young patients undergoing pyloromyotomy may delineate a unique indication for prophylaxis. Additional studies demonstrate an increase in the rate of wound infection associated with the supraumbilical approach, preventable by the administration of antibiotic prophylaxis.^(3-9) However, the results of these investigations frequently fail to reach statistical significance.

Saunders and Williams ⁽¹⁰⁾ studied one hundred and twenty-nine infants with infantile hypertrophic pyloric stenosis that were referred to one consultant surgeon over a 13-year period for whom antibiotics were not given. They found that wound infections developed in 3% of cases. The authors’ interpretation was that that prophylactic antibiotic treatment is not indicated.

Finally, antibiotic prophylaxis has been shown not to significantly alter the rate of wound infection in adult National Nosocomial Infection Surveillance classifications with clean or clean-contaminated wounds.⁽¹¹⁾ Parallel data do not exist for pediatric populations and neonates who are by definition immunocompromised, Furthermore, there is evidence of a reduction of infection rate from 7%-2.3% in this specific instance2. In summary, local consensus demonstrates equipoise and current evidence is inconclusive. We agreed locally to give a single dose of antibiotic prophylaxis at induction, this would be kept under review and modified as further evidence becomes available.

Owing to lack of adequate clinical trials in this setting and definitive evidence based guidance, it would be a good practice to audit the process, identify any shortcomings and review the recommendations at regular intervals. It was recognised at a multidisciplinary meeting however that in order to generate sufficient numbers to make such an audit meaningful would take a significant period of time (given the relatively low rates of infection, low rate of cases per year and difficulty in obtaining robust post discharge follow up data).