Antimicrobial prophylaxis Guideline for Pyloromyotomy Surgery in Children

1. Summary table of routine recommendations

*MRSA risk = previous MRSA infection or known colonisation.

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 intra-abdominal collections. Pyloromyotomy is considered a clean operation that can be approached either laparoscopically or as open surgery without and entry into the viscus.

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 9 consultant paediatric surgeons currently performing this procedure in the Leeds Teaching Hospitals Trust was performed. All 9 responded.  Only three of 9 surgeons (33%) stated that they use a single dose of flucloxacillin as prophylaxis against infection following pyloromyotomy. The remaining six surgeons do not use antibiotic prophylaxis. In comparison to a previous survey within our department with 6 consultants providing this surgery, 50% used antibiotics and this information was used to inform the previous guideline in recommending antibiotic prophylaxis at that time owing to lack of other evidence.

A literature review was performed. Saunders and Williams ⁽²⁾ 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.

Recent publication by Griffin et al ⁽³⁾ studied a large cohort of infants undergoing pyloromyotomy surgery from a national database involving 47 hospitals across United States. In 14,247 patients who underwent pyloromyotomy, there was no difference in complication rates whether or not patients received antibiotics. These results suggest antibiotic prophylaxis is unnecessary for pyloromyotomy.

Another recent consensus article published by Bianchini et al ⁽⁴⁾ representing the Peri-Operative prophylaxis in Neonatal and Paediatric Age (POP-NeoPed) Study Group describes the use of preoperative antibiotic prophylaxis in neonates and children that are undergoing abdominal surgery and has the purpose of providing guidance to healthcare professionals who take care of children to avoid unnecessary and dangerous use of antibiotics in these patients. This risk of surgical site infection in this group lies between 1 - 3% ony and pyloromyotomy does not involve breaching the lumen. The consensus was that antibiotic prophylaxis in this setting in not recommended.

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.⁽⁵⁾  Parallel data do not exist for pediatric populations and neonates who are by definition immunocompromised,

Our previous guideline suggested auditing our practice. We have retrospectively audited 2 years of our data from 2021 to 2023, We had 44 infants during this time period, only 9 (20%) received prophylactic antibiotic at induction. There were no readmissions within 30 days related to SSI. We can safely conclude from our data that antibiotic prophylaxis can be discontinued for pyloromyotomy surgery. There may still be an indication for antibiotic if any accidental breach occurred to the mucosa.

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