title: Impact of antibiotic prophylaxis for intrathecal baclofen pump surgery in pediatric patients.
abstract: OBJECT This study explored antibiotic prophylaxis (AP) in pediatric patients undergoing intrathecal baclofen pump (ITBP) surgery and factors associated with perioperative AP compliance with clinical guidelines. METHODS Data were obtained from the Pediatric Health Information System. The study cohort comprised patients who underwent ITBP surgery within 3 days of admission, between July 1, 2004, and March 31, 2014, with a minimum prior screening period and follow-up of 180 days. Exclusion criteria were prior infection, antibiotic use within 30 days of admission, and/or missing financial data. Chi-square tests and multivariate logistic regressions were used to determine factors associated with compliance with AP guidelines in ITBP surgeries. RESULTS A total of 1,534 patients met the inclusion criteria; 91.5% received AP and 37.6% received dual coverage or more. Overall bundled compliance comprised 2 components: 1) perioperative antibiotic administration and 2) < 24-hour postoperative antibiotic course. The most frequently used antibiotics in surgery were cefazolin (n = 873, 62.2%) and vancomycin (n = 351, 25%). Documented bundled AP compliance rates were 70.2%, 62.0%, 66.0%, and 55.2% in West, South, Midwest, and Northeast regions of the US, respectively. Compared with surgeries in the Northeast, procedures carried out in the West (OR 2.0, 95% C11.4-2.9, p < 0.001), Midwest (OR 1.6, 95% C11.1-2.3, p = 0.007), and South (OR 1.5, 95% C11.1-2.0, p = 0.021) were more likely to have documented AP compliance. Black (OR 0.74, 95% CI 0.55-1.00, p = 0.05) and Hispanic (OR 0.63, 95% CI 0.47-0.86, p = 0.004) patients were less likely to have documented AP compliance in ITBP surgeries than white patients. There were no significant differences in compliance rate by age, sex, type of insurance, and diagnosis. AP process measures were associated with shorter length of stay, lower hospitalization costs, and lower 6-month rates of surgical infection/complication. One of the 2 noncompliance subgroups, missed preoperative antibiotic administration, was correlated with a significantly higher 6-month surgical complication/infection rate (27.03%) compared with bundled compliance (20.00%, p = 0.021). For the other subgroup, prolonged antibiotic use > 24 hours postoperatively, the rate was insignificantly higher (22.00%, p = 0.368). Thus, of direct relevance to practicing clinicians, missed preoperative antibiotics was associated with 48% higher risk of adverse complication/infection outcome in a 6-month time frame. Adjusted hospitalization costs associated with baclofen pump surgery differed significantly (p < 0.001) with respect to perioperative antibiotic practices: 22.83, 29.10, 37.66 (× 1000 USD) for bundled compliance, missed preoperative antibiotics, and prolonged antibiotic administration, respectively. CONCLUSIONS Significant variation in ITBP antibiotic prophylaxis was found. Documented AP compliance was associated with higher value of care, showing favorable clinical and financial outcomes. Of most impact to clinical outcome, missed preoperative antibiotics was significantly associated with higher risk of 6-month surgical complication/infection. Prolonged antibiotic use was associated with significantly higher hospital costs compared with those with overall bundled antibiotic compliance. Future research is warranted to examine factors associated with practice variation and how AP compliance is associated with outcomes and quality, aiming for improving delivery of care to pediatric patients undergoing ITBP procedures.
authors.affiliation: Department of Neurosurgery, Baylor College of Medicine, and.|Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, Texas; and.
authors.forename: I-Wen
authors.initials: IW
authors.lastname: Pan
authors.affiliation: Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, California.
authors.forename: Grace M
authors.initials: GM
authors.lastname: Kuo
authors.affiliation: Department of Neurosurgery, Baylor College of Medicine, and.|Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, Texas; and.
authors.forename: Thomas G
authors.initials: TG
authors.lastname: Luerssen
authors.affiliation: Department of Neurosurgery, Baylor College of Medicine, and.|Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, Texas; and.
authors.forename: Sandi K
authors.initials: SK
authors.lastname: Lam
mesh_terms: D000293:Adolescent; D000367:Age Factors; D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D019072:Antibiotic Prophylaxis / Q000379:methods*; D001418:Baclofen / Q000008:administration & dosage; D016009:Chi-Square Distribution; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D016208:Databases, Factual / Q000706:statistics & numerical data; D016503:Drug Delivery Systems / Q000009:adverse effects*; D005260:Female; D006760:Hospitalization / Q000191:economics; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D009125:Muscle Relaxants, Central / Q000008:administration & dosage; D013530:Surgical Wound Infection / Q000191:economics / Q000209:etiology* / Q000517:prevention & control*
chemical_list: D000900:Anti-Bacterial Agents; D009125:Muscle Relaxants, Central; D001418:Baclofen
keywords: AP = antibiotic prophylaxis; ASHP = American Society of Health-System Pharmacists; ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification; ITBP = intrathecal baclofen pump; LOS = length of stay; PHIS = Pediatric Health Information System; RR = relative risk; SCIP = Surgical Care Improvement Project; SSI = surgical-site infection; USD = US dollars; antibiotic prophylaxis; antibiotics; compliance; intrathecal baclofen pump; pediatric