title: Impact of a new practice guideline on antibiotic use with pediatric tonsillectomy.
abstract: OBJECTIVE
  More than 500,000 children undergo tonsillectomy each year in the United States. Although prior studies suggest that most patients received perioperative antibiotics, practice varies across centers. In 2011, the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) published a practice guideline recommending against perioperative antibiotic use for pediatric tonsillectomy. The impact of this recommendation has not been thoroughly examined.
  
  
  OBJECTIVE
  To determine the impact of the AAO-HNS guideline on the use of perioperative antibiotics and patient outcomes for pediatric tonsillectomy.
  
  
  METHODS
  This was a quasi-experimental study including 9265 children who underwent routine tonsillectomy from January 2009 through August 2012 within a large pediatric health care network containing hospital-based and ambulatory surgical facilities. Data were collected from a shared electronic health record and validated through manual medical record review. We used an interrupted time series analysis with segmented logistic regression and a nonequivalent dependent variable (tympanoplasty) to assess acute changes and differences in trends over time relative to guideline publication.
  
  
  METHODS
  Publication of the AAO-HNS clinical practice guideline.
  
  
  METHODS
  The primary outcome was antibiotic administration on the day of surgery. Secondary outcomes included otolaryngology clinic encounters, emergency department encounters, hospital admissions, and surgical procedures for bleeding in the 30 days following tonsillectomy.
  
  
  RESULTS
  Of 9265 tonsillectomies during the study period, 5359 met inclusion criteria. Immediately after guideline publication, perioperative antibiotic use dropped by 86.5% (P < .001) and was sustained throughout the postintervention period. Rates of otolaryngology clinic encounters, emergency department encounters, and hospital admissions did not change significantly over time. There was a small but statistically significant increase in surgical procedures for bleeding following the intervention from 1.35% (95% CI, 0.57%-2.14%) to 3.48% (95% CI, 1.85%-5.10%).
  
  
  CONCLUSIONS
  AAO-HNS guideline publication decreased perioperative antibiotic use for pediatric tonsillectomy across a large pediatric health care network. Although there were no changes in otolaryngology clinic visits, emergency department visits, or admissions, we found a small but significant increase in surgery for bleeding following guideline publication. Additional studies are necessary to verify this unexpected association.
authors.affiliation: Naval Medical Center San Diego, San Diego, California.
authors.forename: Edmund A
authors.initials: EA
authors.lastname: Milder
authors.affiliation: Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania3Department of Otolaryngology-Head and Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia.
authors.forename: Mark D
authors.initials: MD
authors.lastname: Rizzi
authors.affiliation: Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia.
authors.forename: Knashawn H
authors.initials: KH
authors.lastname: Morales
authors.affiliation: Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
authors.forename: Rachael K
authors.initials: RK
authors.lastname: Ross
authors.affiliation: Center for Clinical Epidemiology and Biostatistics, Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, Philadelphia.
authors.forename: Ebbing
authors.initials: E
authors.lastname: Lautenbach
authors.affiliation: Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania6Center for Clinical Epidemiology and Biostatistics, Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania.
authors.forename: Jeffrey S
authors.initials: JS
authors.lastname: Gerber
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D002648:Child; D005260:Female; D006801:Humans; D008297:Male; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D014068:Tonsillectomy; D016896:Treatment Outcome; D014481:United States
chemical_list: D000900:Anti-Bacterial Agents