Thoracic surgery in children - Guideline for antimicrobial use

Publication: 13/12/2012  --
Last review: 22/03/2017  
Next review: 22/03/2020  
Clinical Guideline
CURRENT 
ID: 2799 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2017  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guidelines for antimicrobial use in paediatric thoracic surgery

  1. Summary table of routine recommendations
  2. Background information

1. Summary table of routine recommendations

It is the responsibility of the surgical team to prescribe the prophylactic antibiotics, and the anaesthetist to ensure that they have been given within one hour before incision.

Procedure

recommendation

Evidence level

Aim of prophylaxis

NNT

Antimicrobial dose/route

Routine

MRSA risk* or true penicillin allergy

Pulmonary lobectomy
(excluding cystic fibrosis)

Yes

D

Prevention of Postoperative Pneumonia

 

IV Co-amoxiclav electronic Medicines Compendium information on Co-amoxiclav 30mg/kg single dose (max 1.2g)

IV Teicoplanin electronic Medicines Compendium information on Teicoplanin
10mg/kg single dose (max 400mg per dose)
&
IV Gentamicin (single daily dose regimen)

Repair of oesophageal atresia (OA) or tracheo-oesophageal fistula (TOF)

Yes

C

Prevention of post-operative pneumonia and surgical site infection

 

IV Amoxicillin electronic Medicines Compendium information on Amoxicillin
30mg/kg 8hourly (max 500mg per dose, can be doubled in severe infection)

IV Metronidazole electronic Medicines Compendium information on Metronidazole
Child 2 months - 18 years 7.5mg/kg 8hourly (max 500mg per dose)
Child 1-2months 7.5mg/kg 12 hourly

IV Gentamicin
Single daily dose regime

24-48 hours

IV Teicoplanin electronic Medicines Compendium information on Teicoplanin
Initially 10mg/kg every 12 hours for 3 doses, then 6mg/kg (max 400mg per dose)

IV Metronidazole electronic Medicines Compendium information on Metronidazole Child 2 months - 18 years
7.5mg/kg 8hourly (max 500mg per dose)
Child 1-2months 7.5mg/kg 12 hourly

IV Gentamicin
Single daily dose regime

24-48 hours

*MRSA risk = previous MRSA infection or known colonisation

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2. Background information

Surgical site infections, post-operative nosocomial pneumonia and empyema are reported complications following non-cardiac thoracic operations. Staphylococcus aureus and Staphylococcus epidermidis are the main organisms reported from surgical site infections in patients undergoing thoracic procedures. Postoperative pneumonia may be caused by a wide range of gram positive (Streptococcus & Staphylococcus sp) and gram negative organisms (Haemophilus influenzae, Moraxella catarrhalis, Klebsiella sp).There are limited studies supporting the efficacy of antimicrobial prophylaxis and no clear optimal choice of antimicrobial agent for thoracic operations. A small single centre randomized controlled trial in adults found Ampicillin-sulbactam to be slightly more effective than cephalosporins for prevention of pneumonia. One cohort found that Cefuroxime was marginally more clinically and more cost effective than Cefepime, however, there are no specific paediatric data. No clear consensus on the duration of antimicrobial prophylaxis has been established. Uncomplicated pulmonary lobectomy does not carry a high risk of infection therefore single dose prophylaxis is appropriate for this procedure. In general, the strength of the recommendation is proportionate to the likelihood of encountering high numbers of microorganisms during the procedure. Pulmonary resection in cases of partial or complete obstruction of an airway is a procedure in which prophylaxis is clearly warranted.

Likewise, antibiotic prophylaxis is strongly recommended for procedures entailing entry into the oesophagus. Approximately 92% of patients with OA have a tracheo-oesophageal fistula (TOF), which is a congenital fistulous connection between the oesophagus and the trachea or a main bronchus. Echocardiographic examination should be arranged pre-operatively to demonstrate any cardiac or vascular abnormality that could affect anaesthetic management or surgical approach. The duration of prophylaxis would depend upon operative variables such as risk of anastomotic leak and the need for post operative ventilation and prophylaxis may be extended up to 48hours depending upon surgical risk assessment. Respiratory complications occur in up to 46% of patients with repaired OA/TOF, 19% have recurrent pneumonia and 23% have repeated episodes of aspiration. These are believed to be secondary to gastro-oesophageal reflux, tracheomalacia, and recurrent TOF or oesophageal stricture.

These guidelines should be applicable to the majority of patients but where the recommendations in these guidelines do not seem appropriate for a particular patient, the surgeon is advised to discuss the case with a microbiologist.

Provenance

Record: 2799
Objective:
Clinical condition:

Thoracic surgery in children

Target patient group: Children undergoing thoracic surgery.
Target professional group(s): Secondary Care Doctors
Pharmacists
Adapted from:

Evidence base

References

  1. Turna A, Kutlu CA, Ozalp T et al. Antibiotic prophylaxis in elective thoracic surgery: Cefuroxime versus Cefepime. Thorac cardiov Surg. 2003;51:94-88
  2. Boldt J, Piper S, Uphus D et al. Preoperative microbiologic screening and antibiotic prophylaxis in pulmonary resection operations. Ann Thorac Suerg. 1999:68:208-11
  3. Kovesi T, Rubin S. Long-term complications of congenital esophageal atresia and/or tracheoesophageal fistula. Chest 2004;126:915-25.

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 1.0

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