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.

*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.