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An audit of prophylactic antibiotic use in laryngeal reconstruction surgery
International Journal of Pediatric Otorhinolaryngology 73 (2009) 1157–1159
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
An audit of prophylactic antibiotic use in laryngeal reconstruction surgery Satyamaanasa Polubothu, Sylvia Harrison, Andrew Clement, Haytham Kubba * Department of Otolaryngology, Royal Hospital for Sick Children, Yorkhill, Glasgow G3 8SJ, United Kingdom
A R T I C L E I N F O
S U M M A R Y
Article history: Received 19 October 2008 Received in revised form 26 April 2009 Accepted 30 April 2009 Available online 5 June 2009
Objective: Published data on the role of antibiotics after open airway reconstruction surgery in children is lacking. We reviewed adherence to our own departmental antibiotic protocol to determine its adequacy and effectiveness. Methods: We reviewed the records of all children undergoing open airway reconstruction surgery 2003– 2007 in our unit which is based in a tertiary referral children’s hospital. Results: 36 children underwent surgery, of whom 32 were given appropriate antibiotic prophylaxis. Failure to give antibiotic prophylaxis was associated with increased rates of infection (wound infection and pneumonia) and with a longer stay in the ITU. Conclusions: We present a revised antibiotic protocol based on our experience and local antibiotic advice. ß 2009 Elsevier Ireland Ltd. All rights reserved.
Keywords: Laryngotracheal reconstruction Laryngotracheoplasty Laryngeal surgery Airway surgery Antibiotic prophylaxis Post-operative infection
1. Introduction The last 20 years have seen a huge improvement in the surgical options available for children with airway disorders, with problems such as subglottic stenosis, glottic webs and subglottic haemangiomas now being treatable by various open airway surgical procedures. Post-operative infection will inevitably hinder recovery and may adversely affect the outcome of the procedure. Inappropriate use of antibiotics however, may increase antimicrobial resistance and will lead to unnecessary costs. While antibiotic prophylaxis has been suggested for paediatric airway surgery [1], there is no published evidence to support this practice. Several papers have demonstrated the benefit of antibiotic prophylaxis in clean contaminated head and neck surgery in adult cancer patients [2–4]. These adults may have poor wound healing due to inadequate nutrition, previous radio- or chemotherapy, or the effects of the cancer itself, so it is difficult to generalise these findings to otherwise-well children. National guidelines suggest antibiotic prophylaxis for cleancontaminated surgery in adults [5] but no mention is made for children. Our own departmental protocol is to use prophylactic antibiotics following airway surgery (7 days of co-amoxyclav, unless there is a history of allergy to penicillin or evidence of colonisation with MRSA). The aims of this audit were therefore as follows. Firstly, to assess compliance with our own departmental
* Corresponding author. Tel.: +44 141 2010297; fax: +44 141 2010865. E-mail address: [email protected] (H. Kubba). 0165-5876/$ – see front matter ß 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijporl.2009.04.026
policy on antibiotic prophylaxis following major open airway surgery, and secondly to compare the rates of infective complications in individuals receiving prophylactic antibiotic compared with those not receiving prophylactic antibiotics. 2. Subjects and methods This study took the form of a retrospective case note review. Inclusion criteria were defined as individuals undergoing major open airway reconstructive surgery in our hospital from January 2003 to December 2007. The relevant subjects were identified from our departmental database and their case notes retrieved for review. From the case notes we recorded what antibiotics were given, if any, and whether any infective complications occurred. 3. Results Over the study period 36 children underwent major open airway reconstruction surgery. The children were aged between 5 days and 18 years (median 4 years) at the time of surgery. 19 were male and 15 were female. Complete records were available for 34(94%). The indication for surgery was subglottic stenosis in 21 (62%), glottic web with subglottic stenosis in 5 (14%), subglottic haemangioma in 2 (6%), upper tracheal stenosis following tracheostomy in 5 (14%), and partial cartilaginous sleeve trachea in 1 (3%). Twelve children had a tracheostomy in place at the time of surgery, while 24 did not. Surgery involved single stage laryngotracheal reconstruction with cartilage grafts in 24 (68%),
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double stage laryngotracheal reconstruction with cartilage grafts in 3 (11%), partial cricotracheal resection in 5 (14%) and resection of subglottic haemangiomas in 2 (7%). In 19 procedures, a nonsuction (Penrose) drain was placed in the wound to prevent surgical emphysema should there be an air leak, while in the other 17 an external pressure dressing was used instead (surgeon preference). 30 of the children (88%) were given prophylactic antibiotics intravenously at the time of surgery and for 7 days afterwards. In 14 cases the antibiotic used was co-amoxiclav. In a further 14 cases the antibiotic regimen used was a combination of a cephalosporin (cefotaxime or cefuroxime) with metronidazole. This combination was used in preference to co-amoxiclav in children with penicillin allergy. Vancomycin was given to 2 children following advice from microbiology because they were known to be colonised with methicillin-resistant Staphylococcus aureus (MRSA). Of these 30 children, 4 (13%) suffered infective complications. 1 child (3%) developed a wound infection and 3 children (10%) developed infection in the chest (pneumonia). Swabs from the infected wound grew no organisms on culture. Endotracheal aspirates from the children with chest infections had no growth in one case, respiratory syncitial virus in the second case and a scanty mixed growth of yeasts, Escherischia coli and Enterococcus faecalis in the other. 4 (12%) children were not given post-operative antibiotic prophylaxis and all 4 suffered infective complications, 1 child developing a chest infection and 3 children developing wound infections. Swabs from two of the infected wounds had no growth on culture, while the third had a heavy growth of Pseudomonas aeruginosa. Endotracheal aspirates from the child with the chest infection showed a heavy mixed growth of Serratia marcescens, P. aeruginosa, Moraxella catarrhalis, and alpha haemolytic Streptococci. The difference in infection rates between the two groups (Fig. 1) is statistically significant (Fisher’s exact test, two-tailed p = 0.0015). All post-operative infections occurred within 3 days of surgery (1 on day 1, 6 on day 2, 1 on day 3). Children suffering postoperative infection had an increased length of stay in ITU (mean 10.2 days) compared with those not suffering post-operative infection (mean 6.9 days). Similarly, the overall length of stay in hospital for individuals suffering post-operative complications was greater (mean 34.6 days) than those who remained infection-free
Fig. 1. Infective complications in children who did and who did not receive prophylactic antibiotics.
(mean 17.6 days). Nobody in our study population required emergency readmission to ITU. All infective complications were successfully managed conservatively with complete resolution and no graft loss. Of the 24 children undergoing single-stage laryngotracheal reconstruction with grafts, 6 suffered a post-operative infection (4 in the wound, 2 in the chest), while 1 of the 3 undergoing double stage reconstruction with grafts suffered a chest infection (25% vs 33%; Fisher’s exact test, two-tailed p = 1). Of the 19 children in whom a drain was used, 2 suffered an infection (wound infection in both cases) compared with 6 of the 17 where a pressure dressing was used (11% vs 35%; two tailed chi squared test with Yates’ correction p = 0.17). Of the 6 infections that occurred in children with pressure dressings, 4 were chest infections and 2 were wound infections. Of the 12 children with a tracheostomy in place at the time of surgery, 2 suffered a post-operative infection compared with 6 of the 24 who did not have a tracheostomy (17% vs 25%; two tailed chi squared test with Yates’ correction p = 0.89). In the children who did not have a tracheostomy in place at the time of surgery, 3 of the infections that occurred were in the chest, 3 in the wound. Of the 2 infections that occurred in children with a tracheostomy at the time of surgery, 1 infection was in the wound and 1 in the chest, but both had isolates that included Pseudomonas. 4. Conclusion Open airway surgery inevitably involves contamination of the tissues of the neck with tracheal secretions. This can lead to wound infection with the possible disastrous consequence of graft loss. Giving a single dose of antibiotics during surgery, as recommended for adult clean-contaminated surgery, is a reasonable measure to reduce this risk. In addition, however, we must consider the fact that prolonged anaesthesia followed by (in most cases) a few days of ventilation in the intensive care unit can lead to pulmonary atelectasis and consequent infection in the chest. This is a specific risk of airway reconstruction surgery that leads us to recommend continuing prophylaxis with antibiotics for the first post-operative week. We have demonstrated the importance of adherence to a prophylactic antibiotic protocol in open airway reconstruction surgery with a statistically significant reduction in post-operative infections in both wound and chest. Failure to adhere to departmental protocols leads to avoidable morbidity including increased length of post-operative ITU stay. We no longer use wound pressure dressings, preferring to use non-suction wound drains to prevent surgical emphysema. Other measures that might potentially reduce infection rates would be to reduce the length of ITU stay by early extubation after surgery, and to have children on ITU awake as far as possible while intubated, thus avoiding prolonged sedation and mechanical ventilation. Of course, neither of these measures is always possible or appropriate. In addition, the fact that one child who underwent a two-stage procedure (no prolonged post-operative intubation) suffered a chest infection shows that even if the ITU stay is avoided altogether some infections will still occur. Possible factors that are more difficult to control are prolonged ventilation during the procedure itself, contamination of the lower airway with blood from the operative site and poor coughing due to chest wall discomfort at the site of rib cartilage graft harvest. Based on local microbiology advice, our departmental guidelines have been that 7 days of co-amoxiclav is the most appropriate antibiotic regime for most children. We recognise, however, that there are circumstances where other antibiotics may be more appropriate. Children colonised with resistant organisms such as MRSA require alternative antibiotics, as do children with penicillin
S. Polubothu et al. / International Journal of Pediatric Otorhinolaryngology 73 (2009) 1157–1159
1159
Table 1 Our current antibiotic prophylaxis protocol for open airway surgery. Antibiotics are given as a single dose intravenously during the procedure, followed by a further 7 day course post-operatively.
summarised in Table 1. While other centres may have a different pattern of local pathogens and antibiotic resistance, the value of audit in determining antibiotic policy cannot be denied.
Indication
Choice of antibiotic
References
Standard protocol Allergy to penicillin Current or recent tracheostomy Colonised with MRSA
Co-amoxyclav Cefotaxime and metronidazole Ceftazidime and metronidazole Vancomycin
allergy. The large proportion of paediatric tracheostomies that are colonised with P. aeruginosa suggests that we should perhaps also be using anti-pseudomonal agents for children who have an established tracheostomy at the time of surgery, and our protocol has now been changed to reflect this. Our current protocol is
[1] C.A.J. Prescott, Factors that influence successful decannulation after surgery for laryngo-tracheal stenosis in children, Int. J. Pediatr. Otorhinolaryngol. 30 (1994) 183–188. [2] G.D. Becker, G.J. Parell, Cefazolin prophylaxis in head and neck cancer surgery, Ann. Otol. Rhinol. Laryngol. 88 (1979) 183–186. [3] M. Piccart, P. Dor, J. Klastersky, Antimicrobial prophylaxis of infections in head and neck cancer surgery, Scan. J. Infect. Dis. Suppl. 39 (1983) 92–96. [4] R.S. Weber, I. Raad, R. Frankenthaler, et al., Ampicillin-sulbactam vs clindamycin in head and neck oncologic surgery. The need for gram-negative coverage, Arch. Otolaryngol. Head Neck Surg. 118 (1992) 1159–1163. [5] SIGN Guideline, 104: Antibiotic Prophylaxis in Surgery, Scottish Intercollegiate Guidelines Network, Edinburgh, 2008.
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
An audit of prophylactic antibiotic use in laryngeal reconstruction surgery Satyamaanasa Polubothu, Sylvia Harrison, Andrew Clement, Haytham Kubba * Department of Otolaryngology, Royal Hospital for Sick Children, Yorkhill, Glasgow G3 8SJ, United Kingdom
A R T I C L E I N F O
S U M M A R Y
Article history: Received 19 October 2008 Received in revised form 26 April 2009 Accepted 30 April 2009 Available online 5 June 2009
Objective: Published data on the role of antibiotics after open airway reconstruction surgery in children is lacking. We reviewed adherence to our own departmental antibiotic protocol to determine its adequacy and effectiveness. Methods: We reviewed the records of all children undergoing open airway reconstruction surgery 2003– 2007 in our unit which is based in a tertiary referral children’s hospital. Results: 36 children underwent surgery, of whom 32 were given appropriate antibiotic prophylaxis. Failure to give antibiotic prophylaxis was associated with increased rates of infection (wound infection and pneumonia) and with a longer stay in the ITU. Conclusions: We present a revised antibiotic protocol based on our experience and local antibiotic advice. ß 2009 Elsevier Ireland Ltd. All rights reserved.
Keywords: Laryngotracheal reconstruction Laryngotracheoplasty Laryngeal surgery Airway surgery Antibiotic prophylaxis Post-operative infection
1. Introduction The last 20 years have seen a huge improvement in the surgical options available for children with airway disorders, with problems such as subglottic stenosis, glottic webs and subglottic haemangiomas now being treatable by various open airway surgical procedures. Post-operative infection will inevitably hinder recovery and may adversely affect the outcome of the procedure. Inappropriate use of antibiotics however, may increase antimicrobial resistance and will lead to unnecessary costs. While antibiotic prophylaxis has been suggested for paediatric airway surgery [1], there is no published evidence to support this practice. Several papers have demonstrated the benefit of antibiotic prophylaxis in clean contaminated head and neck surgery in adult cancer patients [2–4]. These adults may have poor wound healing due to inadequate nutrition, previous radio- or chemotherapy, or the effects of the cancer itself, so it is difficult to generalise these findings to otherwise-well children. National guidelines suggest antibiotic prophylaxis for cleancontaminated surgery in adults [5] but no mention is made for children. Our own departmental protocol is to use prophylactic antibiotics following airway surgery (7 days of co-amoxyclav, unless there is a history of allergy to penicillin or evidence of colonisation with MRSA). The aims of this audit were therefore as follows. Firstly, to assess compliance with our own departmental
* Corresponding author. Tel.: +44 141 2010297; fax: +44 141 2010865. E-mail address: [email protected] (H. Kubba). 0165-5876/$ – see front matter ß 2009 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijporl.2009.04.026
policy on antibiotic prophylaxis following major open airway surgery, and secondly to compare the rates of infective complications in individuals receiving prophylactic antibiotic compared with those not receiving prophylactic antibiotics. 2. Subjects and methods This study took the form of a retrospective case note review. Inclusion criteria were defined as individuals undergoing major open airway reconstructive surgery in our hospital from January 2003 to December 2007. The relevant subjects were identified from our departmental database and their case notes retrieved for review. From the case notes we recorded what antibiotics were given, if any, and whether any infective complications occurred. 3. Results Over the study period 36 children underwent major open airway reconstruction surgery. The children were aged between 5 days and 18 years (median 4 years) at the time of surgery. 19 were male and 15 were female. Complete records were available for 34(94%). The indication for surgery was subglottic stenosis in 21 (62%), glottic web with subglottic stenosis in 5 (14%), subglottic haemangioma in 2 (6%), upper tracheal stenosis following tracheostomy in 5 (14%), and partial cartilaginous sleeve trachea in 1 (3%). Twelve children had a tracheostomy in place at the time of surgery, while 24 did not. Surgery involved single stage laryngotracheal reconstruction with cartilage grafts in 24 (68%),
1158
S. Polubothu et al. / International Journal of Pediatric Otorhinolaryngology 73 (2009) 1157–1159
double stage laryngotracheal reconstruction with cartilage grafts in 3 (11%), partial cricotracheal resection in 5 (14%) and resection of subglottic haemangiomas in 2 (7%). In 19 procedures, a nonsuction (Penrose) drain was placed in the wound to prevent surgical emphysema should there be an air leak, while in the other 17 an external pressure dressing was used instead (surgeon preference). 30 of the children (88%) were given prophylactic antibiotics intravenously at the time of surgery and for 7 days afterwards. In 14 cases the antibiotic used was co-amoxiclav. In a further 14 cases the antibiotic regimen used was a combination of a cephalosporin (cefotaxime or cefuroxime) with metronidazole. This combination was used in preference to co-amoxiclav in children with penicillin allergy. Vancomycin was given to 2 children following advice from microbiology because they were known to be colonised with methicillin-resistant Staphylococcus aureus (MRSA). Of these 30 children, 4 (13%) suffered infective complications. 1 child (3%) developed a wound infection and 3 children (10%) developed infection in the chest (pneumonia). Swabs from the infected wound grew no organisms on culture. Endotracheal aspirates from the children with chest infections had no growth in one case, respiratory syncitial virus in the second case and a scanty mixed growth of yeasts, Escherischia coli and Enterococcus faecalis in the other. 4 (12%) children were not given post-operative antibiotic prophylaxis and all 4 suffered infective complications, 1 child developing a chest infection and 3 children developing wound infections. Swabs from two of the infected wounds had no growth on culture, while the third had a heavy growth of Pseudomonas aeruginosa. Endotracheal aspirates from the child with the chest infection showed a heavy mixed growth of Serratia marcescens, P. aeruginosa, Moraxella catarrhalis, and alpha haemolytic Streptococci. The difference in infection rates between the two groups (Fig. 1) is statistically significant (Fisher’s exact test, two-tailed p = 0.0015). All post-operative infections occurred within 3 days of surgery (1 on day 1, 6 on day 2, 1 on day 3). Children suffering postoperative infection had an increased length of stay in ITU (mean 10.2 days) compared with those not suffering post-operative infection (mean 6.9 days). Similarly, the overall length of stay in hospital for individuals suffering post-operative complications was greater (mean 34.6 days) than those who remained infection-free
Fig. 1. Infective complications in children who did and who did not receive prophylactic antibiotics.
(mean 17.6 days). Nobody in our study population required emergency readmission to ITU. All infective complications were successfully managed conservatively with complete resolution and no graft loss. Of the 24 children undergoing single-stage laryngotracheal reconstruction with grafts, 6 suffered a post-operative infection (4 in the wound, 2 in the chest), while 1 of the 3 undergoing double stage reconstruction with grafts suffered a chest infection (25% vs 33%; Fisher’s exact test, two-tailed p = 1). Of the 19 children in whom a drain was used, 2 suffered an infection (wound infection in both cases) compared with 6 of the 17 where a pressure dressing was used (11% vs 35%; two tailed chi squared test with Yates’ correction p = 0.17). Of the 6 infections that occurred in children with pressure dressings, 4 were chest infections and 2 were wound infections. Of the 12 children with a tracheostomy in place at the time of surgery, 2 suffered a post-operative infection compared with 6 of the 24 who did not have a tracheostomy (17% vs 25%; two tailed chi squared test with Yates’ correction p = 0.89). In the children who did not have a tracheostomy in place at the time of surgery, 3 of the infections that occurred were in the chest, 3 in the wound. Of the 2 infections that occurred in children with a tracheostomy at the time of surgery, 1 infection was in the wound and 1 in the chest, but both had isolates that included Pseudomonas. 4. Conclusion Open airway surgery inevitably involves contamination of the tissues of the neck with tracheal secretions. This can lead to wound infection with the possible disastrous consequence of graft loss. Giving a single dose of antibiotics during surgery, as recommended for adult clean-contaminated surgery, is a reasonable measure to reduce this risk. In addition, however, we must consider the fact that prolonged anaesthesia followed by (in most cases) a few days of ventilation in the intensive care unit can lead to pulmonary atelectasis and consequent infection in the chest. This is a specific risk of airway reconstruction surgery that leads us to recommend continuing prophylaxis with antibiotics for the first post-operative week. We have demonstrated the importance of adherence to a prophylactic antibiotic protocol in open airway reconstruction surgery with a statistically significant reduction in post-operative infections in both wound and chest. Failure to adhere to departmental protocols leads to avoidable morbidity including increased length of post-operative ITU stay. We no longer use wound pressure dressings, preferring to use non-suction wound drains to prevent surgical emphysema. Other measures that might potentially reduce infection rates would be to reduce the length of ITU stay by early extubation after surgery, and to have children on ITU awake as far as possible while intubated, thus avoiding prolonged sedation and mechanical ventilation. Of course, neither of these measures is always possible or appropriate. In addition, the fact that one child who underwent a two-stage procedure (no prolonged post-operative intubation) suffered a chest infection shows that even if the ITU stay is avoided altogether some infections will still occur. Possible factors that are more difficult to control are prolonged ventilation during the procedure itself, contamination of the lower airway with blood from the operative site and poor coughing due to chest wall discomfort at the site of rib cartilage graft harvest. Based on local microbiology advice, our departmental guidelines have been that 7 days of co-amoxiclav is the most appropriate antibiotic regime for most children. We recognise, however, that there are circumstances where other antibiotics may be more appropriate. Children colonised with resistant organisms such as MRSA require alternative antibiotics, as do children with penicillin
S. Polubothu et al. / International Journal of Pediatric Otorhinolaryngology 73 (2009) 1157–1159
1159
Table 1 Our current antibiotic prophylaxis protocol for open airway surgery. Antibiotics are given as a single dose intravenously during the procedure, followed by a further 7 day course post-operatively.
summarised in Table 1. While other centres may have a different pattern of local pathogens and antibiotic resistance, the value of audit in determining antibiotic policy cannot be denied.
Indication
Choice of antibiotic
References
Standard protocol Allergy to penicillin Current or recent tracheostomy Colonised with MRSA
Co-amoxyclav Cefotaxime and metronidazole Ceftazidime and metronidazole Vancomycin
allergy. The large proportion of paediatric tracheostomies that are colonised with P. aeruginosa suggests that we should perhaps also be using anti-pseudomonal agents for children who have an established tracheostomy at the time of surgery, and our protocol has now been changed to reflect this. Our current protocol is
[1] C.A.J. Prescott, Factors that influence successful decannulation after surgery for laryngo-tracheal stenosis in children, Int. J. Pediatr. Otorhinolaryngol. 30 (1994) 183–188. [2] G.D. Becker, G.J. Parell, Cefazolin prophylaxis in head and neck cancer surgery, Ann. Otol. Rhinol. Laryngol. 88 (1979) 183–186. [3] M. Piccart, P. Dor, J. Klastersky, Antimicrobial prophylaxis of infections in head and neck cancer surgery, Scan. J. Infect. Dis. Suppl. 39 (1983) 92–96. [4] R.S. Weber, I. Raad, R. Frankenthaler, et al., Ampicillin-sulbactam vs clindamycin in head and neck oncologic surgery. The need for gram-negative coverage, Arch. Otolaryngol. Head Neck Surg. 118 (1992) 1159–1163. [5] SIGN Guideline, 104: Antibiotic Prophylaxis in Surgery, Scottish Intercollegiate Guidelines Network, Edinburgh, 2008.